Comparison of Heart Rates in Patients Initiated on Ticagrelor Versus Other P2Y12 Inhibitors After an Inferior ST Elevation Myocardial Infarction (STEMI).

BACKGROUND: P2Y12 inhibitors have differing associations of bradyarrhythmias. Ticagrelor has been shown to increase adenosine plasma concentrations leading to increases in bradyarrhythmias. While clopidogrel and prasugrel have not been shown to have any association with bradyarrhythmias. OBJECTIVE: The objective of this study was to determine heart rates after ticagrelor initiation compared to clopidogrel/prasugrel in inferior ST Elevation Myocardial Infarction (STEMI) patients. METHODS: This was a retrospective, multicenter study conducted at 3 primary percutaneous coronary intervention (PCI) centers between January 1, 2017 and September 30, 2022. Adult patients were included if they were diagnosed with an inferior STEMI to the right coronary artery (RCA) and treated with PCI followed by an oral P2Y12 inhibitor. The primary outcome was heart rate at 48 hours or discharge, whichever first, after administration of ticagrelor compared to clopidogrel/prasugrel. RESULTS: This study reviewed 331 patients, 172 in the ticagrelor group and 159 in the clopidogrel/prasugrel group. There were no statistical differences between groups regarding the primary outcome, with a median heart rate of 76 beats per minute (bpm) [67-85] in the ticagrelor group versus 73 bpm [66-84] in the clopidogrel/prasugrel group (P = 0.238). No differences were observed between groups regarding any secondary outcomes. CONCLUSION AND RELEVANCE: There were similar heart rates between ticagrelor and clopidogrel/prasugrel. There were also similarities in the ability to tolerate beta-blocker therapy after initiation of a P2Y12 inhibitor. The results of this study suggest that in inferior STEMIs when using ticagrelor as the P2Y12 inhibitor, there are not increased clinical manifestations of bradycardia.

The Reemergence of Ketamine for Treatment in Critically Ill Adults.

OBJECTIVES: To assess the evidence and discuss the risks and clinical relevance of ketamine for the treatment of various disease states impacting the adult critically ill population. DATA SOURCES: A literature review was performed using PubMed evaluating primary literature published until August 2018. STUDY SELECTION: Case reports, observational studies (cohort, case-control), and randomized controlled trials involving patients 18 years and older in a nonperioperative setting using either IV or intramuscular ketamine were included for analysis. Uses of ketamine discussed focused on critically ill patients in the ICU and emergency department settings. DATA EXTRACTION: Included studies were evaluated for dosing, outcomes, and adverse effects of ketamine. For each study, the design, population, intervention, investigated outcomes, and results were assessed. DATA SYNTHESIS: The evidence was organized according to use of ketamine, which included pain, sedation, status asthmaticus, alcohol withdrawal syndrome, status epilepticus, and acute behavioral psychologic disturbances. Evaluation of the evidence was based on the included primary literature along with any related guideline recommendations. CONCLUSIONS: Ketamine has suggested potential benefit in several disease states impacting critically ill patients including pain, alcohol withdrawal syndrome, status epilepticus, and acute agitation. Further supporting evidence is needed to validate its use in the setting of critical illness.