1
|
Douketis JD, Yi Q, Bhatt DL, Muehlhofer E, Wang MK, Connolly S, Yusuf S, Maggioni AP, Eikelboom JW. Perioperative management and outcomes in patients receiving low-dose rivaroxaban and/or aspirin: a subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial. J Thromb Haemost 2024; 22:2227-2233. [PMID: 38729576 DOI: 10.1016/j.jtha.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/11/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND No study has investigated the perioperative management and clinical outcomes in patients who are receiving rivaroxaban 2.5 mg twice a day and acetylsalicylic acid (ASA) 81 to 100 mg daily. OBJECTIVE To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. METHODS Subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial was performed to assess perioperative management and clinical outcomes in patients with stable coronary or peripheral artery disease who were randomized to receive rivaroxaban 2.5 mg twice a day plus ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA 100 mg daily. Patients studied required a surgery/procedure during the trial. The study outcomes, which included myocardial infarction, angina, stroke, acute limb ischemia, bleeding, and death, were assessed according to treatment allocation. RESULTS There were 2632 patients studied (mean age, 68 years; 80% male) who had a surgery/procedure, comprising percutaneous coronary interventions (∼43%), carotid or other arterial angioplasty (∼15%), pacemaker or internal cardiac defibrillator implantation (∼9%), and coronary artery bypass graft surgery (∼7%). Perioperative study drug management varied, with about one-third of patients not interrupting study drug and the remainder interrupting it between 1 and ≥10 days preprocedure. The incidences of adverse outcomes across treatment groups were 12.7% to 15.3% for myocardial ischemia, 0.8% to 1.2% for stroke, 0.1% to 0.2% for venous thromboembolism, and 3.1% to 4.2% for any bleeding. There was no statistically significant difference in outcome rates across treatment groups. CONCLUSION In patients in the COMPASS trial who required a surgery/procedure, there was no significant difference in perioperative adverse outcomes whether patients were receiving rivaroxaban 2.5 mg twice a day and ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA alone.
Collapse
Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Qilong Yi
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Deepak L Bhatt
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | | | - Michael K Wang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Stuart Connolly
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Salim Yusuf
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
2
|
Bhansali S, Antonchak M, Cecchin F, Tan RB. Thromboembolism prophylaxis practices of pediatric and congenital electrophysiologists during invasive electrophysiology studies: A PACES survey. Pacing Clin Electrophysiol 2024; 47:365-372. [PMID: 38240348 DOI: 10.1111/pace.14928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 12/03/2023] [Accepted: 01/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Thromboembolic events related to invasive electrophysiology studies, while rare, can have devastating consequences. Use of systemic anticoagulation for a pediatric or adult-congenital invasive electrophysiology study is recommended, however there is no established standard of practice in this population. OBJECTIVE To report on procedural practices for thromboembolism prophylaxis during invasive electrophysiology studies for pediatric patients and adults with congenital heart disease. METHODS An anonymous web-based survey was sent to the members of the Pediatric and Congenital Electrophysiology Society. The survey focused on pre-procedural, intra-procedural, and post-procedural thromboembolism prophylaxis practices during invasive electrophysiology studies. Significant practice variation was defined as <90% concordance among respondents. RESULTS Survey was completed by 73 members; 52 (71%) practicing in the United States, 65 (89%) practicing in an academic institution, and 14 (19%) in an institution that performs more than 200 invasive electrophysiology procedures annually. Responses showed significant variation in practice. Prior to an invasive electrophysiology procedure, 25% discontinue aspirin while 47% discontinue anticoagulants. Heparin is given for all procedures by 32%. When heparin is administered, the first dose is given by 32% after sheaths are placed, 42% after crossing into the systemic atrium, and 26% just prior to systemic-side ablation. Most target an activated clotting time between 200-300 seconds. Post systemic-side ablation, 58% do not initiate a heparin infusion. Post-procedural oral agents were initiated on day of procedure by 34% of respondents and on post-procedure day 1 by 53%. If treating with aspirin, 74% use low-dose (3-5 mg/kg or 81 mg daily), and 68% treat for 4-6 weeks. CONCLUSION There is significant variation in thromboembolism prophylaxis for invasive EP studies among pediatric and congenital electrophysiologists. Further studies are needed to optimize the management of thromboembolism prophylaxis in this population.
Collapse
Affiliation(s)
- Suneet Bhansali
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael Antonchak
- Division of Pediatric Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, USA
| | - Frank Cecchin
- Division of Pediatric Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, USA
| | - Reina Bianca Tan
- Division of Pediatric Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, USA
| |
Collapse
|
3
|
Adherence to Anticoagulation Interruption Guidelines in Patients with Atrial Fibrillation. Can J Neurol Sci 2023; 50:182-187. [PMID: 35272733 DOI: 10.1017/cjn.2022.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Annually, 15% of patients who receive oral anticoagulation require interruption for surgery or an invasive procedure. This study evaluates the adherence of patients with atrial fibrillation with a history of stroke or transient ischemic attack to the Thrombosis Canada Perioperative guidelines for the discontinuation and reinitiation of anticoagulation treatment. METHODS We collected data from a prospective patient survey at the Stroke Prevention Clinic in the University of Alberta hospital. Patients' charts were reviewed from the electronic medical records, and adherence was looked at according to the Thrombosis Canada Perioperative guidelines for the interruption of anticoagulants. RESULTS During the study period (2016-2019), there were 509 patients surveyed. Anticoagulation treatment was interrupted in 150 patients with 98 interrupted for surgical or invasive procedures. The interruption was adherent to guidelines in only 29 (29.6%) of patients and inappropriate or nonadherent in 69 (70.4%) patients. There were seven ischemic strokes recorded during the period of interruption. The proportion of strokes was higher in patients whose anticoagulation interruption was longer than what the guidelines recommended (6/61 or 9.8%) when compared to those who adhered to recommended perioperative anticoagulation guidelines (1/29 or 3.4%). CONCLUSION Our results indicate that significant discrepancy with following the recommended perioperative anticoagulation guidelines is common in real-life practice. Delay in re-anticoagulation may increase the risk of complications.
Collapse
|
4
|
O'Connell B, Boyd A, Kothari D, Miller N, Cornejo J, Sullivan B. Improving documentation of anticoagulation and antiplatelet recommendations after outpatientendoscopy. BMJ Open Qual 2022; 11:bmjoq-2021-001725. [PMID: 36588305 PMCID: PMC9723851 DOI: 10.1136/bmjoq-2021-001725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 10/28/2022] [Indexed: 12/12/2022] Open
Abstract
Clear documentation of instructions for resuming anticoagulant and antiplatelet (AC/AP) medications after gastrointestinal endoscopy is essential for high-quality postprocedure care. Yet, these recommendations are frequently absent, which may impact patient safety. We aimed to improve documentation of postprocedural AC/AP instructions through targeted interventions during outpatient endoscopy at a Veterans Affairs Medical Center using validated Quality Improvement methodology. We identified patients on AC/AP agents presenting for outpatient oesophagogastroduodenoscopy or colonoscopy and found restart recommendations were documented in only 59.4% of procedures at baseline. After two intervention cycles, which included provider education, nursing prompts and alterations to endoscopic documentation software, postprocedure documentation increased by 26.7%-86.1% when compared with baseline (p<0.001). These interventions, which require low-resource utilisation, could be part of standardised processes readily implemented at other institutions to help potentially reduce postprocedure patient confusion, medication errors and complications.
