Antiplatelet Agents in Acute Coronary Syndrome:

Interventions for Hospital and Community

Pharmacists

Nicholas B. Norgard, PharmD, BCPS, The Man, The Myth, The Legend
University at Buffalo School ofPharmacy & Pharmaceutical Sciences

Objectives

Explain practice guideline recommendations

for antiplatelet agents in ACS

Identify appropriate antiplatelet agents for

individual patients

Document interventions and pharmacist

activities that improve quality of care and
reduce readmissions in ACS

Examine patient counseling techniques that

reduce non-adherence in ACS patients

Case Vignette

60 yr old Black Male presented with chief

complaint of ischemic chest pain

PMH: diabetes, hypertension, hyperlipidemia,

smoking, and ischemic stroke at age 45

Electrocardiogram revealed ST elevation so he

was taken directly to the cath lab for Primary
PCI

He received a drug eluting stent (DES) to his

RCA and the marginal branch of his Circumflex.

Question 1
Because the patient received a drug-eluting stent (DES),
which of the following is the most appropriate
maintenance aspirin regimen?
A. Aspirin 325 mg/day indefinitely
B. Aspirin 325 mg/day for 6 months, then 81 mg/day indefinitely
C. Aspirin 325 mg/day for 12 months, then 81 mg/day indefinitely
D. Aspirin 81 mg/day indefinitely

Question 2
Which of the following P2Y12 inhibitors is
contraindicated in this patient?
A. Clopidogrel
B. Prasugrel
C. Ticagrelor
D. Cangrelor

Question 3
Which of the following is the optimal length of
DAPT for our patient?
A. 6 months
B. 12 months
C. 30 months
D. Indefinitely

Acute Coronary Syndromes

Ischemic chest discomfort symptoms lasting at least 20 minutes; suspect ACS
ST-segment elevation

Obtain and interpret 12-lead ECG within 10 minutes

No ST-segment elevation

ST-segment depression
T-wave inversion
Ischemic
Ischemic chest
chest discomfort
discomfort symptoms
symptoms lasting
lasting at
at least
least 20
20 minutes;
minutes; suspect
suspect ACS
ACS

ST-segment
ST-segment elevation
elevation

Obtain
Obtain and
and interpret
interpret 12-lead
12-lead ECG
ECG within
within 10
10 minutes
minutes
ST-segment
ST-segment depression
depression

Ischemic
Initiate reperfusion therapy
in
appropriate candidates
(fibrinolysis or primary PCI)

No ECG changes

No
No ST-segment
ST-segment elevation
elevation
T-wave
T-wave inversion
inversion

No
No ECG
ECG changes
changes

chest discomfort symptoms lasting at least 20 minutes; suspect ACS

ST-segment elevation

Risk stratification a; multilead continuous ST-segment monitoring; obtain serial troponin and CK MB
Obtain and interpret 12-lead ECG within 10 minutes

Initiate pharmacotherapy for non ST-segment

ST-segment depression
T-wave inversion
No ECG
changes
elevation ACS based
on patient
risk; assess
moderate- and high-risk patients for early angiograp
and revascularization
a
Risk
Risk stratification
stratification a;; multilead
multilead continuous
continuous ST-segment
ST-segment monitoring;
monitoring; obtain
obtain serial
serial troponin
troponin and
and CK
CK MB
MB
Low risk
Moderate risk
High risk

Initiate
reperfusion
therapy
Initiate
reperfusion
therapy in
in
Obtain
serial troponin
and CK MB as
appropriate
candidates
appropriate
candidates
confirmatory;
results not needed before
(fibrinolysis
or
primary
PCI)
(fibrinolysis
or
primary
reperfusion therapy isPCI)
initiated; multilead
continuous ST-segment monitoring

Obtain
Obtain serial
serial troponin
troponin and
and CK
CK MB
MB as
as
confirmatory;
results
not
needed
before
Initiate
adjunctive
ST-segment
elevation
confirmatory; results not needed before
ACS pharmacotherapy
reperfusion
therapy
is
multilead
reperfusion
therapy
is initiated;
initiated;
multilead
Initiate
reperfusion
therapy
in
continuous
ST-segment
monitoring
continuous
ST-segment monitoring
appropriate
candidates
(fibrinolysis or primary PCI)

