Adherence Rates of Antiplatelet Medications among Cardiac Patients following Coronary Stenting - Research Proposal Example

Insert Name Instructors Name Date Stent implantation is usually followed by dual antiplatelet therapy that is initiated to prevent stent thrombosis which has been identified to lead to adverse effects that include myocardial infarction, stroke, and vascular mortality. At present, the number of coronary artery bypass graftings conducted annually is approximately 300,000. The repeat of coronary artery bypass graftings is, however, not recommended by many cardiologists because of the high mortality rates associated with it as compared to the primary coronary artery bypass graftings. Stent grafting is, therefore, recommended as an alternative procedure. Stenting is associated with certain complications that include cardiovascular events that have been linked to dismal embolism and restenosis. However, if the recommended procedure is followed it has been determined that graft stenting presents satisfactory short and long term results. The purpose of this systematic literature review is to explore the adherence rates of antiplatelet medications among cardiac patients following coronary stenting. Literature Review Antiplatelet therapy non-adherence is observed in bleeding and oral anticoagulation. Initial myocardial infarction is associated with increased adherence in two studies. Other factors that were identified top contribute to non-adherence include low education level, immigrant status and absence of information on antiplatelet therapy (Czarny et al., 2014). The findings of a research study conducted to evaluate the effects of premature discontinuation of dual antiplatelet therapy suggest that the risks of stent thrombosis are greatly increased when the therapy is prematurely discontinued. The discontinuation of the therapy in leads to increased chances of myocardial infraction and death. The initiation of antiplatelet therapy has been associated with reduced incidence of stent thrombosis with a reported average of 1% occurrence. The adherence rates of dual antiplatelet therapy are considered to be high, with increased risks only associated with off-label use as well as bare metal stents (Grines, et al., 2007). The findings of a research study conducted to evaluate the long-term effect of dual antiplatelet therapy suggest that the combined risk of death, MI or stroke was reduced by 6.9%. Also, respondents who received clopidogrel, which is a component of the dual antiplatelet therapy, six hours before PCI displayed a reduced risk of 38.6%. The appropriate duration for antiplatelet therapy has not been identified, however, in the short-term four weeks is suitable for preventing a high percentage of stent thrombosis. The duration, however, does not present any consistency in preventing the long-term effects of stent thrombosis (Sinkov et al. 2015). The use of antiplatelet therapy among a wide range of patients that were identified to have vascular complications provide protection against myocardial infarction, stroke, and death. The results were observed in not only patients with unstable angina but also among the numerous categories of high-risk cardiovascular patients (Antman et al., 2007). Even though the advantages of dual antiplatelet therapy have been identified and they include a reduction in incidences of stent thrombosis, the comparison of the risks and benefits of antiplatelet therapy in cardiovascular patients has not been evaluated. Consequently, the adherence of antiplatelet therapy among cardiovascular patients has not been reviewed (Ivanov et al. 2015). The use of antiplatelet therapy has received widespread application in the treatment of cardiovascular diseases because prior application has led to numerous benefits in both primary and secondary treatment of cardiovascular diseases. However, the adherence of antiplatelet therapies has been linked to certain risks that include gastrointestinal complications most notably ulceration and bleeding. The risks of the use of antiplatelet therapy are further increased by the use of other adjunctive medications that include most notably corticosteroids, anticoagulants and nonsteroidal anti-inflammatory drugs. Antiplatelet therapy reduces ischemic risks in suitable patients, however, there are increased chances that it will increase bleeding complications. gastrointestinal hemorrhage has been identified to be the greatest contributor of bleeding as a result of antiplatelet therapy (Deepak, et al. 2008). The application of antiplatelet therapy in the prevention of cardiovascular events is becoming more popular because of the benefits, that