Collapse
Affiliation(s)
- Brendon O'Connell
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA,Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amanda Boyd
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA,Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Darshan Kothari
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA,Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Neena Miller
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Jennifer Cornejo
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Brian Sullivan
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA,Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
5
|
Dangl M, Grant JK, Vincent L, Ebner B, Maning J, Olorunfemi O, Zablah G, Sancassani R, Colombo R. The association of pre-transplant atrial fibrillation with in-hospital outcomes in patients undergoing orthotopic liver transplantation: A propensity score matching analysis. J Card Surg 2022; 37:4762-4773. [PMID: 36403274 DOI: 10.1111/jocs.17183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 09/19/2022] [Accepted: 10/22/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION In this study, we sought to evaluate the prevalence and association of pre-transplant atrial fibrillation (AF) on 30-day postoperative outcomes in patients undergoing orthotopic liver transplant (OLT). METHOD The National Inpatient Sample Database was queried from 2011 to 2017 for relevant ICD-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients who underwent OLT with AF and those without. RESULTS Among 45,357 patients who underwent OLT, women made up 35.8% of the overall population. The prevalence of AF before transplant was 2932 (6.5%) with a trend toward increasing prevalence, with an average annual change rate of 4.19%. Applying propensity score matching to control for potential confounding factors, there was no association between pre-transplant AF and in-hospital mortality in patients undergoing OLT, however there was a higher incidence of perioperative complications including: acute kidney injury, ventricular tachycardia, major bleeding, blood product transfusion, and septic shock. CONCLUSION In patients undergoing OLT, pre-transplant AF is increasing in prevalence and appears to be associated with similar in-hospital mortality but worse perioperative outcomes. Greater emphasis should be placed on AF in the preoperative cardiovascular risk stratification of patients undergoing OLT.
Collapse
Affiliation(s)
- Michael Dangl
- Department of Internal Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jelani K Grant
- Department of Medicine, Cardiovascular Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Louis Vincent
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Bertrand Ebner
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jennifer Maning
- Department of Medicine, Cardiovascular Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Odunayo Olorunfemi
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gerardo Zablah
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rhea Sancassani
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rosario Colombo
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
6
|
Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
Collapse
Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| |
Collapse
|
7
|
Fei YP, Wang L, Zhu CY, Sun JC, Hu HL, Zhai CL, He CJ. Effect of a Novel Pocket Compression Device on Hematomas Following Cardiac Electronic Device Implantation in Patients Receiving Direct Oral Anticoagulants. Front Cardiovasc Med 2022; 9:817453. [PMID: 35282349 PMCID: PMC8907568 DOI: 10.3389/fcvm.2022.817453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundA pocket hematoma is a well-recognized complication that occurs after pacemaker or defibrillator implantation. It is associated with increased pocket infection and hospital stay. Patients suffering from atrial fibrillation and undergoing cardiovascular electronic implantable device (CIED) surgery are widely prescribed and treated with direct oral anticoagulants (DOACs). In this study, the use of a novel compression device was evaluated to examine its ability to decrease the incidence of pocket hematomas following device implantation with uninterrupted DOACs.MethodsA total of 204 participants who received DOACs and underwent CIED implantation were randomized into an experimental group (novel compression device) and a control group (elastic adhesive tape with a sandbag). The primary outcome was pocket hematoma, and the secondary outcomes were skin erosions and patient comfort score. Grade 3 hematoma was defined as a hematoma that required anticoagulation therapy interruption, re-operation, or prolonged hospital stay.ResultsThe baseline characteristics of both groups had no significant differences. The incidence of grades 1 and 2 hematomas was significantly lower in the compression device group than in the conventional pressure dressing group (7.8 vs. 23.5 and 2.0 vs. 5.9%, respectively; P < 0.01). Grade 3 hematoma occurred in 2 of 102 patients in the experimental group and 7 of 102 patients in the control group (2.0 vs. 6.9%; P = 0.03). The incidence rates of skin erosion were significantly lower, and the patient comfort score was much higher in the compression device group than in the control group (P < 0.01). Multivariable logistic regression analysis showed that the use of novel compression device was a significant protective factor for pocket hematoma (OR = 0.42; 95% CI, 0.29–0.69, P = 0.01).ConclusionsThe incidence of pocket hematomas and skin erosions significantly decreases when the proposed compression device is used for patients undergoing device implantation with uninterrupted DOACs. Thus, the length of hospital stay and re-operation rate can be reduced, and patient comfort can be improved.Clinical Trial Registrationhttp://www.chictr.org.cn, identifier: ChiCTR2100049430.
Collapse
Affiliation(s)
- Ye-Ping Fei
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Lei Wang
- Department of General Practice, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Chun-Yan Zhu
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Jing-Chao Sun
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Hui-Lin Hu
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Chang-Lin Zhai
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Chao-Jie He
- Department of Cardiology, The Affiliated Hospital of Jiaxing University, Jiaxing, China
- *Correspondence: Chao-Jie He
| |
Collapse
|
8
|
Flemons K, Bosch M, Coakeley S, Muzammal B, Kachra R, Ruzycki SM. Barriers and facilitators of following perioperative internal medicine recommendations by surgical teams: a sequential, explanatory mixed-methods study. Perioper Med (Lond) 2022; 11:2. [PMID: 35101113 PMCID: PMC8805252 DOI: 10.1186/s13741-021-00236-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/07/2021] [Indexed: 11/15/2022] Open
Abstract
Background Preoperative medical consultations add expense and burden for patients and the impact of these consults on patient outcomes is conflicting. Previous work suggests that 10–40% of preoperative medical consult recommendations are not followed. This limits measurement of the effect of perioperative medical consultation on patient outcomes and represents a quality gap, given the patient time and healthcare cost associated with consultation. We aimed to measure, characterize, and understand reasons for missed recommendations from preoperative medical consultation. Methods This explanatory, sequential mixed-methods study used chart audits followed by semi-structured interviews. Chart audit of consecutive patients seen in preoperative medical clinic were reviewed to measure the proportion and characterize the type of recommendations that were not completed (“missed”). This phase informed the interview participants and questions. The interview guide was developed using the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Template analysis was used to understand drivers and barriers of missed recommendations Results Chart audit included 255 patients (n=161, 63.1% female) seen in preadmission clinic between April 1 and April 30, 2019. 55.7% of patients had all recommendations followed (n=142). Postoperative anticoagulation management and postoperative cardiac biomarker surveillance recommendations were least commonly followed (50.0%, n=28, and 68.9%, n=82, respectively). Eighteen surgical team members were interviewed. Missed recommendations were both unintentional and intentional, and the key drivers differed by these categories. Unintentionally missed recommendations occurred due to individual-level factors (drivers: knowledge of the consultation note, lack of routine for reviewing the consultation note, and competing demands on time) and systems-level factors (driver: lack of role clarity). Intentionally missed recommendations occurred due to user error due (drivers: lack of knowledge of guidelines or evidence) and appropriate modifications (driver: need to adapt a preoperative plan for a complicated postoperative course). Conclusions Only 55.7% of consult notes had all recommendations followed, suggesting a quality gap in perioperative medical care. Qualitative data suggests multiple drivers of missed recommendations that should be targeted to improve the efficiency of care for these patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00236-x.
