PICO Presentation of Plavix versus Brillinta in Myocardial
PICO Presentation of Plavix versus Brillinta in Myocardial Infarction Patients Shari Hendrickson COHP 450 December 2015
PICO Question In patients who have experienced a myocardial infarction (MI), is Plavix (clopidogrel) or Brillinta (ticagrelor) a better treatment plan to reduce mortality? P: Patients who have experienced a myocardial infarction I: Plavix (clopidogrel) C: Brillinta (ticagrelor) O: Reduction of mortality
Research Process Key Search Words: Plavix (clopidogrel), Brillinta (ticagrelor), myocardial infarction, acute coronary syndrome, antiplatelet therapy, coronary stents Search Engines: Articles were obtained from Pub. Med and High Wire Press Journals via the FLITE library at Ferris State University Results of Search: 841 articles were initially encountered, which was then narrowed down by additional key search words and peer-reviewed articles.
Introduction and Purpose When I began working on a cardiology floor 14 years ago, Plavix was the antiplatelet drug of choice for myocardial infarctions and coronary artery disease. The preferred choice is now Brillinta, but it is also a very expensive treatment. At times, we often have to switch people to Plavix due to the cost. I have chosen my topic to become more informed about the treatment options and to learn why one medication is more effective over the other. I would like to be assured that our patients are receiving the best treatment options, regardless of cost.
References Hibbert, B. , Maze, R. , Pourdjabbar, A. , Simard, T. , Ramirez, D. , Moudgil, R. , … Le. May, M. (2014). A comparative pharmacodynamic study of ticagrelor versus clopidogrel and ticagrelor in patients undergoing primary percutaneous coronary intervention: the Capital Reload study. PLo. S ONE, 9(3), 1 -7. Wallentin, L. , Becker, R. , Budaj, A. , Cannon, C. , Emanuelsson, H. , Held, C. , … Harrington, R. (2009). Ticagrelor versus clopidogrel in patients with acute coronary syndrome. The New England Journal of Medicine, 361(11), 1045 -1057.
Rationale Reasons articles were chosen: v Both articles were part of well-known trials. v Each article was peer-reviewed. v Each article met the criteria of comparing both drugs and acute myocardial infarctions. v Each article was easy to understand the information was organized. v The results were well-defined and measurable.
Type and Design of Study 1 (Hibbert) Study 2 (Wallentin) Type: Quantitative (Forister, 2015, p. 100) Design: Prospective, observational cohort study Design: Prospective, randomized, doubleblind, event-driven study
Method – Study 1 v 52 eligible patients who were presently suffering from chest pain/myocardial infarction were chosen for this study at a regional MI hospital v Over a 3 -month period, consecutive patients were chosen who were in need of percutaneous coronary intervention (PCI). v Those who needed PCI received a loading dose of Brillinta prior to procedure, regardless of prior Plavix usage. Some patients also received a loading dose of Plavix from outlying hospitals prior to transfer. v All patients received twice-a-day Brillinta post-procedure.
Method – Study 2 v This analysis for Study 2 was based on the Platelet v v Inhibition and Patient Outcomes (PLATO) study, which randomly studied 18, 624 patients with acute coronary syndrome and/or myocardial infarction. Patients were treated with loading doses of Brillinta or Plavix prior to coronary intervention and the same medication post-intervention. Each patient received the proper dosage of aspirin following the procedure. Patients were followed up to 12 months post-discharge Study was concluded once 1780 end-point events had occurred (death from vascular causes, MI, or stroke).
Findings Study 1 v Patients who received both Brillinta and Plavix demonstrated more remarkable platelet inhibition than those who just received Brillinta. v These findings stated that both medicines combined were more effective in reducing platelet aggregation than Brillinta alone. v Evidence has shown that patients with higher platelet reactivity (HPR) are more susceptible to adverse events, such as MI, stroke, or death. Study 2 v PLATO study findings consistently show that Brillinta is more effective in reducing myocardial infarction, stroke, or cardiovascular death (10. 8% versus 9. 4%). v The risk of stroke, although low in both groups, was higher with Brillinta (1. 7% versus 1. 0%). v Neither medication increased the risk of overall bleeding v Benefits were the same for short-term (30 days) and longterm (360 days).
