plavix question

[basementbeast]

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question to the group: for chest pain patients that are either aspirin allergic or have severe gi intolerance but are risk-stratified to low risk (chest pain free now, no ekg changes, crappy story) .... do you load a full 300 mg or just give a 75mg dose...???

 

[bulgethetwine]

question to the group: for chest pain patients that are either aspirin allergic or have severe gi intolerance but are risk-stratified to low risk (chest pain free now, no ekg changes, crappy story) .... do you load a full 300 mg or just give a 75mg dose...???

Chest pain free, no EKG changes, crappy story, aspirin allergic/intolerant?

They don't get Plavix in my book.

For all intents and purposes, Plavix is a drug to be initiated on the inpatient. Now, if they're already on it for stents (in which case surely they aren't "low risk" as in your hypothetical situation) then I'll make sure they've gotten their daily dose of 75mg.

 

[Dr.Evil1]

Chest pain free, no EKG changes, crappy story, aspirin allergic/intolerant?

They don't get Plavix in my book.

For all intents and purposes, Plavix is a drug to be initiated on the inpatient. Now, if they're already on it for stents (in which case surely they aren't "low risk" as in your hypothetical situation) then I'll make sure they've gotten their daily dose of 75mg.

If you look at the ACC/AHA 2007 guidelines (link to executive summary) they say the following:
"Clopidogrel (loading dose followed by daily maintenance dose) should be administered to UA/NSTEMI patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance."

Now "loading dose" is also changing. Right now consensus is probably 600 mg of plavix and there is some evidence to suggest that 900 mg is even better.

In your case if I was going to get troponins and rule-out the patient then I would give the plavix. If I felt that the patient was so low risk that I just got an EKG and chest-xray and did not do blood work then I would not give the plavix.

 

[bulgethetwine]

If you look at the ACC/AHA 2007 guidelines (link to executive summary) they say the following:
"Clopidogrel (loading dose followed by daily maintenance dose) should be administered to UA/NSTEMI patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance."

Now "loading dose" is also changing. Right now consensus is probably 600 mg of plavix and there is some evidence to suggest that 900 mg is even better.

In your case if I was going to get troponins and rule-out the patient then I would give the plavix. If I felt that the patient was so low risk that I just got an EKG and chest-xray and did not do blood work then I would not give the plavix.

You do well quoting the ACC/AHH guidelines -- but you've reached a little.

The key phrase in the guidelines is those with UA/NSTEMI. Those people, if aspirin intolerant, do get plavix, although I would add that in practice it often becomes an inpatient initiated drug depending on the input of the interventionist who might potentially cath the patient, and the clinician who may have to do a CABG.

But the case in the OP's scenario -- a low risk patient otherwise allergic to aspirin -- doesn't automatically qualify as "unstable angina" in my book.

 

[southerndoc]

But the case in the OP's scenario -- a low risk patient otherwise allergic to aspirin -- doesn't automatically qualify as "unstable angina" in my book.

I give it to UA/NSTEMI, but for those having STEMI who are destined for the cath lab, I hold it and let the cardiologists give it when the stent is deployed. Nothing is more harmful to a patient than someone who gets clopidogrel in the ED, goes to the cath lab, and needs an emergent CABG for triple vessel disease. It means the patient either gets platelets or they wait 5 days.

Forgive me if I'm uninformed, but to my knowledge there is no data on mortality benefits with giving clopidogrel early (e.g., prior to stent deployment). I am aware of the data supporting its use in UA/NSTEMI in patients not going to the cath lab immediately.

 

[Jeff698]

I don't. I don't think the benefits outweight the risk when given in the ED. We don't give it to our STEMIs either at our (very aggressive) cardiologist's request.

They are concerned that if they get in and find multi-vessel disease that needs emergent CABG they now either delayed the surgery or dramatically increased the risks if the surgery is absolutely necessary now.

Take care,
Jeff

 

[bulgethetwine]

I don't. I don't think the benefits outweight the risk when given in the ED. We don't give it to our STEMIs either at our (very aggressive) cardiologist's request.

They are concerned that if they get in and find multi-vessel disease that needs emergent CABG they now either delayed the surgery or dramatically increased the risks if the surgery is absolutely necessary now.

Take care,
Jeff

That is why I think that Plavix is, in effect, an in-patient drug. I'm not saying I would never give it -- with time and experience has come a loosening of "dogmatic" practice in my habits -- but it would be a very unique set of circumstances -- true NSTEMI, aspirin allergic, in consultation with cards.... it would have to be an almost perfect alignment.