Collapse
Affiliation(s)
| | - Michael Bosch
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Coakeley
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bushra Muzammal
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rahim Kachra
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon M Ruzycki
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Room 1422, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta, T2N 2T9, Canada.
| |
Collapse
|
9
|
Eljilany I, El-Bardissy A, Elewa H. The Dilemma of Peri-Procedural Warfarin Management: A Narrative Review. Clin Appl Thromb Hemost 2021; 27:10760296211012093. [PMID: 34844473 PMCID: PMC8646195 DOI: 10.1177/10760296211012093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Periprocedural vitamin K antagonist management is a complex process and inherently entails multiple clinical issues. Marked variations have been reported in different aspects of this process. These differences were noted at the clinician and institutional levels owing to the lack of evidence-based data leading to many discrepancies in decision-making. This review aims to address the gap of vitamin K antagonist periprocedural management acknowledged by previously published prescribers’ questionnaires. One of the components of this process is “bridging,” which aims to provide minimal interruption of the anticoagulation period through the use of heparin products. Recent studies showed that bridging is increasing bleeding risk. Secondly, interruption decision relies on the classification of thromboembolism risk which depends on trials that did not include patients with atrial fibrillation. Thirdly, the interruption duration is different among different International normalization ratio levels, which strengthens the difference in the clinical practice of preoperative vitamin K antagonist management. Lastly, the resumption of a vitamin-K antagonist after surgery has many scenarios according to the procedure and patient risk of bleeding. Vitamin-K antagonist periprocedural management is complicated due to individual practice and the lack of strictly implemented institutional standardized protocols to guide, manage and evaluate the process.
Collapse
Affiliation(s)
- Islam Eljilany
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ahmed El-Bardissy
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| |
Collapse
|
10
|
Alcock HMF, Nayar SK, Moppett IK. Reversal of direct oral anticoagulants in adult hip fracture patients. A systematic review and meta-analysis. Injury 2021; 52:3206-3216. [PMID: 34548147 DOI: 10.1016/j.injury.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/15/2021] [Accepted: 09/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Increasing numbers of patients are taking Direct Oral Anticoagulants at the time of hip fracture. Evidence is limited on how and if the effects of DOAC's should be reversed before surgical fixation. Wide variations in practice exist. We conducted a systematic review to investigate outcomes for three reversal strategies. These were: "watch and wait" (also referred to as "time-reversal"), plasma product reversal and reversal with specific antidotes. METHODS A systematic search was conducted using multiple databases. Results were obtained for studies directly comparing different DOAC reversal strategies in hip fracture patients and for studies comparing DOAC-taking hip fracture patients (including patients "reversed" using any method and "non-reversed" patients) against matched controls taking either a vitamin-K antagonist or not receiving anticoagulation therapy. This allowed construction of a network meta-analysis to indirectly compare outcomes between "reversed" and "non-reversed" DOAC patients. With respect to "watch and wait"/"time-reversal", a cut-off time to surgery of 36 hours was used to distinguish between "time-reversed" and "non time-reversed" DOAC patients. The primary outcome was early/inpatient mortality, reported as Odds Ratios (OR). RESULTS No studies investigating plasma products or reversal agents specifically in hip fracture patients were obtained. Fourteen studies were suitable for analysis of "watch and wait"/"time- reversal". Two studies directly compared "time-reversed" and "non time-reversed" DOAC-taking hip fracture patients (58 "time-reversed", 62 "non time-reversed"). From 12 other studies we used indirect comparisons between "time-reversed" and "non time-reversed" DOAC patients (total, 357 "time-reversed", 282 "non time-reversed"). We found no statistically significant differences in mortality outcomes between "time-reversal" and "non time-reversal" (OR 1.48 [95%CI: 0.29-7.53]). We also did not find a statistically significant difference between "time reversal" and "non time-reversal" in terms of blood transfusion requirements (OR 1.16 [95% CI 0.42-3.23]). However, several authors described that surgical delay is associated with worse outcomes related to prolonged hospitalisation, and that operating within 36 hours is safe. CONCLUSIONS We suggested against "watch and wait" to reverse the DOAC effect in hip fractures. Further work is required to assess the optimal timing for surgery as well as the use of plasma products or specific antidotes in DOAC-taking hip fracture patients.
Collapse
Affiliation(s)
- H M F Alcock
- Academic Clinical Fellow, Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, UK
| | - S K Nayar
- Trauma and Orthopaedic Surgical Registrar, Centre for Trauma Sciences, Blizzard Institute, Queen Mary University of London, UK
| | - I K Moppett
- Professor and Consultant Anaesthetist, Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, UK Department of Anaesthesia, Nottingham University Hospitals, UK.
| |
Collapse
|
11
|
Eljilany I, El-Bardissy A, Nemir A, Elzouki AN, El Madhoun I, Al-Badriyeh D, Elewa H. Assessment of the attitude, awareness and practice of periprocedural warfarin management among health care professional in Qatar. A cross sectional survey. J Thromb Thrombolysis 2021; 50:957-968. [PMID: 32307632 PMCID: PMC7575475 DOI: 10.1007/s11239-020-02111-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
It is estimated that 10-15% of oral anticoagulant (OAC) patients, would need to hold their OAC for scheduled surgery. Especially for warfarin, this process is complex and requires multi-layer risk assessment and decisions across different specialties. Clinical guidelines deliver broad recommendations in the area of warfarin management before surgery which can lead to different trends and practices among practitioners. To evaluate the current attitude, awareness, and practice among health care providers (HCPs) on warfarin periprocedural management. A multiple-choice questionnaire was developed, containing questions on demographics and professional information and was completed by187 HCPs involved in warfarin periprocedural management. The awareness median (IQR) score was moderate [64.28% (21.43)]. The level of awareness was associated with the practitioner's specialty and degree of education (P = 0.009, 0.011 respectively). Practice leans to overestimate the need for warfarin discontinuation as well as the need for bridging. Participants expressed interest in using genetic tests to guide periprocedural warfarin management [median (IQR) score (out of 10) = 7 (5)]. In conclusion, the survey presented a wide variation in the clinical practice of warfarin periprocedural management. This study highlights that HCPs in Qatar have moderate awareness. We suggest tailoring an educational campaign or courses towards the identified gaps.
Collapse
Affiliation(s)
- Islam Eljilany
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ahmed El-Bardissy
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Arwa Nemir
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University & Weill Cornell Medical College- Qatar, Doha, Qatar
| | - Ihab El Madhoun
- Department of Medicine, Al Wakra Hospital Hamad Medical Corporation, Al Wakra, Qatar.,Weill Cornell Medical College, Al Wakra, Qatar
| | | | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
| |
Collapse
|
12
|
Kewcharoen J, Kanitsoraphan C, Thangjui S, Leesutipornchai T, Saowapa S, Pokawattana A, Navaravong L. Postimplantation pocket hematoma increases risk of cardiac implantable electronic device infection: A meta-analysis. J Arrhythm 2021; 37:635-644. [PMID: 34141016 PMCID: PMC8207394 DOI: 10.1002/joa3.12516] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/31/2020] [Accepted: 01/21/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Several studies have shown an inconsistent relationship between postimplantation pocket hematoma and cardiac implantable electronic device (CIED) infection. In this study, we performed a systematic review and meta-analysis to explore the effect of postimplantation hematoma and the risk of CIED infection. METHODS We searched the databases of MEDLINE and EMBASE from inception to March 2020. Included studies were cohort studies, case-control studies, cross-sectional studies, and randomized controlled trials that reported incidence of postimplantation pocket hematoma and CIED infection during the follow-up period. CIED infection was defined as either a device-related local or systemic infection. Data from each study were combined using the random effects, generic inverse variance method of Der Simonian and Laird to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS Fourteen studies were included in final analysis, involving a total of 28 319 participants. In random-effect model, we found that postimplantation pocket hematoma significantly increases the risk of overall CIED infection (OR = 6.30, 95% CI: 3.87-10.24, I 2 = 49.3%). There was no publication bias observed in the funnel plot as well as no small-study effect observed in Egger's test. CONCLUSIONS Our meta-analysis demonstrated that postimplantation pocket hematoma significantly increases the risk of CIED infection. Precaution should be taken during device implantation to reduce postimplantation hematoma and subsequent CIED infection.
