Benefits of extended treatment with dalteparin in patients with unstable coronary artery disease eligible for revascularization

Different combination strategies for prophylaxis of venous thromboembolism in patients: A prospective multicenter randomized controlled study

The aim was to evaluate the efficacy and safety of different combination strategies for prophylaxis of venous thromboembolism (VTE) after gynecologic surgery in patients at different levels of risk. This was a prospective multicenter randomized controlled study, in which 625 women who would undergo pelvic surgery for gynecologic diseases were stratified into three risk groups and then randomized into four groups to receive graduated compression stockings (GCS) alone (group A), GCS + low molecular weight heparin (LMWH) (group B), GCS + intermittent pneumatic compression (IPC) (group C), and GCS + IPC + LMWH (group C), respectively. The overall incidence of DVT was 5.1%. Group A had the highest incidence of DVT (8.8%), followed by group C (5.2%), group B (3.8%), and group D (2.6%). There was a significant difference in the incidence of DVT between groups A and D. The incidence of DVT was significantly lower in LMWH-treated patients (group B + group D) than in non-LMWH-treated patients (group A + group C). In conclusion, combination prophylaxis, especially LMWH-containing strategies, is better than monoprophylaxis in reducing VTE after gynecologic surgery. Risk-stratified prophylactic strategies should be implemented in patients undergoing gynecologic surgery, with LMWH-containing strategies being recommended for high-risk and very-high-risk patients.

Potential role of rivaroxaban in patients with acute coronary syndrome

Patients with acute coronary syndrome (ACS) continue to be at risk for recurrent ischemic events, despite an early invasive strategy and the use of dual antiplatelet therapy. The anticoagulant pathway remains activated for a prolonged period after ACS and, consequently, has been a target for treatment. Early studies with warfarin indicated its benefit, but the risk of bleeding and the complexities of warfarin anticoagulation resulted in little use of this strategy. Rivaroxaban, apixaban, and dabigatran are new specific inhibitors of anticoagulant factors (Xa or IIa) currently available for the prevention of thrombosis and/or thromboembolism. Thus far, studies with dabigatran and apixaban in ACS have shown no clinical benefit and bleeding has been increased. The ATLAS ACS 2-TIMI 51 trial observed the impact of rivaroxaban 2.5 mg and 5 mg twice daily in patients with recent ACS receiving current management (both early invasive strategy and dual antiplatelet therapy with aspirin and clopidogrel) over a follow-up period of over 1 year. Rivaroxaban 2.5 mg twice daily reduced cardiovascular death, myocardial infarction, or stroke by 16%, and both cardiovascular and all-cause mortality by approximately 20%. Although major bleeding increased from 0.6% to 2.1% and intracranial hemorrhage from 0.2% to 0.6%, there was no increase in fatal bleeding. The role of rivaroxaban in the management of ACS is discussed in this review. The reduction in mortality is the main finding that could lead to the use of rivaroxaban in the management of ACS in high-risk individuals with a low bleeding risk.

Prescription quality in an acute medical ward

PURPOSE

Prescribing is an effective and economical means of delivering health care. The aim of this study is to assess the quality of prescriptions in an Acute Medical Assessment Unit (AMAU) at Aberdeen Royal Infirmary (ARI).

METHODS

Prescription data were collected from all available medication charts of patients admitted to the ward over a 2-week period. Prescription quality indicators were divided into two categories: prescription chart related (e.g. complete patient information and absence of drug-drug interactions (DDIs)) and medication related (e.g. legibility of handwriting, generic prescribing and adherence to hospital's formulary).

RESULTS

Patient identifiers were omitted in 4% (n = 8) of the medication charts included in assessing prescribing quality. Patient allergies were omitted in 36% (n = 76) of charts. At least one DDI was detected in 26% (n = 55) of the charts. The mean number of medications prescribed per patient was seven (95%CI, 6.53-7.65). The median number of medication-related prescribing errors per medication chart was two (interquartile range (IQR), 1-3). The distribution of these errors was significantly higher in charts with five or more medications (p < 0.001).

CONCLUSION

This study demonstrates a relatively acceptable level of prescription quality compared to the published literature. However, the number of DDIs and level of allergy documentation are of concern emphasising the need for continued education in this field.

The role of low-molecular-weight heparins in cardiovascular medicine

Low-molecular-weight heparins (LMWHs) have been shown to be as effective and safe as unfractionated heparin (UFH) for acute phase treatment of acute coronary syndrome in the absence of ST-elevation [unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI)]. LMWHs have practical advantages over UFH, including usual lack of requirement for laboratory monitoring of the anticoagulant response because of their favourable pharmacokinetic properties, and thus represent a simpler and more cost-effective option in clinical practice. The LMWH dalteparin has been shown to provide extended therapy benefit to high-risk UA/NSTEMI patients and can provide a protective bridge until revascularization. While revascularization procedures are now an established intervention for patients with UA/NSTEMI, a new approach for patients who cannot undergo immediate catheter intervention is to continue with medical treatment until revascularization is possible. LMWHs are currently being investigated for use in the catheterization laboratory, in patients undergoing percutaneous coronary intervention procedures, and in conjunction with thrombolytics for treatment of acute myocardial infarction.