This document discusses facts and controversies around stroke and antiplatelet therapy. Some key points:
- Stroke is a major cause of death and disability worldwide. Antiplatelet drugs like aspirin and clopidogrel can help prevent strokes but have risks of bleeding.
- Aspirin is recommended for secondary prevention of cardiovascular events but its benefits may not outweigh risks for primary prevention. Clopidogrel provides slightly greater risk reduction than aspirin for stroke prevention.
- Controversies include adverse effects of bleeding, drug interactions that reduce effectiveness, and recurrence risks after discontinuing antiplatelet drugs. Careful risk-benefit assessment is needed for individual patients.
- Long-term anti
Secondary Prevention after ACS: Focused on Anticoagulant TherapyPERKI Pekanbaru
Dr. Nathania Marliani Kristanti, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 25th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
Secondary Prevention after ACS: Focused on Anticoagulant TherapyPERKI Pekanbaru
Dr. Nathania Marliani Kristanti, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 25th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
Ticagrelor in acute myocardial infarctionVasif Mayan
Potential benefits of dual antiplatelet therapy beyond 1 year after an MI has not been studied
Patients with MI are at increased risk of RECURRENT ISCHAEMIC EVENTS
Intensive secondary prevention is theoretically beneficial
Finding an ideal drug with best risk-benefit ratio is a challenge
TICAGRELOR
--- Direct acting
Not a pro-drug; does not require metabolic activation
Rapid onset of inhibitory effect on the P2Y12 receptor
Greater inhibition of platelet aggregation than clopidogrel
--- Reversibly bound
Degree of inhibition reflects plasma concentration
Faster offset of effect than clopidogrel
Functional recovery of circulating platelets within ~48 hours
PLATO trial
PEGASUS TIMI trial
What are anti-coagulants?
What are the difference between antiplatelet, anticoagulants and thrombolytics?
Coagulation cascade
Virchows Triad
Classification of anti-coagulants?
Indications of anti-coagulants?
Mechanism and site of action of different anti-coagulants?
Beta blockers have a variety of different uses in the management of ischemic heart disease. This presentation by Dr Vivek Baliga, Internal Medicine Physician talks about the role in ST elevation MI.
Ticagrelor in acute myocardial infarctionVasif Mayan
Potential benefits of dual antiplatelet therapy beyond 1 year after an MI has not been studied
Patients with MI are at increased risk of RECURRENT ISCHAEMIC EVENTS
Intensive secondary prevention is theoretically beneficial
Finding an ideal drug with best risk-benefit ratio is a challenge
TICAGRELOR
--- Direct acting
Not a pro-drug; does not require metabolic activation
Rapid onset of inhibitory effect on the P2Y12 receptor
Greater inhibition of platelet aggregation than clopidogrel
--- Reversibly bound
Degree of inhibition reflects plasma concentration
Faster offset of effect than clopidogrel
Functional recovery of circulating platelets within ~48 hours
PLATO trial
PEGASUS TIMI trial
What are anti-coagulants?
What are the difference between antiplatelet, anticoagulants and thrombolytics?
Coagulation cascade
Virchows Triad
Classification of anti-coagulants?
Indications of anti-coagulants?
Mechanism and site of action of different anti-coagulants?
Beta blockers have a variety of different uses in the management of ischemic heart disease. This presentation by Dr Vivek Baliga, Internal Medicine Physician talks about the role in ST elevation MI.
Pharmacogenetics is the study of inherited genetic differences in drug metabolic pathways which can affect individual responses to drugs, both in terms of therapeutic effect as well as adverse effects. The term pharmacogenetics is often used interchangeably with the term pharmacogenomics which also investigates the role of acquired and inherited genetic differences in relation to drug response and drug behavior through a systematic examination of genes, gene products, and inter- and intra-individual variation in gene expression and function.
David Juurlink - Drug Interactions That Can Kill (and How to Avoid Them)SMACC Conference
David Juurlink SMACC Chicago talk 'Drug Interactions That Can Kill (and How to Avoid Them)’ takes us on a journey of drug interactions, case studies, and avoidance strategies.
Juurlink starts by educating us on the two different drug-drug interactions (DDI) - effects of one drug altered by the use of another . First of which is Pharmacokinetic where by one drug alters the level of another, the second Pharmacodynamic being no change in drug levels, and uses this as a basis for his following case studies.
Juurlink speaks of the dreadful literature that is available on the thousands of drug interaction per year, stating that most information comes from case reports and volunteer studies, and suggests that majority of these interaction are avoidable.
Juurlink goes on to discuss the findings of 4 case studies involving the following Drug-Drug Interactions and their effects on the patients.