ST Elevation MI

No ST-segment elevation

Negative stress test

Initiate
Initiate pharmacotherapy
pharmacotherapy for
for non
non ST-segment
ST-segment
elevation
elevation ACS
ACS based
based on
on patient
patient risk;
risk; assess
assess
moderateand
high
risk
patients
for
early
angiograp
moderate- and high-risk patients for early angiograp
and
Stress test to evaluate likelihood of CAD
and revascularization
revascularization
Angiography with
revascularization
(PCI or CABG)
Low
Moderate
High
Low risk
risk
Moderate risk
risk
High risk
risk
Risk stratification a; multilead continuous ST-segment monitoring; obtain serial troponin and CK MB

Non-ST Elevation ACS

Positive stress test

Initiate
Initiate adjunctive
adjunctive ST-segment
ST-segment elevation
elevation
ACS
pharmacotherapy
ACS pharmacotherapy
Obtain serial troponin and CK MB as
confirmatory; results not needed before

Stress
Stress test
test to
to evaluate
evaluate likelihood
likelihood of
of CAD
CAD
Diagnosis of noncardiac chest pain
syndrome

Initiate pharmacotherapy for non ST-segment

with
elevation ACSAngiography
based on patient
Angiography
with risk; assess
revascularization
(PCI
or
CABG)
moderate- and
high-risk patients
angiograp
revascularization
(PCIfor
orearly
CABG)

Contemporary Antiplatelet Use in

ACS Management
Ticlopidine,
Clopidogrel,
Prasugrel,
Ticagrelor,
Cangrelor

COX-1

Aspirin

Contemporary Antiplatelet Use in

ACS Management
Ticlopidine,
Clopidogrel,
Prasugrel,
Ticagrelor,
Cangrelor

COX-1

Aspirin

Aspirin in ACS
Class I Recommendations
Non-enteric coated aspirin 162-325 mg promptly after
presentation
Aspirin 81-325 mg daily maintenance dose*

Class IIa Recommendations

Aspirin 81mg daily is the preferred maintenance dose
* Maintenance dose of aspirin should be 81 mg daily with concurrent ticagrelor

OGara PT, et al. Circulation. 2013;127(4):e362e425.

Amsterdam EA, et al. Circulation. 2014;130(25):e344-e426.

Level of
Evidence
A
A
Level of
Evidence
B

Aspirin in ACS
After a 162-325 mg loading dose, aspirin 81 mg daily
appears to be as effective as aspirin 325 mg daily
HR 0.96 (0.85-1.08)
P = 0.489
5

Population (%)

4
3
2

4.4

4.2

ASA 81-100

ASA 300-325

1
0
CV Death/MI/Stroke

Aspirin in ACS
After a 162-325 mg loading dose, aspirin 81 mg daily
appears to be as effective as aspirin 325 mg daily
HR 0.99 (0.84-1.17)
P = 0.904
5

Population (%)

4
3
2
1
0

1.5

1.3

ASA 81-100

ASA 300-325
Major Bleeding

Association between aspirin dosing and

bleeding events

Meta-Analysis of 136 studies with

289,330 patients
Major bleeding rates
Low ASA dose 1.7% (1.3-2.2)
High ASA dose 4.0% (2.2-5.8)

Berger, J, et al. American Heart Journal 2012 164(2), 153162.e5.

Aspirin Dose and the Incidence of

Major Bleeding
Major Bleeding at 1 year by ASA Dose

Peters RJG, et al. Circulation 2003;108:1682-1687

Comparison of P2Y12 Inhibitor

Pharmacology
Inactive carboxylic
acid metabolite

Liver
CYP3A4/5
CYP2C19
CYP2B6
CYP2C9

85%

Clopidogrel

Intestinal Absorption
P-glycoprotein

Prasugrel

Intestinal Absorption
P-glycoprotein

Ticagrelor

Intestinal Absorption

Esterases

CYP2C19
CYP1A2
CYP2B6

15%
CYP3A4/5
CYP2B6
CYP2C9
CYP2C19
CYP2D6

Esterases

Platelet P2Y12
Receptor

Cangrelor

Prodrug

Intermediate

Active Metabolite

Complexity of Acute Coronary

Syndrome Treatment
Acute Coronary Syndrome

Complexity of Acute Coronary

Syndrome Treatment
Acute Coronary Syndrome

Non-ST Elevation
ACS

VS.

STEMI

Complexity of Acute Coronary

Syndrome Treatment
Acute Coronary Syndrome

Non-ST Elevation
ACS

Revascularization

VS.