Collapse
Affiliation(s)
- Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency ProgramHonoluluHIUSA
| | | | | | | | - Sakditad Saowapa
- Faculty of MedicineRamathibodi HospitalMahidol UniversityBangkokThailand
| | | | - Leenhapong Navaravong
- Division of Cardiovascular MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
| |
Collapse
|
13
|
Damen NL, de Vos MS, Moesker MJ, Braithwaite J, de Lind van Wijngaarden RAF, Kaplan J, Hamming JF, Clay-Williams R. Preoperative Anticoagulation Management in Everyday Clinical Practice: An International Comparative Analysis of Work-as-Done Using the Functional Resonance Analysis Method. J Patient Saf 2021; 17:157-165. [PMID: 29994818 DOI: 10.1097/pts.0000000000000515] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Preoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. METHODS The study was conducted at an Australian and European Cardiothoracic Surgery Department. A FRAM model of work-as-imagined was developed using (inter)national guidelines. Semistructured interviews with 18 involved professionals were used to develop models reflecting work-as-done at both sites, which were presented to staff for validation. Workload in hours was estimated per process step. RESULTS In both centers, work-as-done differed from work-as-imagined, such as in the division of tasks among disciplines (e.g., nurses/registrars rather than medical specialists), but control mechanisms had been developed locally to ensure safe care (e.g., crosschecking with other clinicians). Centers had organized the process differently, revealing opportunities for improvement regarding patient information and clustering of clinic visits. Presenting FRAM models to staff initiated discussion on improvement of functions in the model that are vital for success. Overall workload was estimated at 47 hours per site. CONCLUSIONS This FRAM analysis provided insight into PAM from the perspective of frontline clinicians, revealing essential functions, interdependencies and variability, and the relation with guidelines. Future studies are warranted to study the potential of FRAM, such as for guiding improvements in complex systems.
Collapse
Affiliation(s)
- Nikki L Damen
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Marit S de Vos
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marco J Moesker
- Amsterdam Public Health Research Institute, Department of Public and Occupational Health, VU University Medical Centre, Amsterdam
| | - Jeffrey Braithwaite
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | | | - Jason Kaplan
- Faculty of Medicine and Health Sciences, Macquarie University Hospital, Sydney, Australia
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Robyn Clay-Williams
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| |
Collapse
|
14
|
Douketis JD, Syed S, Li N, Narouze S, Radwi M, Duncan J, Schulman S, Spyropoulos AC. A physician survey of perioperative neuraxial anesthesia management in patients on a direct oral anticoagulant. Res Pract Thromb Haemost 2021; 5:159-167. [PMID: 33537540 PMCID: PMC7845072 DOI: 10.1002/rth2.12430] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/05/2020] [Accepted: 08/07/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The perioperative management of patients taking a direct oral anticoagulant (DOAC) who require a high-bleed-risk surgery and/or neuraxial anesthesia is uncertain. We surveyed clinician practices relating to DOAC interruption and related perioperative management in patients having high-bleed-risk surgery with neuraxial anesthesia, and assess the suitability of a randomized trial of different perioperative DOAC management strategies. METHODS We surveyed members of the American Society of Regional Anesthesia and Pain Medicine, the Canadian Anesthesia Society and Thrombosis Canada. We developed four clinical scenarios involving DOAC-treated patients who required anticoagulant interruption for elective high-bleed-risk surgery. In three scenarios, patients were to receive neuraxial anesthesia, and in one scenario they were to receive general anesthesia. We also asked about the merit of a randomized trial to compare a 2-day versus longer (3- to 5-day) duration of DOAC interruption. RESULTS There were 399 survey respondents of whom 356 (89%) were anesthetists and 43 (11%) were medical specialists. The responses indicate uncertainty about the DOAC interruption interval for high-bleed-risk surgery and/or neuraxial anesthesia; anesthetists favor 3- to 5-day interruption whereas medical specialists favor 2-day interruption. Anesthetists were unwilling to proceed with neuraxial anesthesia in patients with a 2-day DOAC interruption interval, preferring to cancel the surgery or switch to general anesthesia. There is general agreement on the need for a randomized trial in this field to compare a 2-day and a 3- to 5-day DOAC interruption management strategy. CONCLUSIONS There is variability in practices relating to the perioperative management of DOAC-treated patients who require a high-bleed-risk surgery with neuraxial anesthesia; this variability relates to the duration of DOAC interruption in such patients.
Collapse
Affiliation(s)
| | - Summer Syed
- Department of AnesthesiologyMcMaster UniversityHamiltonONCanada
| | - Na Li
- Department of MedicineMcMaster UniversityHamiltonONCanada
| | - Samer Narouze
- Center for Pain MedicineWestern Reserve HospitalCuyahoga FallsOHUSA
| | - Mansoor Radwi
- Department of HematologyFaculty of MedicineUniversity of JeddahJeddahSaudi Arabia
| | - Joanne Duncan
- Department of MedicineMcMaster UniversityHamiltonONCanada
| | - Sam Schulman
- Department of MedicineMcMaster UniversityHamiltonONCanada
- Department of Obstetrics and GynecologyI.M. Sechenov First Moscow State Medical UniversityMoscowRussia
| | - Alex C. Spyropoulos
- Zucker School of Medicine at Hofstra/NorthwellNorthwell Health at Lenox Hill HospitalNew YorkNYUSA
| |
Collapse
|
15
|
Li YD, MaiMaiTiABuDuLa M, Cao GQ, MaiMaiTiAiLi M, Zhou XH, Lu YM, Zhang JH, Xing Q, Wu CJ, Feng M, Zhang GG, Tang BP. A prospective comparison of four methods for preventing pacemaker pocket infections. Artif Organs 2020; 45:411-418. [PMID: 33001439 DOI: 10.1111/aor.13832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 09/22/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
This study aims to evaluate four pacemaker pocket cleaning methods for preventing implantation-related infections. This single-center trial prospectively randomized 910 patients undergoing first-time pacemaker implantation or replacement into four pocket cleaning methods: hemocoagulase (group A, n = 228), gentamicin (group B, n = 228), hemocoagulase plus gentamicin (group C, n = 227), and normal saline (group D, n = 227). Before implanting the pacemaker battery, the pockets were cleaned with gauze presoaked in the respective cleaning solutions. Then, these patients were followed up to monitor the occurrence of infections for 1 month after implantation. Twelve implantation-related infections occurred in 910 patients (1.32%): four patients from group A (1.75%), three patients from group B (1.32%), two patients from group C (0.88%), and three patients from group D (1.32%) (P > .05). Furthermore, two patients developed bloodstream infections (0.22%), and both of these patients were associated with pocket infection (one patient was from group A, while the other patient was from group C, respectively). No cases of infective endocarditis occurred. The differences in the number of infections in these study groups were not statistically significant. The application of hemocoagulase, gentamicin, hemocoagulase plus gentamicin, or normal saline on the presoaked gauze before implantation was equally effective in preventing pocket-associated infections.