SMX/TMP + sulfonylureas
Macrolides + digoxin
APAP + warfarin
SMX/TMP + ACEI/ARB
Juurlink provides us with a short list of trigger drugs that we should be aware of, a list of meds that warrant extra caution and list of possible safer alternatives. He also suggests that it is of the up most importance to have a good pharmacist to turn to as they are given more information on drugs interactions then physicians. And, to utilise resources such as pharmacy times - where you can get information on drug interactions at a push of the button.
Juurlink also suggests that an Informed patient is a very useful safety mechanism.
Antiplatelet therapy there is a gap between guidelines and implementationA.Salam Sharif
platelets play an important role in cardiovascular diseases, the final event leading to ACS is a spontaneous atherosclerotic plaques which initiates a platelet response with platelet adhesion to vascular wall with activation and agregation and finally clot formation with clinical sequences od CV deaths, MI and myocardial ischemia and arrhythmias, so atiplatelet therapy is crucial in treatment of ACS, in the topic I review the traditional agents and new agents , focusing on guidelines and real world of their cinical uses .
Diabetes and acute coronary syndrome
Diabetic patients as compared to non diabetics withacute cornary syndrome (ACS) at 2 years showed a
1.8 fold increase in cardiovascular deaths
1.4 fold increase in myocardial infarctions (MI)
www.srisriholistichospitals.com
Secondary prevention of ischemic strokeSudhir Kumar
A patient who has suffered ischemic stroke is at a higher risk of getting strokes in future. This is called recurrent stroke. The current presentation looks at the factors responsible for stroke recurrence, and discusses strategies to reduce the risk of stroke recurrence.
this slide was prepared for NCD programme June, 2012, the informations shown here were taken from both JN7 and NICE guideline.useful for family practitioners, community clinic doctors.Thanks
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. Dr. Mohammad Tanvir Islam
Assistant Professor
Department of Internal Medicine
Bangabandhu Sheikh Mujib Medical University
3. Some Facts on Stroke
Every year around 15 million people
around the world suffer a stroke
5.5 million among them dies
Third leading cause of death
Incidence of stroke is increasing
4. 87% of the strokes are infarctive
Thrombosis
Thromboembolic events
11. 0.5 1.0 1.5 2.0
Non-fatal MI
Vascular Mortality
Major extracranial bleed
Serious Vascular Events
Antiplatelet Better Antiplatelet Worse
Rate Ratios for
Vascular Events
0
P<0.0001
Source: Antithrombotic Trialists’ Collaboration. Lancet 2009;373:1849-1860
Any stroke
P-value
P=0.40
P=0.70
P<0.0001
P=0.0001
Aspirin Evidence:
Primary Prevention
Antithrombotic Trialists’ (ATT) Collaboration
Aspirin reduces the risk of MI and vascular events at the expense of bleeding
12. PRIMARY PREVENTION:
ATC review-
benefit was not found to exceed harm for primary
prevention.
HOT trial (ASA 75 mg versus placebo for primary
prevention in hypertensive patients)
showing no effect on mortality or stroke
benefit was outweighed by an increased incidence of
bleeding
13. In patients with DM
Low-dose aspirin for adults with diabetes mellitus
who have a 10-year cardiovascular risk >10%
Not be used for at low risk and that aspirin
Might be considered for those at intermediate (10-
year risk in the 5%–10% range) risk.