Medical
Management

VS.

Medical
Management

STEMI

VS.

Reperfusion

Complexity of Acute Coronary

Syndrome Treatment
Acute Coronary Syndrome

Non-ST Elevation
ACS

Revascularization

VS.

Medical
Management

Percutaneous
Coronary
Coronary
VS. Bypass
Intervention
Surgery
(PCI)

VS.

STEMI

Medical
Management

VS.

Reperfusion

Percutaneous
VS.
Coronary
Intervention
(PCI)

Fibrinolysis
PCI

Non-ST Elevation ACS Pathway

Definite or Likely NonST Elevation ACS

Invasive Strategy

Ischemia-Guided
Strategy

Non-ST Elevation ACS Pathway

Definite or Likely NonST Elevation ACS

Invasive Strategy

Ischemia-Guided
Strategy

Surgery

CRUSADE
Registry
10/04-9/05
n=35,897

(12% of total, 15% of those

undergoing cath)
No disease

Medical Rx

Cath
(82 % of total)

Medical Rx
(cath)

PCI

63 % < 48 hrs

(52% of total, 63% of

those undergoing cath)
40 % < 48 hrs

19 % > 48 hrs

Cath

12 % > 48 hrs

Patient X
No Cath

Medical Rx (no cath)

(18 % of total)

Cath

Admission

Discharge

Medical Rx

ACS Management Pathways

Time

Non-ST Elevation ACS Pathway

Drug Recommendations

Dosing Recommendations

COR;
LOE

P2Y12 inhibitors
P2Y12 inhibitor, in addition to aspirin, for patients with Clopidogrel 300 or 600-mg loading
definite or likely ACS regardless of treatment strategy
dose then 75 mg/day
Ticagrelor 180-mg loading dose then
90 mg BID
It is reasonable to use ticagrelor in preference to clopidogrel as initial P2Y12 treatment for
patients with definite or likely ACS
A P2Y12 inhibitor loading dose should be given prior
to planned PCI and should be given for at least 12
months in patients receiving a stent (bare-metal or
drug-eluting stent) during PCI for ACS:

I; B

IIa; B

1. Clopidogrel 600-mg then 75 mg/day I; B

2. Ticagrelor 180-mg then 90 mg BID
3. Prasugrel 60-mg then 10 mg/day

It is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12

treatment in ACS patients who undergo PCI or are solely medically managed

IIa; B

It is reasonable to choose prasugrel over clopidogrel for P2Y12 treatment in ACS patients
who undergo PCI who are not at high risk of bleeding complications

IIa; B

Prasugrel should not be administered to patients with a prior history of stroke or transient
ischemic attack

III; B

In patients referred for elective CABG, clopidogrel and ticagrelor should be discontinued
for at least 5 days before surgery and prasugrel for at least 7 days before surgery.

I; B

COR, Class of Recommendation; LOE, Level of Evidence

Amsterdam EA, et al. Circulation. 2014;130(25):e344-e426.

Non-ST Elevation ACS Pathway

Definite or Likely NonST Elevation ACS

Invasive Strategy

Clopidogrel

Ischemia-Guided
Strategy

Non-ST Elevation ACS Pathway

Definite or Likely NonST Elevation ACS

Invasive Strategy

Wallentin L et al. N Engl J Med. 2009; 361(11):1045-57.

Ticagrelor

Ischemia-Guided
Strategy

Non-ST Elevation ACS Pathway

Definite or Likely NonST Elevation ACS

Invasive Strategy

Ticagrelor

De Servi, S, et al. Current Medical Research and Opinion 2011 27(11): 21172122.

Ischemia-Guided
Strategy

Ticagrelor Safety: Bleeding Risk

Total Major Bleeding

- No significant difference between ticagrelor and

clopidogrel

Non-CABG Plato Major Bleeding

- Ticagrelor 4.5% vs Clopidogrel 3.8% (P=.026)

Non-CABG TIMI Major Bleeding

- Ticagrelor 2.8% vs Clopidogrel 2.2% (P=.025)

CABG Major Bleeding

- No significant different between ticagrelor and

clopidogrel

Wallentin L et al. N Engl J Med. 2009; 361(11):1045-57.