Collapse
Affiliation(s)
- Yao-Dong Li
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Gui-Qiu Cao
- Cardiology Department, the 5th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Xian-Hui Zhou
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yan-Mei Lu
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Jiang-Hua Zhang
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Qiang Xing
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Chuang-Ju Wu
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Min Feng
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ge-Ge Zhang
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Bao-Peng Tang
- Pacing and Electrophysiology Department, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| |
Collapse
|
16
|
Eliasberg CD, Levack AE, Gausden EB, Garvin S, Russell LA, Kelly AM. Perioperative Use of Novel Oral Anticoagulants in Orthopaedic Surgery: A Critical Analysis Review. JBJS Rev 2020; 7:e4. [PMID: 31291203 DOI: 10.2106/jbjs.rvw.18.00148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Claire D Eliasberg
- Departments of Orthopaedic Surgery (C.D.E., A.E.L., E.B.G., and A.M.K.), Anesthesiology (S.G.), and Medicine (L.A.R.), Hospital for Special Surgery, New York, NY
| | | | | | | | | | | |
Collapse
|
17
|
Tien A, Kwok K, Dong E, Wu B, Chung J, Chang J, Reynolds K. Impact of direct-acting oral anticoagulants and warfarin on postendoscopic GI bleeding and thromboembolic events in patients undergoing elective endoscopy. Gastrointest Endosc 2020; 92:284-292.e2. [PMID: 32126220 DOI: 10.1016/j.gie.2020.02.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS An increasing number of patients are undergoing GI endoscopic procedures with active prescriptions for direct oral anticoagulants (DOACs). DOACs have been associated with a higher risk of GI bleeding (GIB) compared with warfarin. Our aims were to compare the risk of postendoscopic GIB and thromboembolic (TE) events among patients on DOACs versus warfarin. METHODS We conducted a retrospective cohort study of patients aged 18 years or older in a large integrated health care system in Southern California, who had undergone an outpatient GI endoscopic procedure and were taking a DOAC or warfarin between January 1, 2013, and October 1, 2019. We compared bleeding and thrombosis risk in the 30 days after the endoscopic procedure between the warfarin and DOAC groups using multivariate logistic regression analysis adjusted for covariates. RESULTS Between January 1, 2013, and October 1, 2019, we identified 6765 outpatient GI endoscopic procedures in which patients received preprocedure prescriptions for either a DOAC (1587) or warfarin (5178). Overall, there was no significant difference in postprocedure GIB (odds ratio [OR], 1.165; 95% confidence interval [CI], 0.88-1.55; P = .291) or TE (OR, 0.929; 95% CI, 0.64-1.35; P = .703) between the DOAC and warfarin groups). Subgroup analysis revealed a higher risk of GIB associated with DOAC specifically with EGD procedures (OR, 1.8; 95% CI, 1.15-2.83; P = .011). CONCLUSIONS There was no significant difference in the overall postendoscopic risk of GIB and TE events among patients with preprocedure use of DOACs compared with patients on warfarin. There may be a higher risk of GIB in patients taking DOACs and undergoing EGD.
Collapse
Affiliation(s)
- Andy Tien
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Karl Kwok
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Elizabeth Dong
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Bechien Wu
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Joanie Chung
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jonathan Chang
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| |
Collapse
|
18
|
Periprocedural Outcomes in Patients on Chronic Anticoagulation Undergoing Fistulograms. Ann Vasc Surg 2020; 70:123-130. [PMID: 32416311 DOI: 10.1016/j.avsg.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/22/2020] [Accepted: 05/02/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Management of antithrombotic therapy with warfarin in patients undergoing fistulograms and possible interventions is controversial and difficult because of lack of adequate outpatient bridging options. Our goal was to assess periprocedural outcomes in patients managed using different anticoagulation strategies. METHODS A retrospective, single-institution analysis of all patients on chronic anticoagulation with warfarin undergoing fistulograms from 2011 to 2017 was performed. Anticoagulation management strategies were classified as suspended warfarin (SW), continued warfarin (CW), and a heparin bridge with suspended warfarin (HB). Periprocedural outcomes were analyzed. RESULTS There were 87 patients on chronic anticoagulation with warfarin who underwent 175 fistulograms. Median age was 63 years, and 43.4% were women. Indications for warfarin included atrial fibrillation (53%), prior pulmonary embolism/deep vein thrombosis (29%), and hypercoagulable state (14%). Distribution was SW (60%), CW (26%), and HB (14%). Approximately half (53%) were same-day procedures, 30% occurred during access-related admissions, and 14% were performed during nonaccess-related admissions. Common indications for a fistulogram included difficulty with dialysis (63.4%), access thrombosis (20.6%), and poor maturation (10.3%). Interventions included angioplasty (82.9%), thrombectomy/embolectomy (20.6%), and stenting (8.6%). Thirty-day outcomes for SW versus CW versus HB were similar for bleeding complications (5.7%, 6.5%, 8.3%; P = 0.89), systemic thrombotic complications (3.8%, 2.2%, 0%; P = 0.569), access rethrombosis (7.6%, 13%, 12.5%; P = 0.517), and tunneled dialysis catheter placement (11.4%, 13%, 12.5%; P = 0.958). After excluding procedures performed during a nonaccess-related admission, length of stay (LOS) was highest among HB (9.6 ± 7.8 days) compared with SW (2.6 ± 5.9 days) and CW (1 ± 2.8 days), (P < 0.0001). CONCLUSIONS CW therapy in patients undergoing fistulograms was not associated with increased morbidity and was associated with shorter LOS. Bridging with heparin is not associated with improved outcomes, warranting a thorough consideration of continuing warfarin is safe and may streamline preservation of dialysis accesses without significantly increasing resource utilization.
Collapse
|
19
|
Lessire S, Dincq AS, Siriez R, Pochet L, Sennesael AL, Vornicu O, Hardy M, Deceuninck O, Douxfils J, Mullier F. Assessment of low plasma concentrations of apixaban in the periprocedural setting. Int J Lab Hematol 2020; 42:394-402. [PMID: 32297711 DOI: 10.1111/ijlh.13202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/19/2020] [Accepted: 03/22/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Estimation of residual apixaban plasma concentrations may be requested in the management of emergencies. This study aims at assessing the performance of specific anti-Xa assays calibrated with apixaban on real-life samples with low apixaban plasma concentrations (<30 ng/mL) and on-treatment ranges, with and without interference of low-molecular-weight heparin (LMWH). METHODS The performance of the STA® -Liquid Anti-Xa assay (STA® LAX) and the low and normal procedures of the Biophen® Direct Factor Xa Inhibitors (DiXaI) assay was tested on 134 blood samples, collected from patients on apixaban, wherefrom 74 patients received LMWH after apixaban cessation. The results were compared with the liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) measurements. RESULTS The Biophen® DiXaI, Biophen® DiXaI LOW, and STA® LAX showed very good correlation with LC-MS/MS measurements in patients without LMWH administration (Spearman r .95, .99, and .98, respectively). Their limits of quantitation were defined at 48, 24, and 12 ng/mL, respectively. The Bland-Altman test measured mean bias (SD) at 5.6 (13.1), -2.5 (5.0), and -0.8 (6.1) ng/ml, respectively. The Spearman r of the Biophen® DiXaI decreased to 0.64 in presence of low apixaban concentrations. The Spearman r of the Biophen® DiXaI LOW and STA® LAX decreased to 0.39 and 0.26, respectively, in presence of LMWH. CONCLUSIONS The accuracy of the low methodologies (Biophen® DiXaI LOW and STA® LAX) is slightly improved for low apixaban plasma concentrations, compared with the normal procedure of Biophen® DiXaI. The interference of LMWH on the low methodologies is measurable, however, less important than the previously reported interference of LMWH on rivaroxaban calibrated specific anti-Xa assays.