 

[roja]

I wouldn't give plavix either in this patient. loading or either. 1- this patient doesn't meet the 'criteria' (if you go with the criteria). 2- the data is not that great. The plavix people quote RRR (not ARR) and the NNT is pretty ridiculous.

 

[WilcoWorld]

Do any of you give Asprin AND Plavix, or are you all reserving Plavix for the ASA allergic?

 

[basementbeast]

hey guys, that's for the perspectives!👍

 

[bluejay68]

For STEMI patients going to cath, I usually give ASA 325mg and Plavix 300mg. The data that shows increased risk of bleeding during/post CABG with Palvix is based on a bleeding score that the authors of that particular paper made up on thier own, not the TIMI major/minor bleeding scores that are routinely used in the literature.

If you look at Plavix using TIMI major/minor bleeding scores, there was no increase in TIMI major bleeding at CABG (TIMI minor increase only). My opinion is that the data for Plavix benefiting these patients is real, and if there is no increase in significant bleeding at CABG (which is what the data show), then we should be giving it. The Cardiac Surgeons have been slow to come around on this, but I think giving Plavix will become more accepted in the next few years (it remains somewhat institution-specific based on input from Cards, Cardiac Surgery and EM). For unstable angina patients who cannot take aspirin for one reason or another, I'll give PLavix 75mg.

 

[southerndoc]

For STEMI patients going to cath, I usually give ASA 325mg and Plavix 300mg. The data that shows increased risk of bleeding during/post CABG with Palvix is based on a bleeding score that the authors of that particular paper made up on thier own, not the TIMI major/minor bleeding scores that are routinely used in the literature.

If you look at Plavix using TIMI major/minor bleeding scores, there was no increase in TIMI major bleeding at CABG (TIMI minor increase only). My opinion is that the data for Plavix benefiting these patients is real, and if there is no increase in significant bleeding at CABG (which is what the data show), then we should be giving it. The Cardiac Surgeons have been slow to come around on this, but I think giving Plavix will become more accepted in the next few years (it remains somewhat institution-specific based on input from Cards, Cardiac Surgery and EM). For unstable angina patients who cannot take aspirin for one reason or another, I'll give PLavix 75mg.

I didn't realize the data was there to show that giving clopidogrel in the ED v. stent deployment significantly improved mortality.

Are you sure that the 30-60 minute difference in giving it early in the ED is actually statistically significant?

I've heard others say that they do it because they "think it improves mortality," but who also say it's anecdotal evidence when the cardiothoracic surgeons say they have more bleeding complications and patients require more packed reds in the OR during their CABG. We all know that increased packed red cells increases your risk of ARDS and other complications.

 

[GeneralVeers]

I give 300 mg loading dose to all patients who I am admitting for NSTEMI or unstable angina. Aspirin allergy shouldn't make a difference.

I also don't care if they get GI intolerance. If they start vomiting or get stomach pain, it's better than their coronaries re-occluding.

 

[southerndoc]

I give 300 mg loading dose to all patients who I am admitting for NSTEMI or unstable angina. Aspirin allergy shouldn't make a difference.

I also don't care if they get GI intolerance. If they start vomiting or get stomach pain, it's better than their coronaries re-occluding.

I also give to NSTEMI's, but don't for STEMI's.

On another note: how many of you guaiac before administering heparin (as we're supposed to do), and how many will withhold heparin in an NSTEMI/STEMI when the stool is guaiac positive?

 

[GeneralVeers]

I also give to NSTEMI's, but don't for STEMI's.

On another note: how many of you guaiac before administering heparin (as we're supposed to do), and how many will withhold heparin in an NSTEMI/STEMI when the stool is guaiac positive?

I posed this question a few months ago on this forum after an attending told me it was REQUIRED to do this. There was no consensus, however it seemed like we could all agree that it's reasonable to check on someone at high risk for GI bleed (alcoholic, really old person). We all did agree that in the presence of heme positive stool that none of us would withhold Plavix or Lovenox.

 

[roja]

Required? your kidding? oh my. I would say that almost nothing is 'required' there are relative contra-indications. And although we always talk about 'absolute' contraindications, I guarantee someone can come up with a case where there were enough mitigating factors to over-ride those.


Heme positive brown stool is not a contraindication to heparin in a STEMI/Non-STEMI. Its nice for the people following to know what hte state was to monitor it. But unless they are pouring blood from the rectum, I think that the MI is probably going to kill them before there heme positive brown stool.

But that's just me, and I'm punchy because I haven't had coffee.