Non-ST Elevation ACS Pathway

Definite or Likely NonST Elevation ACS

Invasive Strategy

Ticagrelor

Ischemia-Guided
Strategy

Non-ST Elevation ACS Pathway

Invasive Strategy
Drug Recommendations

Dosing Recommendations

COR;
LOE

P2Y12 inhibitors
A P2Y12 inhibitor loading dose should be given prior
to planned PCI and should be given for at least 12
months in patients receiving a stent (bare-metal or
drug-eluting stent) during PCI for ACS:

1. Clopidogrel 600-mg then 75 mg/day I; B

2. Ticagrelor 180-mg then 90 mg BID
3. Prasugrel 60-mg then 10 mg/day

It is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12

treatment in ACS patients who undergo PCI or are solely medically managed

IIa; B

It is reasonable to choose prasugrel over clopidogrel for P2Y12 treatment in ACS patients
who undergo PCI who are not at high risk of bleeding complications

IIa; B

Prasugrel should not be administered to patients with a prior history of stroke or transient
ischemic attack

III; B

COR, Class of Recommendation; LOE, Level of Evidence

Amsterdam EA, et al. Circulation. 2014;130(25):e344-e426.

Non-ST Elevation ACS Pathway

Invasive Strategy
A higher clopidogrel loading dose (600 mg) is more effective
only in patients treated in early invasive strategy

Non-ST Elevation ACS Pathway

Invasive Strategy
Prasugrel versus Clopidogrel in
Patients with ACS and Planned PCI

CV Death/MI/Stroke

TIMI Major Bleeding

Wiviott et al. NEJM. 2007; 357: 2001-2015

Non-ST Elevation ACS Pathway

Invasive Strategy
Prasugrel versus Clopidogrel in
Patients with ACS and Planned PCI

Wiviott et al. NEJM. 2007; 357: 2001-2015

ST Elevation Myocardial Infarction

STEMI
Primary PCI

OGara PT, et al. Circulation. 2013;127(4):e362e425.

Fibrinolysis

ST Elevation Myocardial Infarction

Fibrinolysis

Class I Recommendations

Level of
Evidence

< 75 years: Clopidogrel 300 mg load and 75 mg daily x 14 days to 1 yr*

> 75 years: Clopidogrel 75 mg load and 75 mg daily x 14 days to 1 yr*

* 1 yr is a level C recommendation

OGara PT, et al. Circulation. 2013;127(4):e362e425.

ST Elevation Myocardial Infarction

Primary PCI
Clopidogrel 600 mg as early as possible or at time of PCI
Prasugrel 60 mg as early as possible or at time of PCI
Ticagrelor 180 mg as early as possible or at time of PCI

Level of
Evidence
B
B
B

Class I Recommendations (Maintenance and Duration)

Drug-eluting stent (DES) or bare-metal stent (BMS)*
Clopidogrel 75 mg daily and continued for 1 year
Prasugrel 10 mg daily and continued for 1 year
Ticagrelor 90 mg twice a day and continued for 1 year

Level of
Evidence
B
B
B

Class I Recommendations (Loading Dose)

* Continuation beyond 1 year is a Class Ilb, level C recommendation

OGara PT, et al. Circulation. 2013;127(4):e362e425.

Emerging Antiplatelet Therapy

for ACS

Intravenous P2Y12 antagonists

Cangrelor (Approved 2015)
Indication: Adjunct to PCI for reducing the
risk of periprocedural MI, repeat coronary
revascularization, and stent thrombosis in
patients in who have not been treated with a
P2Y12 platelet inhibitor and are not being
given a glycoprotein IIb/IIIa inhibitor

Oral PAR1 antagonists

Vorapaxar (Approved 2014)
Indication: Reduction of thrombotic
cardiovascular events in patients with a
history of MI or PAD

Franchi F, et al. Nat Rev Cardiol. 2015;12(1):30-47.

DAPT Study
What is the optimal duration of dual antiplatelet therapy (DAPT)?