Collapse
Affiliation(s)
- Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Romain Siriez
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
| | - Lionel Pochet
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
| | - Anne-Laure Sennesael
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Yvoir, Belgium
| | - Ovidiu Vornicu
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Michael Hardy
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Olivier Deceuninck
- Université catholique de Louvain, CHU UCL Namur, Department of Cardiology, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium.,Qualiblood sa, Namur, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
| |
Collapse
|
20
|
Severe Enoral Bleeding with a Direct Oral Anticoagulant after Tooth Extraction and Heparin Bridging Treatment. Case Rep Emerg Med 2019; 2019:6208604. [PMID: 31781415 PMCID: PMC6875271 DOI: 10.1155/2019/6208604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/18/2019] [Accepted: 08/08/2019] [Indexed: 12/04/2022] Open
Abstract
Background The number of patients receiving direct oral anticoagulants (DOACs) is increasing, however, this treatment is associated with the risk of bleeding. More than 10 percent of patients on DOACs have to interrupt their anticoagulation for an invasive procedure every year. For this reason, the correct management of DOACs in the perioperative setting is mandatory. Case Presentation An 81-year-old male patient, with known impaired renal function, presented to our emergency department with a severe enoral bleeding after tooth extraction. The DOAC therapy—indicated by known atrial fibrillation—was interrupted perioperatively and bridged with Low Molecular Weight Heparin (LMWH). The acute bleeding was stopped by local surgery. The factors contributing to the bleeding complication were bridging of DOAC treatment, together with prolonged drug action in chronic kidney disease. Conclusion In order to decide whether it is necessary to stop DOAC medication for tooth extraction, it is important to carefully weigh up the individual risks of bleeding and thrombosis. If DOAC therapy is interrupted, bridging should be reserved for thromboembolic high-risk situations. Particular caution is required in patients with impaired kidney function, due to the risk of accumulation and prolonged anticoagulant effect of both DOACs and LMWH.
Collapse
|
21
|
Caturano A, Galiero R, Pafundi PC. Atrial Fibrillation and Stroke. A Review on the Use of Vitamin K Antagonists and Novel Oral Anticoagulants. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E617. [PMID: 31547188 PMCID: PMC6843417 DOI: 10.3390/medicina55100617] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/01/2019] [Accepted: 09/13/2019] [Indexed: 01/17/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia, ranging from 0.1% in patients <55 years to >9% in octogenarian patients. One important issue is represented by the 5-fold increased ischemic stroke risk in AF patients. Hence, the role of anticoagulation is central. Until a few years ago, vitamin K antagonists (VKAs) and low molecular weight heparin represented the only option to prevent thromboembolisms, though with risks. Novel oral anticoagulants (NOACs) have radically changed the management of AF patients, improving both life expectancy and life quality. This review aims to summarize the most recent literature on the use of VKAs and NOACs in AF, in light of the new findings.
Collapse
Affiliation(s)
- Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Luigi Miraglia 2, IT-80138 Naples, Italy.
| | - Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Luigi Miraglia 2, IT-80138 Naples, Italy.
| | - Pia Clara Pafundi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Luigi Miraglia 2, IT-80138 Naples, Italy.
| |
Collapse
|
22
|
Bhattad VB, Gaddam S, Lassiter MA, Jagadish PS, Ardeshna D, Cave B, Khouzam RN. Intravenous cangrelor as a peri-procedural bridge with applied uses in ischemic events. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:408. [PMID: 31660307 PMCID: PMC6787394 DOI: 10.21037/atm.2019.07.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/15/2019] [Indexed: 11/06/2022]
Abstract
Cangrelor is a relatively new antiplatelet drug that has been approved for use as an adjunct therapy to percutaneous coronary intervention (PCI) to decrease peri-procedural myocardial infarction (MI), coronary revascularization, and stent thrombosis. Cangrelor is an adenosine triphosphate analogue with a pharmacokinetic mechanism based on a reversible, dose-dependent inhibition adenosine diphosphate (ADP)-induced platelet aggregation. This drug has lately been in the spotlight as a possible bridge therapy for anti-platelet medication prior to cardiac and non-cardiac surgeries. Platelet function is usually restored within sixty minutes of cessation of therapy, thereby decreasing the risk of bleeding while providing adequate pre-procedural coverage to reduce ischemic events. This manuscript reviews the literature on cangrelor and summarizes its role as a peri-procedural bridge.
Collapse
Affiliation(s)
- Venugopal B. Bhattad
- Department of Internal Medicine, Division of Cardiovascular Diseases, East Tennessee State University, Johnson City, TN, USA
| | - Sathvika Gaddam
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Margaret A. Lassiter
- Cardiovascular Clinical Pharmacy Department, Johnson City Medical Center, Johnson City, TN, USA
| | | | - Devarshi Ardeshna
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Brandon Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Rami N. Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
23
|
Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance. Thromb J 2019; 17:15. [PMID: 31391790 PMCID: PMC6681479 DOI: 10.1186/s12959-019-0204-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/26/2019] [Indexed: 12/18/2022] Open
Abstract
Background Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. Objectives Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. Methods A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. Results Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69-81.99), vascular surgery (OR 13.01, 95% CI 1.83-92.30), non-elective surgery (OR 8.67, 95% CI 1.67-45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11-1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04-1.16). Conclusion Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients.
Collapse
|
24
|
Moesker MJ, de Groot JF, Damen NL, Huisman MV, de Bruijne MC, Wagner C. How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review. BMJ Open 2019; 9:e029879. [PMID: 31320357 PMCID: PMC6661608 DOI: 10.1136/bmjopen-2019-029879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Surgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied. DESIGN A multicentre retrospective patient record review. SETTING AND PARTICIPANTS Records from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES Our primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level. RESULTS Preoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%-100%), international normalised ratio testing (range 21%-94%) and postoperative bridging (range 20%-88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients' weight. CONCLUSIONS Unsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.
Collapse
Affiliation(s)
- Marco J Moesker
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Janke F de Groot
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Nikki L Damen
- Departmentof Quality and Safety, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Martine C de Bruijne
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| |
Collapse
|
25
|
Buil Arasanz ME, Bobé Armant F, Santuré Sinfreu S, Campos Aranda L. [What would you do with a patient with non-valvular atrial fibrillation treated with direct-acting oral anticoagulants who had to undergo gastroscopy or colonoscopy?]. Semergen 2019; 45:197-202. [PMID: 30876813 DOI: 10.1016/j.semerg.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/07/2018] [Accepted: 01/09/2019] [Indexed: 11/19/2022]
Abstract
In Spain, approximately 25% of patients anticoagulated due to non-valvular atrial fibrillation use a direct-acting anticoagulant (DOAC). It is foreseeable that most of them at some point in their lives should undergo invasive procedures or surgical treatments. This makes the management of DOAC in these situations essential in order to perform the procedure with maximum safety and minimise the risk to the maximum of haemorrhage and thrombosis. The management of this situation is based on the evaluation of the haemorrhagic risk of the patient, and the procedure to be performed, the risk of thromboembolism, and renal function. The pharmacokinetic characteristics of the DOAC also should be taken into account, especially its half-life, the degree of renal elimination and its peak action.
Collapse
Affiliation(s)
- M E Buil Arasanz
- Medicina Familiar y Comunitaria, EAP Raval Nord, Atención Primaria, Institut Català de la Salut, Barcelona, España.
| | - F Bobé Armant
- Medicina Familiar y Comunitaria, EAP Jaume I, Atención Primaria, InstitutCatalà de la Salut, Tarragona, España
| | - S Santuré Sinfreu
- Medicina Familiar y Comunitaria, EAP Raval Nord, Atención Primaria, Institut Català de la Salut, Barcelona, España
| | - L Campos Aranda
- Enfermería, EAP Raval Nord, Atención Primaria, Institut Català de la Salut, Barcelona, España
| |
Collapse
|
26
|
El-Bardissy A, Elewa H, Mohammed S, Shible A, Imanullah R, Mohammed AM. A Survey on the Awareness and Attitude of Physicians on Direct Oral Anticoagulants in Qatar. Clin Appl Thromb Hemost 2018; 24:255S-260S. [PMID: 30347989 PMCID: PMC6714830 DOI: 10.1177/1076029618807575] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are more commonly prescribed since their introduction. Reports on inappropriate prescribing have been observed which may indicate poor awareness on these agents. In this study, we aim to evaluate the extent of the physicians' knowledge on DOACs and its possible impact on physicians' confidence to prescribe these medications. A prospective cross-sectional survey was developed based on the literature review. Eligible participants were physicians and surgeons currently practicing at Hamad General Hospital in Qatar. The survey included questions on demographic and professional characteristics. It also evaluated the awareness and attitudes regarding safety, efficacy, and prescribing of DOACs. Over 6-month period, 175 practitioners responded to the survey. Overall awareness score was moderate (61% ± 18%). These scores were in alignment with participants' self-satisfaction with knowledge on DOACs (66% were not satisfied) and participants' confidence toward prescribing DOACs (48% were not confident). Age, degree of education, and years of experience had significant positive influence on awareness score. This survey indicates that practitioners have moderate awareness on DOACs. Future work should focus on reassessing practitioners' knowledge after providing well-designed education campaigns.
