darkhorse
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A 75-year-old woman with no past medical history presents to the emergency department 4 hours after the onset of stuttering, severe substernal chest pain with radiation to the left arm and jaw. After two sublingual nitroglycerin tablets in the emergency department, the patient is free of chest pain. Electrocardiography reveals 2-mm ST-segment depression in leads I, aVL, V5, and V6. The initial troponin I level is elevated at 8 ng/mL. The patient has no clear-cut medical contraindications to anticoagulation. The patient is treated with aspirin, intravenous β-blocker, and intravenous nitroglycerin. In addition to the medications that have been started, which of the following would be the optimal management strategy at this time?
A. Unfractionated heparin, tirofiban.
B. Enoxaparin.
C. Clopidogrel, enoxaparin.
D. Clopidogrel, enoxaparin, tirofiban.
E. Clopidogrel, enoxaparin, tirofiban, diltiazem.
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| cool doctor
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B?
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| amritt786
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C
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parda kajj layin sayian saadi changi mandi da
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| tamerbashir
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B
CLOPIDOGREL USED AFTER MI FOR 12 MONTH OR AFTER CARDIAC STENT AND PCI FOR 3 MONTHS
WHAT IS THE TIROFIBAN 
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| drduck
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i think A...
action of clopidogrel and tirofiban is quite similar....so why to give both of them....
patien has no contraindications....so one can use unfrac heparin...also bcos he is hospitalised....no big deals.
clinically some physicians prefer comination of aspirin and clopidogrel....but i dont think there is need for both tirofiban and clopedogrel....somehow even i m not completely sure...
i m waiting for the right answer....
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| drduck
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TIROFIBAN......or ABXICIMAB......and few more of this class of drug are known to act on GP2b3a receptor on the platelets....
they in other words prevent platelet AGGREGATION....so prevent clot formation and infarction....
they are excellent drugs but can only be given by parenteral route...mostly subcuteneous route. are expensive too.
most importantly unlike sreptokinase they do not lyse the clot rather prevent further clotting.
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| doyoudig
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D. Clopidogrel, enoxaparin, tirofiban.
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| Vietnamese
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C. Pt had Non-ST Elevation MI, require follow-up, if high-risk we can add Tirofiban. At present, tirofiban have not required yet.
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| darkhorse
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The correct answer is D
Educational Objectives
Recognize the optimal medical management for non-ST-segment elevation acute coronary syndrome.
Critique
This patient presents with non-ST-segment elevation myocardial infarction (NSTEMI). The medical therapy of this disorder has evolved considerably over the past several years. First-line antianginal medications include β-blockers and nitrates. Calcium channel antagonists are reserved for patients who have contraindications to β-blockers or nitrates, and those patients who remain symptomatic and/or hypertensive on appropriate doses of these agents. Because the pathophysiology of the disorder involves formation of both platelet and fibrin thrombi, therapy with antiplatelet and antithrombotic agents is indicated. Studies have demonstrated that treatment with a combination of heparin (or low-molecular-weight heparin) and a small molecule glycoprotein IIb/IIIa receptor inhibitor (such as tirofiban or eptifibatide) is superior to heparin therapy alone in these patients (PRISM-PLUS and PURSUIT studies). In patients with acute coronary syndrome (unstable angina or NSTEMI), therapy with clopidogrel and aspirin is superior to aspirin alone. In patients without a contraindication to anticoagulation, beginning clopidogrel in addition to aspirin is an appropriate strategy and is associated with a lower incidence of subsequent myocardial infarction and stroke (CURE study). Lastly, evidence from both observational and randomized clinical trials shows that the early initiation of a statin in patients hospitalized with an acute coronary syndrome is associated with a reduction in ischemic complications (MIRACL study). Based on recent clinical trial data (TACTICS TIMI-1 8), coronary angiography would be indicated in this patient with NSTEMI, as she has elevated tropon ins and ST-segment depression.
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| cool doctor
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thanks darkhorse
but I know that if you consider angiography as an option you shouldnt use clopidogrel!!
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| alzheimer
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Patient with ST depression and refractory ischemia are considered high risk and should br referred for angiography and revascularisation..In this case, the patient has ST depression...Before angiography, u should add answer  D.
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