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Antithrombin III activation
8%
12/143
Direct factor Xa inhibition
GPIIb/IIIa inhibition
18%
26/143
Irreversible ADP receptor antagonism
47%
67/143
Inhibition of cyclooxygenase-2
9%
13/143
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This patient with recent coronary stent placement was most likely prescribed clopidogrel, which is an irreversible ADP receptor antagonist commonly used in the setting of percutaneous coronary intervention. Under physiologic conditions, activated platelets will secrete ADP, which binds to ADP receptors (P2Y12) on other platelets, leading to GPIIb/IIIa activation and fibrinogen binding, resulting in clot formation. Clopidogrel counters this via an irreversible blockade of ADP receptors. Because of this, clopidogrel is used after percutaneous coronary intervention (PCI) with stent placement. Other examples of ADP receptor antagonists include ticlopidine and prasugrel. Incorrect Answers: Answer 1: Antithrombin III activation is the mechanism of action of heparin, low molecular weight heparin, and fondaparinux. Heparin may be used off label during PCI itself but there is no indicated use for these medications for management of patients after PCI. Answer 2: Direct factor Xa inhibition is the mechanism of action of rivaroxaban and apixaban. These medications are not indicated in the standard management of patients undergoing PCI; however, studies have indicated utility for rivaroxiban in patients with atrial fibrillation undergoing PCI. Answer 3: GPIIb/IIIa inhibition is the mechanism of action of abciximab, eptifibatide, and tirofiban. As with heparin, these medications can be used during PCI itself but are not indicated in the management of patients after PCI. Answer 5: Inhibition of cyclooxygenase-2 (COX-2) is the mechanism of celecoxib. Inhibition of COX-1 is actually what is involved in the anti-platelet effect of acetylsalicylic acid (aspirin). COX-2 inhibition may actually promote platelet aggregation via the inhibition of prostacyclin production, which prevents platelet aggregation. Bullet Summary: Clopidogrel is an irreversible ADP receptor antagonist commonly used after percutaneous coronary intervention and stent placement.
3.7
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