Heartfelt with Dr Melissa Walton-ShirleyView all posts »
ARYMYDA-5: Academia meets common senseAug 10, 2010 08:24 EDT
I'm as wild about hunting and killing platelets as the next fellow, but I've long insisted that most ACS patients can be stabilized with heparin, aspirin, a beta-blocker, and perhaps a 2b3a inhibitor without clopidogrel preloading. I've refused to kill platelets "Dick Cheney style" all these years and am happy that ARMYDA-5 supports those of us who insist we should take the time to find out what we are shooting at and actually take aim before we pull the trigger.
About three months ago, I was asked to see a patient with normal ST segments and detectable troponin. She had settled down quite nicely with my usual ACS cocktail before she made her ICU debut. Shortly after her arrival there, she was seen by the admitting physician, who immediately loaded this nice patient with 300 mg of clopidogrel. She dutifully swallowed all four tablets a full two hours after she had become pain free. When I went back to the ICU to check on this virgin in the cardiac world, I was more than a wee bit aggravated because (1) I had just had a conversation with this same physician about the issue of periprocedural bleeding risk, particularly if CABG were to be necessary, and (2) she was completely stable with normal ST segments, pain free, and soon to be on her way to the cath lab within a few hours when her platelets were murdered in cold blood.
The physician's assistant contacted me by phone after seeing my note (which did mention the possibility of a waiting period if indeed CABG were required, now that she had been loaded with clopidogrel). In a very nice but pointed way, the assistant injected into the conversation such phraseology as "behind the times," "substandard care," and "against usual protocol." My crime? Gasp! Waiting until after the coronary anatomy was defined before writing the "popular-as-Facebook" order for clopidogrel preloading.
I defended my stance by stating that in the entire four years of our PCI program here, I don't recall our interventionalist taking anyone back to the cath lab emergently who wasn't completely predictable based on anatomy. I also explained that since my partner and I have practiced here for over 20 years and are familiar with many of our patient population, it would be good for them to discuss the case with us prior to loading. It's that patient whose coronary anatomy has been recently defined or the patient with a long-standing history of poor distal targets whom I'll load or even reload . . . but not virgins to the cardiac world unless there are extenuating circumstances. Despite my eloquent and impassioned explanation, the indignant team member was not convinced and added that most surgeons don't seem to be delayed by a recent clopidogrel load. (What the heck?)
Just to make certain someone hadn't come down from the mountain with a totally new revelation from the surgical world, I contacted three surgeons at three different facilities for a discussion. I asked each of them about the whole preloading issue. They all stated that if you could get the patient into the OR BEFORE laboratory evidence of the clopidogrel-induced platelet massacre, you could get away with it; otherwise, you are stuck waiting for about five days before you can go to the OR without spending several units of pack cells and/or suffering through a few "take–backs" for bleeding. One of them actually said "And yes, transfusion translates into increased mortality." Another went so far as to tell me that one of their colleagues routinely chides THEM for waiting to take the patient to the OR on a fresh clopidogrel load until it is HIS turn. He conveniently "hems and haws" for a few days and looks for any excuse known to humankind before he'll take the patient. Vindicated, I passed my information along to the physician assistant but recognized that all-too-familiar condescending smugness that follows every anecdotal claim of success.
I really appreciate the ARMYDA-5 trial because it supports the "all-important" yet disrespected element of common sense. When considering the many pros and cons of every study design, interpretation bias, financial incentives, exclusionary criteria, crossover impact, etc, it confirms that clinical judgment is all we really should rely on at the end of the day. My clinical judgment has told me for years that it makes very little sense to place a patient at increased risk of periprocedural bleeding until I know for certain that the patient is going to need CABG, PCI, or medical therapy when I literally have my scrubs on going to the cath lab.
I'm tempted to leave the ARMYDA-5 trial on a certain someone's desk and see how "they like those apples," but I think I'll simply do the mature adult thing (after I stick out my tongue at him and say "I told you so"). I'll just casually mention the trial results in passing. I should just be satisfied that it's a beautiful thing indeed when academia meets common sense and helps our patients. Besides, with my future new best friend ticagrelor coming down the pike, I'm hoping this argument will become a moot point altogether, and platelet hunting can become a veritable skeet shoot indeed.