226 DUAL ANTI-PLATELET THERAPY: AUDIT OF COMMUNICATION OF DIAGNOSIS AND DURATION ACROSS PRIMARY AND SECONDARY CARE

Background

Dual Anti-Platelet Therapy (DAPT) is indicated in vascular disease & duration of treatment depends on factors such as indication, age, bleeding risk, disease severity & co-morbidities. Inappropriately prolonged DAPT may increase the risk of major bleeding without a reduction in all-cause mortality and decisions for the duration of DAPT are best made by specialists in secondary care which should be communicated definitively to partners in primary care.

Methods

A retrospective search of patients prescribed Aspirin and a PY2 inhibitor from 01/01/2020 to 30/04/2022 was conducted. Patients were excluded if DAPT was not prescribed concurrently or if the patient deceased before the duration of DAPT had passed. Each record was evaluated to determine if: (1) Secondary care correspondence stated indication & duration of treatment; (2) Patients had stop dates for DAPT on their prescription; (3) Patients had been on DAPT for correct duration and (4) Any errors/improvements were identified.

Results

Number of patients met criteria = 81, Average Age = 69.7yrs, Male = 58%, Female = 42%. 12% of letters from Secondary Care did not specify a duration. 43% did not have a stop date on their prescriptions. 19% prescribed DAPT for the incorrect duration. 15% classified as having a serious medication error (DAPT >3yrs, No obvious indication for DAPT, DAPT & Antithrombotic therapy without review). 14.8% not prescribed a PPI & 4.9% admitted to hospital with a GI bleed. 24.7% Patients prescribed Esomeprazole/Omeprazole & Clopidogrel

Conclusion

DAPT is an important pharmacotherapy intervention in the treatment of vascular disease, but it's duration should be regularly assessed by specialists and clearly communicated to prescribers in Primary care to optimise treatment and reduce bleeding risk. Clinical system warnings have now been utilised to alert prescribers to well defined time limits of DAPT and patients on less appropriate PPI's have been switched. Secondary care colleagues have been reminded of the importance of clear and concise communication of clinical interventions and plans.

Founder effect for the T93MDHCR7 mutation in Smith-Lemli-Opitz syndrome

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive MCA-MR disorder caused by mutations within the 7-dehydrocholesterol reductase gene, DHCR7. The diagnosis is based on the biochemical findings of elevated plasma 7-dehydrocholesterol (7DHC) levels. It is a panethnic condition with variable mutation frequencies in different populations. Ten Cuban patients and four Canadian patients of Mediterranean ancestry with SLOS are reported herein. All these patients are at the mild end of the clinical spectrum (the highest Kelley-Hennekam severity score was 28 in one patient). All patients had genotypes which were compound heterozygous or homozygous for T93M; in all the Mediterranean patients the T93M mutation appeared to be associated with the J haplotype. Another compound heterozygote for T93M was of Ukrainian/Irish ancestry; in this patient the T93M was associated with a new haplotype designated K. The T93M mutation was initially reported as the most common in a series of patients from Italy. Our identification of a single haplotype associated with the T93M mutation in patients whose ancestors originate in the region of the Mediterranean Sea basin suggests a founder effect.

Incidence of Smith-Lemli-Opitz syndrome in Ontario, Canada

Smith-Lemli-Opitz syndrome (OMIM 270400) (SLOS) is caused by inherited enzymatic deficiency of 3beta-hydroxysterol-Delta7-reductase (7-dehydrocholesterol-Delta7-reductase, DHCR7). SLOS is diagnosed clinically by the demonstration of elevated levels of 7-dehydrocholesterol (7DHC) in body fluids or tissues. SLOS is associated with mental retardation of variable degree and severe behavior abnormalities. The physical abnormalities range from minor facial anomalies to lethal malformations of the central nervous system, heart, kidneys, and other organs. The exact incidence of SLOS is not known. Although there exist estimates of the incidence of SLOS ranging from 1 in 20,000 to 1 in 60,000, no prospective studies of the incidence of SLOS, based on the clinical data and biochemical diagnosis of SLOS, have been performed. Five unrelated cases of SLOS were diagnosed in Ontario during a 12-month period. The diagnoses were made based on the demonstration of elevated 7DHC in plasma or amniotic fluid. The birth rate for Ontario for that period was 132,000 births. The incidence of SLOS in Ontario was at least 1 in 26,500 pregnancies in 1999-2000. Given that 86% of the population of Ontario is of European origin, the incidence of SLOS in the Ontario population of European origin was at least 1 in 22,700. As infants with mild forms of SLOS born during this period may remain undiagnosed, these numbers likely are underestimates. This observation has implications for prenatal and newborn screening for this potentially treatable inherited disorder.