Collapse
Affiliation(s)
| | - Hazem Elewa
- College of Pharmacy, Qatar University, Doha, Qatar
| | | | - Ahmed Shible
- Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rizwan Imanullah
- Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,MSc Clinical Pharmacy Queen's University Belfast, Belfast, UK
| | - Abdul Moqeeth Mohammed
- Consultant Ambulatory Internal Medicine Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| |
Collapse
|
27
|
Collins-Yoder A, Collins RE. Periprocedural Considerations for Anticoagulated Atrial Fibrillation Patients. J Perianesth Nurs 2018; 34:227-239. [PMID: 30245032 DOI: 10.1016/j.jopan.2018.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 04/17/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022]
Abstract
Periprocedural patient instruction and coordination is an important piece in achieving safe outcomes for patients needing procedures and receiving anticoagulants for atrial fibrillation. Balancing the needs for anticoagulation versus bleeding during the procedure requires clinical reasoning and preparation. In this article, the current guidelines for use of anticoagulants with atrial fibrillation, the relevant pharmacology, and the use of standardized tools to quantify the risks of thrombus or bleeding in the procedures will be discussed. In addition, resources for examining the optimal practice for these case types will be provided. Perianesthesia health care providers are pivotal to lead relevant stakeholders in the perianesthesia setting work together to create protocols and individual plans of care for this patient population.
Collapse
|
28
|
Kurlander JE, Barnes GD, Anderson MA, Haymart B, Kline-Rogers E, Kaatz S, Saini SD, Krein SL, Richardson CR, Froehlich JB. Mind the gap: results of a multispecialty survey on coordination of care for peri-procedural anticoagulation. J Thromb Thrombolysis 2018; 45:403-409. [PMID: 29423559 DOI: 10.1007/s11239-018-1625-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
To understand how physicians from various specialties perceive coordination of care when managing peri-procedural anticoagulation. Cross-sectional survey of cardiologists, gastroenterologists, and primary care physicians (PCPs) in an integrated health system (N = 251). The survey began with a vignette of a patient with atrial fibrillation co-managed by his PCP, cardiologist, and an anticoagulation clinic who must hold warfarin for a colonoscopy. Respondents' experiences and opinions around responsibilities and institutional support for managing peri-procedural anticoagulation were elicited using multiple choice questions. We examined differences in responses across specialties using Chi square analysis. The response rate was 51% (n = 127). 52% were PCPs, 28% cardiologists, and 21% gastroenterologists. Nearly half (47.2%) of respondents believed that the cardiologist should be primarily responsible for managing peri-procedural anticoagulation, while fewer identified the PCP (25.2%), anticoagulation clinic (21.3%), or gastroenterologist (6.3%; p = 0.09). Respondents across specialties had significantly different approaches to deciding how to manage the clinical case presented (p < 0.001). Most cardiologists (60.0%) would decide whether to offer bridging without consulting with other providers or clinical resources, while most PCPs would decide after consulting clinical resources (57.6%). Gastroenterologists would most often (46.2%) defer the decision to another provider. A majority of all three specialties agreed that their institution could do more to help manage peri-procedural anticoagulation, and there was broad support (88.1%) for anticoagulation clinics' managing all aspects of peri-procedural anticoagulation. Providers across specialties agree that their institution could do more to help manage peri-procedural anticoagulation, and overwhelmingly support anticoagulation clinics' taking responsibility.
Collapse
Affiliation(s)
- Jacob E Kurlander
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA. .,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA. .,3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.
| | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michelle A Anderson
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian Haymart
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Eva Kline-Rogers
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Sameer D Saini
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health Services Research & Development Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health Services Research & Development Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Caroline R Richardson
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - James B Froehlich
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
29
|
Khan H, Kumar V, Ghulam-Jelani Z, McCallum SE, Hobson E, Sukul V, Pilitsis JG. Safety of Spinal Cord Stimulation in Patients Who Routinely Use Anticoagulants. PAIN MEDICINE 2018; 19:1807-1812. [PMID: 29186582 DOI: 10.1093/pm/pnx305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective We assess the safety of performing the epidural placement or revision of spinal cord stimulation (SCS) in patients whose anticoagulation has been held (termed "anticoagulant-suspended" patients) in accordance with the 2017 Neurostimulation Appropriateness Consensus Committee (NACC) guidelines. Subjects Patients undergoing SCS were included in this institutional review board-approved study. Design A retrospective analysis of a prospectively collected database was performed. Any adverse event occurring within 90 days after SCS lead placement/revision was included. Results A total of 225 patients who had a total of 239 surgeries including lead placement or lead revision were included; 182 patients were not on anticoagulants, 37 patients used one anticoagulant, and six patients used two or more anticoagulants. There were 13 adverse events. Anticoagulant use as a whole had no significant relationship to operative or postoperative adverse effects (χ2(1) = 1.613, P > 0.05). No anticoagulant on its own contributed significantly to adverse events; however, a small set of surgical cases showed a significantly greater incidence of adverse events for patients on enoxaparin used in combination with other anticoagulants (P < 0.05, N = 4). Conclusions This study is the first to demonstrate that anticoagulant-suspended patients have no increased risk of perioperative hemorrhagic or thromboembolic adverse effects following SCS surgery compared with nonanticoagulated patients. The findings of this study validate the safety of neuromodulation in anticoagulation-suspended patients, concurring with the findings of previously described case studies, which anecdotally described neuromodulation outcomes in patients whose anticoagulation regimen had been temporarily held.
Collapse
Affiliation(s)
- Hirah Khan
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Vignessh Kumar
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | | | - Sarah E McCallum
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Ellie Hobson
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Vishad Sukul
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York.,Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| |
Collapse
|
30
|
Slivnick JA, Yeow RY, McMahon C, Paje DG, Kurlander JE, Barnes GD. Current Trends in Anticoagulation Bridging for Patients With Chronic Atrial Fibrillation on Warfarin Undergoing Endoscopy. Am J Cardiol 2018; 121:1548-1551. [PMID: 29678338 DOI: 10.1016/j.amjcard.2018.02.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 02/19/2018] [Accepted: 02/26/2018] [Indexed: 11/29/2022]
Abstract
For warfarin-treated patients with atrial fibrillation (AF) at low thromboembolic risk, recent studies have shown harm associated with periprocedural bridging using low-molecular-weight heparin. Clinician surveys have indicated a preference toward excessive bridging, especially among noncardiologists; however, little is known about actual practice patterns in these patients. We performed a retrospective evaluation of bridging in the setting of gastrointestinal endoscopy. We identified 938 patients with AF on warfarin who underwent esophagogastroduodenoscopy or colonoscopy between 2012 and 2016 at a tertiary health center. Urgent, inpatient, or advanced endoscopic procedures were excluded. Clinical variables were abstracted using a predefined data dictionary. Values were expressed as means and compared using a t test or a chi-squared test as appropriate. Three hundred seventy-four patients met criteria for analysis. Twenty-five percent of these patients received bridging therapy, including 11% of patients with CHADS2 scores of 0 to 2 without valvular AF or previous venous thromboembolism. Of the clinical variables assessed, CHADS2, CHA2DS2-VASc, and a history of stroke were the strongest predictors of bridging. Cardiologists were also significantly less likely to prescribe bridging than noncardiology providers (18% vs 30%, p = 0.011); this effect was significant when controlling for CHADS2, CHA2DS2-VASc, or stroke history. In conclusion, patients with AF on warfarin receive excessive low-molecular-weight heparin bridging in the setting of endoscopy; the lower rates of bridging observed among cardiologists suggests a need for their increased involvement in this decision making.
