In Reference to “Optimizing Non-cardiac Prescription in a Cardiac Patient”

Sir/Ma’am, This letter is in reference to “Optimizing Non-cardiac Prescription in a Cardiac Patient.” The article is very well written and is very apt in the current era when optimization of noncardiac medications for cardiac patients poses a challenge to the treating physician. Many of these patients have multiple comorbidities and seek specialist advice for each one of them, who in turn, treat only the part related to their own specialty. Thus, the patient ends up with a complex regimen with contributions from Sall specialists from whom he seeks advice. Therefore, it becomes a challenge to treat the patient holistically and integrate all the prescriptions and simplify the regimen that may be best suited for the patient, addressing all of his comorbidities, without letting any of his problems being left uncovered. It is here that optimization of the prescription becomes crucial; such as using drugs that may address multiple comorbidities, avoiding serious drug interactions, and modifying the dosage, if their concomitant use becomes inevitable. Fifty percent of all heart failure patients suffer from iron deficiency with resultant reductions in functional capacity, quality of life, and life expectancy. This is independent of left ventricular ejection fraction or presence of anemia. However, the AFFIRM–AHF trial showed that treatment with ferric carboxymaltose reduced the risk of heart failure hospitalizations but did not reduce the risk of cardiovascular death.1 Sometimes gastrointestinal (GI) bleed is only suspected with progressive decline in hemoglobin levels without an obvious bleeding source. Endoscopy is often crucial. While aspirin causes GI bleeding by direct inhibition of cyclooxygenase-1, and thus reducing the protective effect of prostaglandins, P2Y12 inhibitors are believed not to be directly ulcerogenic, but to impair ulcer healing by blocking platelet aggregation, angiogenesis, and endothelial proliferation. Clopidogrel carries a lesser risk of GI bleed compared to ticagrelor and prasugrel.2 While the development of an antidote for ticagrelor, PB2452, a monoclonal antibody fragment, is in progress,3 the TWILIGHT trial showed ticagrelor monotherapy was associated with a lower incidence of clinically relevant bleeding in high-risk patients who have completed 3 months of dual antiplatelet therapy, than ticagrelor plus aspirin, with no higher risk of death, myocardial infarction, or stroke.4 The 2020 ESC guidelines for the management of ACS suggests that in patients with NSTE-ACS and stent implantation who are at high risk of bleeding (e.g., PRECISE-DAPT>_25 or ARC-HBR criteria met), discontinuation of P2Y12 receptor inhibitor therapy after 3 to 6 months should be considered and aspirin continued after completion of dual antiplatelet therapy. In patients at very high-risk of bleeding, defined as a recent bleeding episode in the past month or planned, not deferrable surgery in the near future, 1 month of Department of General Medicine, RG Kar Medical College, Kolkata, West Bengal, India Corresponding Author: Sandip Ghosh, Department of General Medicine, RG Kar Medical College, Kolkata, West Bengal, India, e-mail: ghosesandyy@yahoo.co.in How to cite this article: Ghosh S. In Reference to “Optimizing Noncardiac Prescription in a Cardiac Patient”. Bengal Physician Journal 2021;8(1):28–29. Source of support: Nil Conflict of interest: None