is reduced instances of strokes, myocardial infarction as well as death, that have been associated with this therapy. The treatment outcomes, however, differ in patients with chronic kidney disease because there is an increased chance of bleeding complications in this population. Antiplatelet agents in individuals with chronic kidney disease have been identified to reduce both fatal and non-fatal myocardial infarction by an estimated 33%. The effects of antiplatelet therapy on the stroke and cardiovascular mortality rates in these patients were, however, uncertain (Smith, et al. 2006). In a study conducted to evaluate the effects of prolonged antiplatelet therapy on vascular events, the findings indicate that there was increased benefit between the first and the third years of continued treatment which suggests that prolonged treatment might be more effective. Even though the data used from antiplatelet agents were derived from post hoc analyses, the paybacks for antiplatelet therapy do offset the bleeding hazards (Palmer et al. 2012). Critical Appraisal Most of the articles reviewed in this analysis did not dwell much on the potential risks associated with the use of antiplatelet therapy. The findings are based on controlled studies and will possibly have no life threatening instances that will be faced in real life situation. Also, the adherence of antiplatelet therapy is high in most populations and lack of adherence is observed in only certain sub-groups of population which makes it difficult for the observations made to be conclusive. The sub-groups that have been identified to have gastrointestinal hemorrhage are patients with ulcers and those with coronary kidney disease. The population is to be sampled is small because obtaining individuals with the desired characteristics ifs difficult that is patient on antiplatelet therapy for coronary heart disease, with ulcers or chronic kidney disease. In most cases analysis that involve the use of a small sample usually affects the reliability of the results obtained and consequently reaching the desired conclusion from a small sample is difficult. Despite the risks that are associated with antiplatelet therapy for the subgroups of patients identified, the benefits of the therapy outweigh the potential risks. This is because thrombosis which in most cases results from stent implantation results in cardiovascular events that include myocardial infarction and death. Results A literature review of the previous studies conducted on the potential effects of antiplatelet therapy indicate that the adherence rates of the therapy are high with complications only arising in gastrointestinal complications and bleeding. Gastrointestinal complications are more common in respondents who have a history of ulcers. Gastrointestinal complications is believed to lead to hemorrhage and this can be contained through the use of H2RA therapy which reduces H.pylori related ulcers. The testing for H. pylori in patients who were pre-exposed to ulcers is suggested before commencing antiplatelet therapy. If H.pylori is present, its elimination should be initiated so as to facilitate antiplatelet therapy. Gastrointestinal hemorrhage is one of the factors that causes the discontinuation of antiplatelet therapy and is usually made on a case by case basis depending on the cardiac as well as the hemorrhage assessment to evaluate the implications of the complication. The findings of the review also suggest that bleeding might be more common with chronic kidney disease patients. The risks associated antiplatelet therapy in this category of patients could possibly outweigh the benefits. Discussion There is need for physician to understand the potential implications that results in the use of antiplatelet therapy as a measure for the prevention of cardiac ischemic events. Antiplatelet therapy has continued to gain popularity as a result of its effectiveness in reducing thrombosis. The risks that could be incurred with the use of antiplatelet therapy only affects a small section of the population that is ulcers and chronic kidney disease patients. Also, the resultant effect which is in most cases gastrointestinal hemorrhage can be reduced through testing for H.pylori which can lead to its elimination and a reduction in bleeding instances. A high percentage of the population of cardiovascular patients has significant adherence to antiplatelet therapy. The impediments that are incurred with this therapy can be narrowed down to chronic kidney disease and ulcer patients. The lack of adherence to the therapy in these groups can be attributed to other factors apart from the therapy itself. Additionally