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Long-Term Use of Ticagrelor in Patients with Prior Myocardial Infarction

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Well hello everyone i am fayian correa and today i’m going to talk about long-term use of chicago in patients with pre-order meocalical infraction in the first the definition er the first we have to know mercurical infraction is a global problem the the schema cardiomyopathy patients who had a hair attack have a higher risk of recurring ischemic event which

Suggests that this population may obtain benefits from intensive second prevention hi i’m dr prabhakar shetty i am chief of cardiology at columbia sheriff hospital national bangalore cardiomyopathy refers to weakening of the heart muscle due to blockage of the coronary arteries so this is usually a patient’s develop heart attacks and more than one attack or

Blockage of more than one coronary artery leads to depression of the heart muscle function and this is actually measured by ejection fraction ejection fraction refers to the volume of blood ejected by the heart during each heartbeat normally this is around 55 to 65 percent that is if the heart volume is 100 ml 65 ml or 60 ml of blood is ejected in a normal

Healthy heart this is called ejection flexion and and in patients with depressed heart function this is depressed so it will be lower than 55 so in ischemic empathy for example patients may have an injection fashion like 25 30 or 40 percent well applications in medicine a key element in excrement heart disease is on unstable anteromatous plague on pilot

Aggregation aspirin p2y 12 antagonists such as ticarilor have been shown to reduce the risk of ischemic events in the first year after acute coronary syndrome cells predominate in the axial stream while the biconvex disc shaped platelets are marginated along the vessel wall where they are well positioned to monitor the integrity of the endothelium the normal

Endothelium provides a non-adhesive surface to circulating platelets however when vessel wall injury occurs for example by cutting or severing of a vessel or as shown here by a puncture and there is endothelial damage the initial response of platelets is that of adhesion to collagen fibers in the exposed sub-endothelium collagen is one of the most thrombogenic

Components of the sub-endothelial matrix responsible for the initiation of platelet adhesion a number of adhesive receptors on the platelet surface membrane interact either directly or indirectly with collagen initial binding of platelets is considered to occur via the integrin alpha-2 beta-1 gp1a2a receptor which allows for further binding to collagen via the

Gp6 receptor initiating transmembrane and subsequently intracellular signaling adhesion of platelets to the exposed subendothelium is influenced by shear rates at high shear alpha 2 beta 1 and gp6 are not sufficient to initiate binding to collagen and binding of the gp1b95 receptor to von willebrand factor abbreviated here as vwf that is immobilized on collagen

Becomes essential in platelet adhesion platelet adhesion at the site of vessel wall damage initiates activation events that result in aggregation adherent platelets undergo a dramatic shape change to an irregular sphere with multiple philly podia spreading on the sub endothelium increasing their area of surface contact adherent platelets also secrete or release

The contents of their storage granules the alpha and dense granules by an exocytic process this provides a high local concentration of effector molecules essential for platelet plug formation at the cytovascular injury for example the aggregating agent adp is released from the dense granules platelet activation stimulates the formation of another aggregating

Agent thromboxane a2 abbreviated here as txa2 via the arachidonic acid cascade details are shown in figure 26.5 the most potent platelet aggregating agent thrombin shown here as factor 2a is formed via the coagulation pathway from prothrombin or factor 2 on the pro coagulant surface of the activated platelet details are shown in figure 26 6. adp thromboxane

A2 and thrombin bind to specific platelet membrane receptors and stimulate aggregation on and around the platelets adherent to the subendothelium via receptor-mediated signal transduction events aggregation is an active metabolic process binding of any of the agonists to their respective membrane receptors initiates signaling pathways that ultimately convert

Integrin alpha 2b beta 3 or gp2b3a from a low affinity resting state to a high affinity activated state for binding extracellular soluble ligands such as plasma fibrinogen and von willebrand factor fibrinogen is shown here the transmission of an intracellular signal leads to disruption of the complex between the cytoplasmic tails of alpha 2b beta 3 followed by a

Conformational change in its extracellular globular head domains from a bent to an extended state promoting the binding to fibrinogen and the platelets membrane receptors result in cascade of reactions which lead to activation of gp2 b3 a fibrogenic receptors which in turn bind to fibrin strands that connects the blade together in the cloth additionally thromboxane

Produced by cox-1 enzyme also activates fibrinogenic receptors let’s now have a look at the three major antiplatelet groups a blocking of adp receptors will indirectly inhibit the activation of fibrinogenic receptors thus platelet will not be able to bind to fibrin and the platelet aggregation will be interrupted famous example of this group is clobidogrel on

The other hand a reversible inhibition of thromboxine by aspirin will hold fibrinogenic receptor activation finally fibrinogenic receptor inhibitors such as absciximab are monoclonal antibodies that are directly blocked the receptors and inhibit fibrin binding continue with pros and cons cross reduce the risk of suffering on this gaming event again in the short

On long term overall i tend to lean towards what the european society cardiology guidelines recommend where a preference is given to extended patients uh to peraza girl or tech cagure over clip integral first uh so in this country since uh there’s there’s not socialized medicine and affordability is is an issue or more or less universal healthcare and affordability

Is an issue uh if a patient can take a twice a day regimen uh and their insurance will pay for it i would give preference to utilizing that category because that’s what the question was about initially uh and then if they tolerated the first 12 months without complications and they have elevated risk for subsequent mis maybe this is not their first mi are they

Continuing to smoke are they a diabetic in those types of patients i would consider continuing on tychargalore in the long term however if the patient was started on clopidogrel additionally tolerated the first 12 months did not have another event i don’t have the best data to say well at that point in time am i better off switching them from looking at a girl to

Technical so it’s kind of up to the clinician in the second place cons due to very mechanisms of action of these drugs it is known that there is a greater risk of bleeding and disorders of blood cells and the reputation gastrotoxic effect issue applied inequality the price of ticker lore and the other anti-pilot agents in this family are too high for consumer

Or emergency use in conclusions the addition of thicker allure at a dose of 90 milligrams trace deal daily or 60 milligrams twice daily to long those aspirin reduce the risk of cardiac cardiovascular death muchaca infraction or stroke and increasing the risk of timing major bleeding among patients who had a meocarical infraction one to three years earlier thanks

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Long-Term Use of Ticagrelor in Patients with Prior Myocardial Infarction By Fabián Correa