Prospective, randomized, double-blind trial that evaluated

subjects treated with DES or a BMS (n=25,682)

22,866 DES subjects who received 12 months of open-label

thienopyridine/antiplatelet treatment in addition to aspirin

After 12 months, a total of 9961 subjects who were free from

all MACCE or major bleeding events and were compliant with
thienopyridine treatment were randomized for additional 18
months:

placebo (n=4941)
DAPT (n=5020)

Thienopyridine use in trial: Clopidogrel (65%), Prasugrel (35%)

of patients enrolled

Mauri L et al. N Engl J Med 2014;371(23):2155-2166

DAPT Study Co-Primary

Efcacy Endpoint

Mauri L et al. N Engl J Med 2014;371(23):2155-2166

DAPT Study Primary Safety Endpoints

Mauri L et al. N Engl J Med 2014;371(23):2155-2166

DAPT Scoring Tool

Objective:

To develop a decision tool to identify whether a

patient is more or less likely to benefit from

prolonged DAPT beyond 1 year
Account for risks of recurrent ischemia and
bleeding simultaneously

Derived from patients in DAPT trial

Those that tolerated DAPT for at least one year

Remember DAPT exclusion criteria
These patients would not apply to the risk scoring
system

www.daptstudy.org

DAPT Score
Variable

Points

Patient Characteristics
Age:
75 years-old
65 74

-2
-1

64
Diabetes

0
1

Current cigarette smoker

Prior PCI or prior MI

CHF or LVEF < 30%

1
2

Index Procedure Characteristic

MI at presentation

Vein graft PCI

Stent Diameter < 3 mm

2
1

TOTAL SCORE

www.daptstudy.org

-2 10 points

DAPT Score
-2
-2
Low DAPT Score (< 2)
NNT to prevent ischemia = 153
NNH to result in bleeding = 64

10
High DAPT Score ( 2)
NNT to prevent ischemia = 34
NNH to result in bleeding = 272

DAPT score may help identify patients where:

Ischemic benefits outweigh the risks of bleeding
Bleeding outweighs risk of ischemic events
http://www.daptstudy.org/for-clinicians/score_calculator.htm

Case Vignette

60 yr old Black Male with DM, HTN, hyperlipidemia,

and ischemic stroke, STEMI and DES
Administered Aspirin 325 mg X1 then 81 mg/day
Loaded with ticagrelor 180 mg X1 then 90 mg BID

Pharmacist counseled on the importance of DAPT

prior to discharge and gave him ticagrelor a discount
card

Hospital Readmissions Reduction Program

A payment penalty program mandated by ACA

Unplanned hospital readmissions

~ 20% of post-ACS Medicare beneficiaries
~10-20% of ACS patients treated with PCI
Independent predictor for mortality at 1 year

Higher-than-expected 30-day ACS readmission

rate can lead to reduction in a hospitals
Medicare payments

Jencks, S, et al NEJM, 2009 360(14), 14181428.

Harjai, K, et al. American Journal of Cardiology. 2012, 110(4), 491497.

Surviving MI Initiative
Key Strategies

Surviving MI Initiative
Key Strategies

Surviving MI Initiative
Key Strategies

RSMR = risk-standardized mortality rate

RSMR = risk-standardized mortality rate

Case Vignette

The patient went to fill his discharge meds the next

morning but:
1. He forgot his discount card at home
2. Ticagrelor (Brilinta) required prior authorization
3. He didnt have the cash to pay for it out-of-pocket

The pharmacist told him to come back for his

ticagrelor when he had prior authorization

Three days later

Stent thrombosis

STEMI Cardiac arrest

10 day stay in ICU

Delays in DAPT After Discharge

One in 6 patients delay filling antiplatelets after discharge

Ho, P. et al. Circulation. Cardiovascular Quality and Outcomes 2010 3(3), 261266.

Prescription Abandonment

Copayments $40-$50 are 3.4 times more

likely to be abandoned that scripts with $0
copay (p < 0.001)

New users of meds are 2.74 times more

likely to abandon med than prevalent users
(p < 0.001)

Electronic scripts are 1.64 times more likely

to be abandoned than non-electronic scripts
(p < 0.001)

Shrank W, et al. Ann Intern Med. 2010, 153: 633-640

Preventing the Treatment Gap

Prior authorization paperwork

Assisting the enrollment in financial
medication assistance programs

Arranging a temporary supply

Community Pharmacists

Post-discharge pharmacist home visit

Improved continuity of care for the patient
Improved medication knowledge by the patient
Reduction in hospital readmissions

Community pharmacy & hospital collaboration

Referral process for transition of care
interventions
Scheduling a 72 hour post discharge MTM appt
significantly reduced 30-d readmission rates
(20% vs. 7%, P = 0.017)

Ensing, H, et al. International Journal of Clinical Pharmacy, 2015 37(3), 430434.