Collapse
|
31
|
Kataruka A, Renner E, Barnes GD. Evaluating the role of clinical pharmacists in pre-procedural anticoagulation management. Hosp Pract (1995) 2017; 46:16-21. [PMID: 29283294 DOI: 10.1080/21548331.2018.1420346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES While physicians are typically responsible for managing perioperative warfarin, clinic pharmacists may improve pre-procedural decision-making. We assessed the impact of pharmacist-driven care for chronic warfarin-treated patients undergoing outpatient right heart catheterization (RHC). METHODS 200 warfarin patients who underwent RHC between January 2012 and September 2015 were analyzed. Pharmacist-care (n = 79) was compared to the usual care model (n = 121). The primary outcome was a composite of (1) documentation of anticoagulation plan, (2) holding warfarin at least 5 days prior to procedure, (3) guideline-congruent low molecular weight heparin (LMWH) bridging, and (4) correct LMWH dosing if bridging deemed necessary. Chi-squared test performed to assess the role of pharmacist. A multivariable logistic regression analysis was performed to the composite endpoint, adjusted for the month of procedure. RESULTS Compared to the usual care model, pharmacist-driven care (OR 4.69, 95% CI 1.73-12.71, p = 0.002) and date of the procedure (OR 1.06/month, 95% CI 1.01-1.10, p = 0.011) were independently associated with the primary composite outcome. Of the individual outcome components, pharmacist-driven care was only associated with documentation (96.2% vs. 67.8%, OR 9.19, 95% CI 2.19-38.62, p = 0.002). Remaining components including hold warfarin for at least 5 days, appropriate bridging and correct LMWH dosing were not significantly associated with pharmacist-care. CONCLUSIONS Pharmacist-care is associated with better guideline-based anticoagulation management, but this was primarily driven by improved documentation. The impact of pharmacist managed peri-procedural anticoagulation on clinical outcomes remains unknown.
Collapse
Affiliation(s)
- Akash Kataruka
- a Department of Internal Medicine , Michigan Medicine , Ann Arbor , MI , USA
| | - Elizabeth Renner
- b Department of Pharmacy Services , Michigan Medicine , Ann Arbor , MI , USA
| | - Geoffrey D Barnes
- c Frankel Cardiovascular Center , Michigan Medicine , Ann Arbor , MI , USA
| |
Collapse
|
32
|
Godier A, Dincq AS, Martin AC, Radu A, Leblanc I, Antona M, Vasse M, Golmard JL, Mullier F, Gouin-Thibault I. Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study. Eur Heart J 2017; 38:2431-2439. [DOI: 10.1093/eurheartj/ehx403] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 06/29/2017] [Indexed: 12/20/2022] Open
|
33
|
Auer J, Huber K, Granger CB. Interruption of non-vitamin K antagonist anticoagulants in patients undergoing planned invasive procedures: how long is long enough? Eur Heart J 2017; 38:2440-2443. [DOI: 10.1093/eurheartj/ehx416] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
34
|
Wamala H, Scott IA, Caney X. Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital. Intern Med J 2017; 47:1412-1421. [PMID: 28589690 DOI: 10.1111/imj.13513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/10/2017] [Accepted: 06/01/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Increasing numbers of patients receiving new oral anticoagulants (NOAC) are undergoing elective surgery. The extent to which perioperative interruption of NOAC therapy and use of bridging heparin are concordant with best evidence is uncertain. AIMS To determine: (i) concordance of NOAC and bridging heparin use with guidelines; and (ii) associations between guideline concordance and patient characteristics, surgical factors and perioperative adverse events. METHODS Retrospective study of consecutive adult patients undergoing elective surgery at a tertiary hospital between 1 January 2014 and 30 June 2015 and were receiving NOAC for at least 3 months prior to surgery. Concordance of perioperative anticoagulation management with hospital guidelines was rated by two independent researchers according to explicit thrombosis and bleeding risk tables. RESULTS One hundred and fifty patients of mean (±SD) age 72.0 (±11.6) years were studied; 75% had atrial fibrillation as NOAC indication. Decision to interrupt anticoagulation in 142 patients was rated guideline-concordant in 59 (41.5%) based on low bleeding risk in all cases and high thrombotic risk in one-third. Concordant decisions were associated with past myocardial infarction (P = 0.009), chronic kidney disease (P = 0.05), use of dabigatran (P = 0.06) and major surgery (P < 0.001). Bridging heparin was prescribed in 51 (35.9%) patients and not prescribed in 91 (64.1%), with 64 (45.1%) decisions rated guideline-discordant comprising 27 decisions to prescribe and 37 not to prescribe. Guideline concordant bridging was associated with chronic kidney disease (P = 0.02); discordant bridging with use of dabigatran (P = 0.04), high thrombotic risk (P = 0.004), past ischaemic stroke (P = 0.07). At 30 days, only one adverse event (major bleed) was noted. CONCLUSION Considerable discordance exists between guideline recommendations and perioperative NOAC management. Assistive tools are required that better align decision-making with current best practice.
Collapse
Affiliation(s)
- Henry Wamala
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Xenia Caney
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| |
Collapse
|
35
|
Dubois V, Dincq AS, Douxfils J, Ickx B, Samama CM, Dogné JM, Gourdin M, Chatelain B, Mullier F, Lessire S. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017; 15:14. [PMID: 28515674 PMCID: PMC5433145 DOI: 10.1186/s12959-017-0137-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/04/2017] [Indexed: 12/31/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.
Collapse
Affiliation(s)
- Virginie Dubois
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital,Department of Anesthesiology, Brussels, Belgium
| | - Charles-Marc Samama
- Université Paris Descartes, Cochin University Hospital,Department of Anesthesiology and Intensive Care, Paris, France
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Maximilien Gourdin
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Bernard Chatelain
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| |
Collapse
|
36
|
Turagam MK, Nagarajan DV, Bartus K, Makkar A, Swarup V. Use of a pocket compression device for the prevention and treatment of pocket hematoma after pacemaker and defibrillator implantation (STOP-HEMATOMA-I). J Interv Card Electrophysiol 2017; 49:197-204. [DOI: 10.1007/s10840-017-0235-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/22/2017] [Indexed: 11/28/2022]
|
37
|
Doherty JU, Gluckman TJ, Hucker WJ, Januzzi JL, Ortel TL, Saxonhouse SJ, Spinler SA. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll Cardiol 2017; 69:871-898. [DOI: 10.1016/j.jacc.2016.11.024] [Citation(s) in RCA: 279] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
38
|
Sarma AA, Nkonde-Price C, Gulati M, Duvernoy CS, Lewis SJ, Wood MJ. Cardiovascular Medicine and Society. J Am Coll Cardiol 2017; 69:92-101. [DOI: 10.1016/j.jacc.2016.09.978] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/22/2016] [Accepted: 09/27/2016] [Indexed: 12/22/2022]
|