 

[Jeff698]

We all did agree that in the presence of heme positive stool that none of us would withhold Plavix or Lovenox.

That really begs the question, then, why do it at all if it isn't going to change what you do?

I may buy Roja's "so the team upstairs will know to monitor it" but they'll be monitoring it anyway.

Take care,
Jeff

 

[bulgethetwine]

I posed this question a few months ago on this forum after an attending told me it was REQUIRED to do this. There was no consensus, however it seemed like we could all agree that it's reasonable to check on someone at high risk for GI bleed (alcoholic, really old person). We all did agree that in the presence of heme positive stool that none of us would withhold Plavix or Lovenox.

With youth comes dogmatism.

I agree with Roja. Contra-indications exist, but phrases like 'REQUIRED' and 'ALWAYS' and 'NEVER' are usually the writ of an administrator. That's why we usually have guidelines as opposed to regulations. Most of the time.😉

 

[GeneralVeers]

That really begs the question, then, why do it at all if it isn't going to change what you do?

I may buy Roja's "so the team upstairs will know to monitor it" but they'll be monitoring it anyway.

Take care,
Jeff

That's exactly the question I ask before almost every rectal exam. How is this going to change my management?

 

[roja]

That really begs the question, then, why do it at all if it isn't going to change what you do?

I may buy Roja's "so the team upstairs will know to monitor it" but they'll be monitoring it anyway.

Take care,
Jeff

My personal opinion on this is that they are monitoring it upstairs and really, its not changing anything I do. However, we all work together, and if it makes things smoother in terms of my relationships upstairs, I will go ahead and do it. For me, it becomes a 'picking my battles' kind of thing. The rectal makes it easier for you upstairs? fine. I can do that pretty easy. (its a monster in our hospital for guiacs to get done ont he floors.) I don't think it matters much really, but its makes the day easier and I have more important battles to fight. Just my general approach. 🙂

 

[WilcoWorld]

It will change your management when your finger comes out dripping with melana or bright red blood. I recognize that significant GI bleeds should pretty much all be evident on ROS, but it is possible that you'd only pick it up on physical exam, and frank melan or a brisk bleed would change my management.

I must admit, however, I hate having the "I'm concerned about your heart, so I need to stick a finger in your butt" conversation.

 

[docB]

I don't give it to the routine rule outs, so-so story, neg trop, non diagnostic EKG. For the NSTEMIs I put the question to the cardiologist. That way if there's an angry CT surgeon looking for someone to bitch at (which as far as I can tell takes up about 50% of the working day for the average CT surgeon) the cardiologist has to justify the Plavix load.

 

[waterski232002]

To respond to the OP's question.... I agree that there is a big difference between the "low risk patient" you ask about, and the ACC/AHA guidelines which advocate the use of ASA or Plavix for UA/NSTEMI. Personally, I wouldn't give plavix to the low risk patient because these people are just that... low risk. And we see so many low risk patients every day in the ER and the vast majority end up being nothing. In fact, when they're low risk, I usually have an alternative diagnosis like GERD, MS pain, asthma, bronchitis, dehydration, etc... and I'm getting the EKG and/or enzymes just to re-assure myself. I'd rather start treating their real problem... Acid reflux or MS pain. Unstable angina is very specific... CP of cardiac origin which has acutely worsened, is present at rest, is not relieved by SL nitro, or lasts for longer than 20 min. These people would get plavix (as an asa substitute), and also a heparin gtt in addition to the usual cocktail of nitro, morph, beta blockers.

Me being a hypocrite... I'd dispense an ASA like candy for low risk CP, but b/c of my own personal bias I wouldn't dispense plavix so liberally.

As far as plavix before a potential CABG. We give all our STEMI's a plavix loading dose of 600mg where I work. The reason why (according to cardiology) is because patients who come in with an acute STEMI have an inciting lesion, and even if they have 3 vessel disease, they will stent the single stenotic lesion responsible for the current infarct, then the patient can wait 5 days for their CABG and have it done on a non-emergent basis.

 

[basementbeast]

great discussion....i brought it up since i seem to be on a chest pain run at work and had seen a lot of "i get anaphylaxis when i take asa" or other such reactions....

 

[docB]

Me being a hypocrite... I'd dispense an ASA like candy for low risk CP, but b/c of my own personal bias I wouldn't dispense plavix so liberally.

I'm the same way. Why are we like that? Is it justified? It might be just based on the expense.

 

[basementbeast]

another thing...and this may be more along the lines treating myself as opposed to the patient.....these low risk patients, pain is now gone...i may end up administering --- NOTHING! ntg ordered PRN perhaps...