14. Source: Antithrombotic Trialists’ Collaboration. BMJ 2002;324:71–86
Category % Odds Reduction
Acute MI
Acute CVA
Prior MI
Prior CVA/TIA
Other high risk
CVD
(e.g. unstable angina, heart failure)
PAD
(e.g. intermittent claudication)
High risk of embolism (e.g. Afib)
Other (e.g. DM)
All trials
1.00.50.0 1.5 2.0
Control betterAntiplatelet better
Effect of antiplatelet treatment* on vascular events**
*Aspirin was the predominant antiplatelet agent studied
**Include MI, stroke, or death
Aspirin Evidence:
Secondary Prevention
Aspirin reduces the risk of adverse cardiovascular events
15. 19,185 patients with ischemic CVA, MI, or PAD randomized to daily
aspirin (325 mg) or clopidogrel (75 mg) for 2 years
Clopidogrel provides slightly greater risk reduction than aspirin
Months of follow-up
0
3
6
0 3 6 9 12 15 18 21 24 27 30 33 36
Cumulativerisk*(%)
8.7% RRR, p=0.043
Aspirin
Clopidogrel
Source: CAPRIE Steering Committee. Lancet 1996;348:1329-1339
CVA=Cerebrovascular accident, MI=Myocardial
infarction, PAD=Peripheral arterial disease
*Composite of myocardial infarction, ischemic stroke, or vascular death
Clopidogrel Evidence:
Secondary Prevention
Clopidogrel versus Aspirin in Patients at Risk of
Ischemic Events (CAPRIE) Trial
16. DIPYRIDAMOLE
The ESPS-2 trial
The benefit of combination aspirin-extended-release
dipyridamole was significantly greater than the two
components alone
Significantly greater than placebo
(OR 0.59, 95% CI 0.48-0.73)
18. Adverse effects of antiplatelet drugs
Bleeding
Gastrointestinal
Nose bleeding
Intracerebral bleeding
Bleeding from puncture & surgical site
Headache
Hypersensitivity
Exacerbation of asthma
19. A systemic review (13 randomized trials with a follow-up of
1 year)
0
2
4
6
8
10
12
14
16
18
Total bleeding rates
20. Aspirin resistance
laboratory resistance and clinical resistance
Laboratory resistance is defined as the failure of
aspirin to inhibit platelet TXA2 production
clinical resistance
noncompliance,
drug interactions (i.e. with NSAID),
genetic polymorphisms of COX-1 and other genes
involved in thromboxane production,
increase biosynthesis of thromboxane by alternative
sources
increased platelet turnover
21. Drug interaction between clopidogrel and
proton pump inhibitors
PPIs might diminish the antiplatelet effects of
clopidogrel
Possibly through inhibition of the CYP 2C19
isoenzyme
Inhibiting conversion of clopidogrel into its active
metabolite
No RCT showed significant decrease in antiplatelet
effect
PPIs should not be prescribed routinely
22. Stroke costs the United States an estimated $34
billion each year.
This total includes the cost of health care services,
medications to treat stroke, and missed days of work
23. prevalence of stroke in Bangladesh is 0·3%
2.55% of the total number of disabilities
Disability-adjusted life-years lost due to stroke (485
per 10 000 people)
stroke severely impacts Bangladesh's economy
One DALY can be thought of as one lost year of "healthy" life
Burden of stroke in Bangladesh.
Islam MN, Moniruzzaman M, Khalil MI, Basri R, Alam MK, Loo KW, Gan SH
24. Cost of Aspirin 1x100=172 BDT (52 BDT/month)
Clopidogrel 1x100=1200 BDT (360BDT/month)
Aspirin+Clopidogrel 375BDT/month
We on an average earn 7709 BDT per month
26. The probability of a recurrent stroke after the first
stroke is
>3% to 10% in the first month and
≈5% to 14% in the first year
twice the probability of death
Increased cardiovascular complications
Primary prevention is particularly important because
>76% of strokes are first events.
27. Antiplatelet discontinuation
PRoFESS study
Recurrent stroke
Absolute excess risk of 0.77% within 30 days after
discontinuation of ASA + ERDP and 0.40% within 30 days
after discontinuation of clopidogrel populations.
A combined vascular endpoint
an absolute excess risk of 2.02% within 30 days after
discontinuation of ASA + ERDP and 1.83% within 30 days
after discontinuation of clopidogrel
28. Igor Sibon, MD; and Jean–Marc Orgogozo, MD
4.49% of strokes were related to a recent APD
discontinuation, but
All cases occurred between 6 and 10 days after drug
discontinuation (p < 0.0001)
This temporal pattern has biologic plausibility
because the inhibited platelets circulate in the blood
for about 10 days
30. AHA/ASA Guideline
Aspirin (50–325 mg/d) monotherapy (Class I; Level
of Evidence A) or the combination of aspirin 25 mg
and extended-release dipyridamole 200 mg twice
daily as initial therapy
Clopidogrel (75 mg) monotherapy is a reasonable
option
The combination of aspirin and clopidogrel might be
considered for initiation within 24 hours of a minor
ischemic stroke or TIA and for continuation for 21
days )
31. DAP therapy should be used in the acute post-stroke
and early prevention time period (e.g.first 3 months),
where the risk of stroke recurrence is highest.
Recommended for up to 9 months in stroke patients
who were treated with stenting
32. PPIs should not be prescribed routinely
But only after a careful risk-benefit assessment on
an individual patient basis
33. Discontinuation after ulcer bleeding
Decision must be made on an individual basis
Often advised to discontinue ASA until ulcers have
healed (Bhatt et al.,2008)
No evidence that non-ASA antiplatelet drugs will
reduce this bleeding risk (Lanas et al., 2006)
American college of cardiology foundation (ACCF), American heart association (AHA),
The American college of gastroenterology
34. So, “For How Long?”
Lets consider
The role of antiplatelet drugs in stroke prevention
Their efficacy
Their side effects
Recurrence of stroke after discontinuation
Economic burden of stroke Vs Economic burden of
antiplatelets