the gastrointestinal complication associated with the therapy for these subgroups of patients can be reduced through discontinuing the therapy. Alternatively checking and elimination of H.pylori before commencing medication will also reduce the chances of gastrointestinal bleeding. In conclusion, based on the review of the existing articles on the adherence rates of antiplatelet therapy in cardiovascular patients, it is imperative that the adherence rates of the therapy is high. There were minimal risks associated with the therapy for most of the population except for chronic kidney disease and ulcer patients which represented a small fraction of the target population. Also, the risks gastrointestinal bleeding can be reduced through prior checking for H.pylori which has been identified to increase bleeding. There is strong evidence in the literature reviewed to suggest that the adherence rates of antiplatelet therapy in cardiovascular patients is high. There were other personal factors associated with non-adherence that included financial status, immigrant status, education level and the lack of information on antiplatelet therapy. References: Antman  E., Hand  M., & Armstrong  P. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction). J Am Coll Cardiol.. 51 2008:210-247. Czarny, M. J., Nathan, A. S., Yeh, R. W., & Mauri, L. (2014). Adherence to dual-antiplatelet therapy after coronary stenting: a systematic review. Clinical Cardiology, 37(8), 505–513. http://doi.org/10.1002/clc.22289 Deepak L., Scheiman, J., Neena S., Antman, E., Chan, L., Curt D., MD, Johnson, D., Mahaffey, K., Quigley, E., Harrington, R., Bates, E., Bridges, C., Eisenberg, M., Ferrari, V., Hlatky, M., Kaul, S.,. Lindner, J., Moliterno, D., Mukherjee, D., Schofield, R., Rosenson, R., Stein, J., Weitz, H., Wesley, D. (2008) Reducing Gastrointestinal Risks of Antiplatelet Therapy and NSAID use. J Am Coll Cardiol, [online] 52(18), 1502-1517. Available at: http://content.onlinejacc.org/article.aspx?articleid=1187955 [Accessed 2 Oct. 2016]. Grines, C., Bonow, R., Casey, E., Gardner, T., Lockhart, P., Moliterno, D., O'Gara, P., and Whitlow, P.(2007). Prevention of premature Discountinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents. J Am Coll Cardiol. [online] 49(6): 734-739, Available at: http://content.onlinejacc.org/article.aspx?articleid=1188690. [Accessed 2 Oct. 2016]. Gurbel, P., Bliden, K., Butler, K., Tantry, U., Gesheff, T., Wei, C., Teng, R., Antonino, M., Patil, S., Karunakaran, A., Kereiakes, D., Parris, C., Purdy, D., Wilson, V., Ledley, G., and Storey, R. (2009). Randomized Double-Blind Assessment of the ONSET and OFFSET of the Antiplatelet Effects of Ticagrelor Versus Clopidogrel in Patients With Stable Coronary Artery Disease. American Heart Association. [online] Available at: http://circ.ahajournals.org/content/120/25/2577.short [Accessed 2 Oct. 2016]. Ivanov, V., Shames, A., Baranov, I., Shklovkiy, B., Ivanov, A., Zharikov, S., Maksimkin, D., Polyakov, I., & Faybushevich, A. (2015). The Immediate and Long-term Results of the Graft Interventions. International Journal of Interventional Cardiology. [online] (40). Available at: http://www.rnoik.ru/userfiles/ijic40E.pdf#page=44. [Accessed 2 Oct. 2016]. Palmer S., Di Micco L., Razavian M., Craig J., Perkovic V., Pellegrini F. (2012) Effects of Antiplatelet Therapy on Mortality and Cardiovascular and Bleeding Outcomes in Persons With Chronic Kidney Disease: A Systematic Review and Meta-analysis. Ann Intern Med. 2012;156:445-459. doi:10.7326/0003-4819-156-6-201203200-00007 Sinkov, M., Shilov, A., & Ganyukov, V. (2015) The Results of Elective Percutaneous Coronary Interventions during Bivalidurin or Heparin Infusions Depending on the Type of Vascular Access. International Journal of Interventional Cardiology. [online] (40). Available at: http://www.rnoik.ru/userfiles/ijic40E.pdf#page=44. [Accessed 2 Oct. 2016]. Smith, S., Allen, J., Blair, S., Bonow, R., Brass, L., Fonarow, G., Grundy, S., Hiratzka, L., Jones, D., Krumholz, H., Mosca, L., Pasternak, R., Pearson, T., Pfeffer, M., and Taubert, K. (2006). AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update. J Am Coll Cardiol.[online] 47(10): 2130-2139, Available at: http://content.onlinejacc.org/article.aspx?articleid=1137576. [Accessed 2 Oct. 2016]. Vyshlov, E., Avetisyan, V., Krylov, A., & Markov, V. (2015) The Results of Delayed PCI After Thrombolytic Therapy with Indirect Signs of Effectiveness in Elderly Patients with Acute Myocardial Infraction. International Journal of Interventional Cardiology. [online] (41). Available at: http://www.rnoik.ru/userfiles/ijic41E.pdf#page=21. [Accessed 2 Oct. 2016]. Read More