| Course | NRNP 6557 Adult Acute Care: Comprehensive Patient Management II |
|---|---|
| Week | Week 10 |
| Paper type | Case presentation slide deck |
| Length | About 1,100 words across 8 slides with speaker notes |
| Format | Slide deck with speaker notes, APA 7 |
| School | Walden University |
| Program | MSN Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) |
| Updated | October 2026 |
Free sample paper for NRNP 6557 Week 10
Case Presentation: Should a Man Who Bled on Ticagrelor Six Weeks After His Stent Be Switched to Clopidogrel?
Student Name
College of Nursing, Walden University
NRNP 6557: Adult Acute Care: Comprehensive Patient Management II
Instructor Name
Month Day, Year
Slide 1: Summary statement
67-year-old man, NSTEMI with LAD drug-eluting stent 6 weeks ago
Admitted with duodenal ulcer bleeding on aspirin + ticagrelor; type 2 MI on day 3
Decision: continue ticagrelor to 12 months, or switch to clopidogrel now
Speaker notes: The man we are discussing is composite; he fished commercially until he retired and is now 67. Six weeks ago he had a heart attack without ST elevation, and his LAD was stented. He was admitted with bleeding from a duodenal ulcer while taking aspirin and ticagrelor, and on day 3 he had a type 2 infarction from anemia. He went home on both drugs. The decision I am bringing to you is whether his P2Y12 inhibitor should now be switched from ticagrelor to clopidogrel.
Slide 2: Background, compressed
Ulcer: 1.5 cm, visible vessel, clipped; H. pylori positive, treatment started
Cause: naproxen added to dual antiplatelet therapy
Hemoglobin 13.1 to 7.4 g/dL; 4 units transfused in total
Ticagrelor held 66 hours, then resumed; aspirin never stopped
Echo after type 2 MI: ejection fraction 50%
Speaker notes: Everything else about the admission is on this one slide, because none of it is in dispute. The ulcer was treated endoscopically and he has started Helicobacter pylori therapy. The naproxen is gone. His ticagrelor was paused for 66 hours and restarted after the type 2 infarction. His ejection fraction is preserved, so there is no new heart failure indication driving the choice.
Slide 3: The findings that bear on the decision
Bleeding: major, transfusion-requiring, on potent dual therapy
Bleeding risk remains: ulcer healing, age 67, kidney function reduced
Ischemic risk remains: stent at 6 weeks, recent MI
Practical: ticagrelor copay unaffordable for him; twice-daily dosing
Speaker notes: Four findings bear on the decision, and they pull in opposite directions. He has just had a major bleed on potent therapy, and his bleeding risk has not disappeared. At the same time, his stent is only six weeks old and he has had two ischemic events in two months. And there is a practical finding that matters as much as any laboratory value: he told us ticagrelor's copay is more than he can pay, which makes stopping it altogether the likeliest way this plan fails.
Slide 4: The case for ticagrelor
PLATO, 18,624 ACS patients: death, MI, or stroke at 12 months 9.8% ticagrelor vs 11.7% clopidogrel (Wallentin et al., 2009)
Non-CABG major bleeding higher with ticagrelor: 4.5% vs 3.8%
His ischemic risk is real: recent MI, fresh stent, type 2 MI in hospital
Speaker notes: The case for continuing ticagrelor is strong and should be heard in full. In PLATO, ticagrelor reduced the composite of vascular death, infarction, or stroke compared with clopidogrel at 12 months, 9.8% against 11.7%, and reduced death from any cause. That benefit came with more major bleeding not related to bypass surgery, 4.5% against 3.8% (Wallentin et al., 2009). A cardiologist who wants to keep him on ticagrelor has the larger trial on their side.
Slide 5: The case for switching
TOPIC, 645 ACS patients event-free at 1 month: switch to clopidogrel vs continue newer agent (Cuisset et al., 2017)
Net events at 1 year: 13.4% switched vs 26.3% unchanged
Bleeding BARC 2 or higher: 4.0% vs 14.9%; ischemic events not different
ESC update: consider a less potent P2Y12 inhibitor after significant bleeding (Valgimigli et al., 2018)
Speaker notes: The case for switching comes from a smaller but more closely matched trial. In TOPIC, patients one month after an acute coronary syndrome who had been event-free were randomized to switch to clopidogrel or continue their newer agent. The switched group had half the rate of the combined outcome, driven by much less bleeding, 4.0% against 14.9%, with no significant difference in ischemic events (Cuisset et al., 2017). TOPIC excluded patients who had already bled, so our patient is at higher bleeding risk than its participants, which strengthens rather than weakens the argument. The European Society of Cardiology's focused update also names switching to a less potent inhibitor as an option after significant bleeding (Valgimigli et al., 2018).