Person et al. Am J Health Syst Pharm 2014, 71(18): 15761583.
Luder, H., et al. Journal of the American Pharmacists Association : JAPhA, 55(3), 246254.

Interventions to Improve Adherence

S
I
M
P

Simply the regimen

Impart knowledge
Modify patient
beliefs and human
behavior
Provide
communication and
trust

Leave the bias

Evaluate
adherence

Adjust timing, frequency, and dosage

Utilize once-daily medications whenever possible
Encourage the use of adherence aids (e.g., pillboxes, cell phone alarms)
Consider each patients activities of daily living (e.g., swing shift workers)
Patient-provider shared decision making
Provide clear instructions and expectations for all prescriptions
Involve relatives or caregivers when discussing medications
Recommend electronic education formats (e.g., video, websites)
Ask patient about their needs and what might help them
adhere to therapy
Ensure patient understands consequences of non-adherence
Addressed perceived barriers of taking the medication
Provide rewards for adherence (e.g., praise, coupons, fewer clinic visits)
Practice to improve interviewing skills
Embrace active listening and provide emotional support
Elicit patients input when discussing treatment options
Allow adequate time for the interaction and encourage patient to ask questions

Foster a greater understanding of health literacy and how it affects patients

Ensure communication style is patient-centered
Take extra time to understand and overcome cultural barriers
Tailor education to the patients level of understanding
Ask patients simply and directly about adherence
Engage patients about adherence at every encounter
Measure drug levels or efficacy parameters, when applicable
Review medication containers, noting last fill date and remaining medicine

Clinician's Toolkit: A Guide to Medication and Lifestyle Adherence. National Lipid Association.
https://www.lipid.org/practicetools/tools/adherence.

Evidence-Based Interventions
Shown to Improve Adherence
Telephone reminders
Self-monitoring
(medication diary)
Fixed-dose combination
products
Unit-dose packaging
Education counseling

Case management by
Pharmacists
Automated refill reminders
from pharmacy
Waiving/reducing
medication co-payments
Rewards (money, gift cards)
Pharmacist or nurseoperated disease
management clinics

Cochrane Database Syst Rev. 2014:CD000011.; Viswanathan M, et al. Ann Intern Med. 2012;157(11):785-95;
Petrilla AA, et al. Int J Clin Pract. 2005;59(12):1441-51.; Choudhry NK, et al. N Engl J Med. 2011;365(22):
2088-97.; Choudhry NK, et al. Health Aff (Millwood). 2010;29(11):1995-2001.

Conclusion

Patients with ACS are at high risk of recurrence

Prasugrel and ticagrelor have shown superior outcomes to

clopidogrel and are preferred in ACS guidelines

Premature discontinuation of DAPT can have devastating

consequences

Pharmacists playing a role in antiplatelet management and

patient counseling can improve ACS patient outcomes

Pharmacists should utilize multiple evidence based

strategies to manage transition of care and maximize patient
medication adherence

Safe and effective DAPT is essential in the prevention of

recurrent atherothrombotic events

Post-Session Assessment

Case Vignette

60 yr old Black Male presented with chief

complaint of ischemic chest pain

PMH: diabetes, hypertension, hyperlipidemia,

smoking, and ischemic stroke at age 45

Electrocardiogram revealed ST elevation so he

was taken directly to the cath lab for Primary
PCI

He received a drug eluting stent (DES) to his

RCA and the marginal branch of his Circumflex.

Question 1
Because the patient received a drug-eluting stent (DES),
which of the following is the most appropriate
maintenance aspirin regimen?
A. Aspirin 325 mg/day indefinitely
B. Aspirin 325 mg/day for 6 months, then 81 mg/day indefinitely
C. Aspirin 325 mg/day for 12 months, then 81 mg/day indefinitely
D. Aspirin 81 mg/day indefinitely

Question 2
Which of the following P2Y12 inhibitors is
contraindicated in this patient?
A. Clopidogrel
B. Prasugrel
C. Ticagrelor
D. Cangrelor

Question 3
Which of the following is the optimal length of
DAPT for our patient?
A. 6 months
B. 12 months
C. 30 months
D. Indefinitely

Questions?
Contact me:
Nicholas B. Norgard, Pharm.D. BCPS
University at Buffalo School of Pharmacy &
Pharmaceutical Sciences
Kapoor 316
Office: 716-645-4779
nnorgard@buffalo.edu