Ethical Considerations v Each study obtained written informed consent v Completely randomized v Neither study used placebos v Each study was closely monitored and reviewed by an ethics committee
Strength, Quality, and Credibility Study 1 v Written by members of the Division of Cardiology in Ontario, Canada v PLOS One is a publication of numerous peer-reviewed articles (PLOS, 2015). v Authors have declared that no competing interests existed v Appropriate references – including well-known PLATO trial Study 2 v The lead investigator, Dr. Lars Wallentin, is a professor of cardiology and has led many national clinical trials regarding cardiovascular disease (Bloomberg, 2015). v The New England Journal of Medicine is well-known for up-to-date clinical research v References are thorough
Evidence-Based Practice “Evidence-based practice calls for health practitioners to answer questions by gathering and analyzing data…” )Forister, 2016, p. 46). v Delayed onset of platelet inhibition seen in MI patients could result in post-intervention ischemic events (Hibbert, 2014). v While cost was not mentioned in either article, it does play a role in health care today. It is important to have research and studies to support physician and hospital preference in regards to the most safe medication for patients. v Both articles clearly state that Brillinta is superior in regards to platelet inhibition and has lower mortality rates than Plavix (9. 8% versus 11. 7%) (Wallentin, 2009).
Communication Level Findings are communicated at a variety of levels: § Physician to physician preference § Standard of care presented at forums and conferences § Further studies may be conducted at individual institutes and organizations § Follow-up may continue to monitor results and make adjustments.
Implications for Change “Generalizability…a finding that justifies the inference that it represents something more than the specific observations on which it was based” (Forister, 2016). v Treatment for cardiovascular disease and coronary intervention was changed because of studies that have been conducted. Standard of care is now Brillinta – for most physicians. There are still patients that receive other medications (such as Plavix) that may not be the best choice, but are chosen for tolerance and cost. v Plavix worked for many years, but now there is something more effective. Brillinta does not make Plavix less effective, only less used.
Barriers v Cost v Inability of physician to accept change v Intolerance to certain side effects from medications v Patient refusal or non-compliance v Reduction of other risk factors - smoking cessation, weight loss, dietary changes
Additional Related PICO Questions In patients with coronary artery disease, is Brillinta or Brillinta with Plavix more effective in reduction of mortality or to prevent rethrombosis? In patients with coronary artery disease, is Brillinta or Plavix cheaper as post-intervention treatment?
Conclusion v Brillinta is more effective in the treatment of post-MI patients than Plavix. v Brillinta is the preferred treatment of choice for coronary artery disease. v Brillinta has a lower rate of mortality over Plavix (9. 8% versus 11. 7%). v Further research and practice change can make the preferred treatment a more cost-effective choice. Programs are currently in place for some patients to afford proper treatment.
References About plos. (2015). Plos One. Retrieved from https: //www. plos. org Company overview of uppsala university hospital. (2015). Bloomberg Business. Retrieved from http: //www. bloomberg. com/research/stocks/private/person. asp? person. Id=6137247 5&privcap. Id=52614495 Forister, J. G. , & Blessing, J. D. (2016). Introduction to research and medical literature for health professionals (4 th ed. ). Burlington, MA: Jones & Bartlett Learning. Hibbert, B. , Maze, R. , Pourdjabbar, A. , Simard, T. , Ramirez, D. , Moudgil, R. , … Le. May, M. (2014). A comparative pharmacodynamic study of ticagrelor versus clopidogrel and ticagrelor in patients undergoing primary percutaneous coronary intervention: the Capital Reload study. PLo. S ONE, 9(3), 1 -7. Wallentin, L. , Becker, R. , Budaj, A. , Cannon, C. , Emanuelsson, H. , Held, C. , … Harrington, R. (2009). Ticagrelor versus clopidogrel in patients with acute coronary syndrome. The New England Journal of Medicine, 361(11), 1045 -1057.
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