Slide 6: The ordering argument
The ischemic benefit of ticagrelor is proven in patients who had not bled
The bleeding cost of ticagrelor has already been paid once in this patient
A drug he cannot afford protects no one: nonadherence risk dominates
Proposal: switch to clopidogrel 75 mg daily, keep aspirin, keep pantoprazole
Speaker notes: Here is the argument. PLATO shows the benefit of ticagrelor in a population that, on average, had not bled. Our patient has, and the bleeding was severe enough to cause an infarction of its own. TOPIC shows that switching after the first month reduces bleeding without a detectable rise in ischemic events. And the practical finding decides it for me: a drug he cannot afford is a drug he is likely to stop, and stopping all P2Y12 therapy six weeks after a stent is far more dangerous than taking a less potent one reliably. I propose switching to clopidogrel 75 mg daily, keeping aspirin, and keeping pantoprazole, which is less likely than omeprazole to interfere with clopidogrel's activation.
Slide 7: The ask
Cardiology: agree to the switch at the 7-day clinic visit
Primary care: confirm the new prescription is filled within 48 hours
Pharmacy: reconcile and remove ticagrelor from all lists
Speaker notes: My ask is specific. I would like the cardiology team to agree to the switch at his clinic visit next Tuesday, rather than continuing ticagrelor by default until the 12-month mark. I would like primary care to confirm the prescription is filled, and pharmacy to remove ticagrelor from every list so he does not end up taking both.
Slide 8: Anticipated questions
Q: Isn't switching after a type 2 MI risky?
Q: What about CYP2C19 poor metabolizers?
Q: Why not drop aspirin instead and keep ticagrelor alone?
Speaker notes: First, the type 2 infarction was caused by anemia, not by a new clot in the stent, and it resolved with transfusion; it does not tell us ticagrelor's extra potency was protecting him. Second, some patients activate clopidogrel poorly because of their CYP2C19 genotype; genotype testing could guide the choice, and if he turns out to be a poor metabolizer the switch should be reconsidered. Third, dropping aspirin and continuing ticagrelor alone reduced bleeding without more ischemic events in TWILIGHT, but only after three months of dual therapy in patients who had not had a major bleed (Mehran et al., 2019). He is at six weeks and has bled, so he is outside that trial, and he still could not afford the ticagrelor.
References
Cuisset, T., Deharo, P., Quilici, J., Johnson, T. W., Deffarges, S., Bassez, C., Bonnet, G., Fourcade, L., Mouret, J. P., Lambert, M., Verdier, V., Morange, P. E., Alessi, M. C., & Bonnet, J. L. (2017). Benefit of switching dual antiplatelet therapy after acute coronary syndrome: The TOPIC (timing of platelet inhibition after acute coronary syndrome) randomized study. European Heart Journal, 38(41), 3070-3078. https://doi.org/10.1093/eurheartj/ehx175
Mehran, R., Baber, U., Sharma, S. K., Cohen, D. J., Angiolillo, D. J., Briguori, C., Cha, J. Y., Collier, T., Dangas, G., Dudek, D., Džavík, V., Escaned, J., Gil, R., Gurbel, P., Hamm, C. W., Henry, T., Huber, K., Kastrati, A., Kaul, U., . . . Gibson, C. M. (2019). Ticagrelor with or without aspirin in high-risk patients after PCI. The New England Journal of Medicine, 381(21), 2032-2042. https://doi.org/10.1056/NEJMoa1908419
Valgimigli, M., Bueno, H., Byrne, R. A., Collet, J.-P., Costa, F., Jeppsson, A., Jüni, P., Kastrati, A., Kolh, P., Mauri, L., Montalescot, G., Neumann, F.-J., Petricevic, M., Roffi, M., Steg, P. G., Windecker, S., Zamorano, J. L., Levine, G. N., & ESC Scientific Document Group. (2018). 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. European Heart Journal, 39(3), 213-260. https://doi.org/10.1093/eurheartj/ehx419
Wallentin, L., Becker, R. C., Budaj, A., Cannon, C. P., Emanuelsson, H., Held, C., Horrow, J., Husted, S., James, S., Katus, H., Mahaffey, K. W., Scirica, B. M., Skene, A., Steg, P. G., Storey, R. F., & Harrington, R. A. (2009). Ticagrelor versus clopidogrel in patients with acute coronary syndromes. The New England Journal of Medicine, 361(11), 1045-1057. https://doi.org/10.1056/NEJMoa0904327
NRNP 6557 Week 10 instructions, in plain terms
The tenth week of NRNP 6557 often asks for a case presentation that argues a clinical decision. You open with a summary statement, compress background, present the findings relevant to the decision, argue both sides, state your recommendation and anticipate questions. Faculty treat chronological walkthroughs as the main trap. Cite trials and guidelines in APA 7 on the final slide or in notes. Slide counts are usually limited. Recording requirements vary by section. Speaker notes should be full sentences. NRNP 6557 faculty want the decision stated on the first slide. Each side should get its own slide with evidence. The ordering argument should explain why bleeding risk and ischemic risk are weighed as they are. Speaker notes carry the reasoning. Anticipated questions show preparation.
Inside the NRNP 6557 Week 10 example
The presentation runs to a manageable number of slides or sections with the spoken text written out beneath each, because a presentation graded on argument is judged on what is said as much as on what is shown. It opens on a summary statement of one or two sentences naming the patient in demographic terms, the problem, and the decision at issue. The middle carries only the findings bearing on that decision, with the rest compressed into a single background slide. The ordering argument occupies the center, evidence visible on the slide rather than only in the speech. It closes with the ask, what the presenter wants from the audience, and a short set of anticipated questions with answers prepared. The patient is composite and no images or records from a real case appear.
Where the marks sit in the NRNP 6557 Week 10 rubric
Chronology is the trap. A presentation walking through the admission day by day arrives at the argument with the audience already tired, and rubric language about organization is usually aimed at that. The second loss is slides carrying paragraphs, which forces a listener to choose between reading and listening. Third, evidence mentioned only in speech leaves nothing on the slide for a grader to see, and it is a cheap fix. Presentations stopping after the plan, with no ask, drop the closing section entirely. Where a recording is submitted, timing overruns cost points in many sections, and a presenter reading the notes verbatim loses the delivery marks a written script was supposed to support.
NRNP 6557 Week 10 help: mistakes that cost marks
Presentations lose credit when they walk through the admission day by day and reach the decision with the audience already tired. Lead with the question. Another common gap is presenting only one side. Give both a slide. Writers also overload slides with text. Keep reasoning in the notes. Avoid ending without a clear ask. Anticipate questions about bleeding and ischemic risk. Check trial names and years. Close with the recommendation restated. Writers also forget to state what the audience should decide or approve. Make the ask explicit. Another frequent slip is quoting trials without their populations. Add who was enrolled. Keep the deck within the slide limit. Practice the timing.
Get a NRNP 6557 Week 10 example written to your instructions
Send the Week 10 prompt, the slide template if the classroom supplies one, and the rubric, and the desk returns a presentation example with the speaking text written beneath each section. Free the first time, back inside 24 to 48 hours. Nothing from your clinical site, and no record a preceptor has signed, goes into it.
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NRNP 6557 Week 10 questions, answered
Slides or a paper?
Whatever the prompt names, and both exist in these classrooms. The sample is built as slides with the spoken text underneath, which converts easily into a structured paper by promoting the speaker notes into body paragraphs. What does not convert is a deck of bullet fragments, so the example is written in full sentences from the start.
What belongs in the summary statement?
Age band, relevant context, the presenting problem and the decision the presentation exists to argue. It is the hardest two sentences in the file and the ones most worth rewriting. The version in the sample is short enough to say in one breath, which is a fair test of whether the argument underneath has actually been settled.
Do I have to record myself?
Some sections ask for a recording and some accept the file alone. The sample supports both, since the speaking text is written out and can be read aloud within a typical time limit. Where a recording is required, the anticipated questions section usually stays in the submitted file even though it is not spoken aloud.
Where can I find a free NRNP 6557 Week 10 sample paper?
The eight-slide ticagrelor versus clopidogrel presentation is laid out here with speaker notes, both cases, the ordering argument and the ask.
What decision does the NRNP 6557 Week 10 deck ask for?
Whether the man who bled on ticagrelor six weeks after his stent should switch to clopidogrel.