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Mitchell M, Sullinger D, Dyer D, Hickey G, Kaczorowski D, Minor J, Murray H, Ramanan R, Rhinehart Z, Schmidhofer M, Rivosecchi RM. Evaluation of Newly Integrated Bivalirudin Titration Protocol in Patients With Mechanical Circulatory Support. Ann Pharmacother 2023:10600280231206130. [PMID: 37887435 DOI: 10.1177/10600280231206130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Patients with cardiogenic shock or end-stage heart failure can be maintained on mechanical circulatory support (MCS) devices. Once a patient undergoes placement of a device, obtaining and maintaining therapeutic anticoagulation is vital. Guidelines recommend the use of institutional protocols to assist in dosing and titration of anticoagulants. OBJECTIVE The purpose of this study was to characterize the use of bivalirudin before and after the implementation of a standardized titration protocol in patients with MCS. METHODS A retrospective review of patients who received bivalirudin for MCS (VA ECMO [veno-arterial extracorporeal membrane oxygenation], Impella, or LVAD [left ventricular assist device]) before and after the implementation of the titration protocol into the electronic health record (EHR) was conducted. The primary outcome was to compare the proportion of therapeutic activated partial thromboplastin time (aPTT). Secondary outcomes included number of subtherapeutic and supratherapeutic aPTTs, incidence of bleeding and clotting events, bivalirudin titrations per day, and percentage of patients with therapeutic aPTT level. RESULTS A total of 100 patients were included (precohort = 67; postcohort = 33). The proportion of therapeutic aPTTs was significantly higher in the postcohort than that in the precohort (62% vs 48%; P < 0.001). The postcohort had 0% of patients failing to achieve therapeutic aPTT levels. The number of titrations per day was significantly lower in the postcohort, with 1.20 titrations per day versus 1.93 in the precohort (P < 0.001). CONCLUSIONS Implementation of the bivalirudin titration nomograms within the EHR significantly increased the number of therapeutic aPTTs, reduced the number of patients who never achieved a therapeutic aPTT, and reduced the required number of titrations per day.
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Affiliation(s)
- Madeline Mitchell
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Danine Sullinger
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Duke Dyer
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gavin Hickey
- Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joni Minor
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Holt Murray
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zachary Rhinehart
- Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Schmidhofer
- Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bashline MJ, Rhinehart Z, Kola O, Fowler J, Kaczorowski D, Hickey G. Impella 5.0 is associated with a reduction in vasoactive support and improves hemodynamics in cardiogenic shock: A single-center experience. Int J Artif Organs 2022; 45:462-469. [PMID: 35365048 DOI: 10.1177/03913988221083993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment of cardiogenic shock (CS) often requires the use of vasopressors and inotropic agents, which are associated with an increase in mortality. Data on change in vasopressor and inotrope requirements post Impella 5.0 placement is scarce. Thus, we aimed to study the ability of Impella 5.0 to reduce these requirements. METHODS Retrospective analysis of consecutive patients with CS receiving Impella 5.0 was performed. Vasopressor-Inotrope Score (VIS) and a Modified Catecholamine Equivalent score (MCES) was calculated prior to and up to 72 h post-Impella implantation. Primary outcome was change in MCES from baseline to 48-h post implantation and secondary outcomes included change in VIS, changes in MCES according to SCAI Stage and to underlying etiology, and freedom from mortality at 30-days. RESULTS Twenty-eight patients with median age of 61 (48, 67) years were included. Impella 5.0 was associated with significant reduction in MCES from baseline [9.7 (5.3, 17)] to 48 h [5.7 (3.8, 7.5), p = 0.001]. VIS was also significantly reduced from baseline [8.3 (3.8, 19.9)] to 48 h [5.0 (2.5, 8), p = 0.003]. MCES at 48 h was significantly reduced in patients with SCAI Stage E versus Stage C (p = 0.026) and with acute myocardial infarction versus acute decompensated heart (p = 0.003). Thirty-day survival was 0% in patients that had a baseline MCES ⩾ 10 without a reduction in MCES of at least 5 at 24 h. CONCLUSION Impella 5.0 is associated with a significant reduction in MCES and VIS scores in patients presenting with CS with 30-day survival being dependent on MCES.
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Affiliation(s)
- Michael J Bashline
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zachary Rhinehart
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Olivia Kola
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey Fowler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Kaczorowski
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gavin Hickey
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Rusiecki J, Rao Y, Cleveland J, Rhinehart Z, Champion HC, Mathier MA. Sex and menopause differences in response to tadalafil: 6-minute walk distance and time to clinical worsening. Pulm Circ 2015; 5:701-6. [PMID: 26697177 DOI: 10.1086/683829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a female-predominant disease, but there are little data on treatment response by sex and menopausal status. In this retrospective analysis of the Pulmonary Arterial Hypertension and Response to Tadalafil (PHIRST) randomized clinical trial, we assessed treatment response between the sexes by examining change in 6-minute walk distance (6MWD) and time to clinical worsening (TCW). We examined the effect of menopausal status on the same treatment measures. 6MWD was recorded before and after 16 weeks of treatment with tadalafil or placebo in the PHIRST study cohort of 340 subjects (264 females, 76 males). A univariate analysis was used to assess the effect of sex on change in 6MWD and TCW. Multivariate linear regression and Cox proportional hazards models were built for 6MWD and TCW, respectively. Women were subdivided by age as a surrogate for menopausal status. The linear trend test and the log-rank test were performed on change in 6MWD and TCW by age. For tadalafil-treated patients, a significant difference in change in 6MWD by sex (mean: 48.6 m for males vs. 34.7 m for females; P = 0.01) was found, but it was not significant in multivariate analysis (P = 0.08). There was a trend toward a female age-dependent effect in change in 6MWD; the premenopausal group showed the greatest improvement. A significant sex- or age-dependent effect on TCW was not present. In conclusion, this retrospective analysis of the PHIRST trial suggests that men and premenopausal women may experience greater functional improvement when treated with tadalafil than older women, but there was no consistent sex or menopausal effect on TCW.
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Affiliation(s)
- Jennifer Rusiecki
- Pulmonary Allergy and Critical Care Medicine, Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh/University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Youlan Rao
- United Therapeutics, Research Triangle Park, North Carolina, USA
| | - Jody Cleveland
- United Therapeutics, Research Triangle Park, North Carolina, USA
| | - Zachary Rhinehart
- Pulmonary Allergy and Critical Care Medicine, Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh/University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hunter C Champion
- Pulmonary Allergy and Critical Care Medicine, Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh/University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael A Mathier
- Pulmonary Allergy and Critical Care Medicine, Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh/University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Olafiranye O, Kip KE, Rhinehart Z, Mulukutla SR, Aiyer A, Strollo PJ, Reis SE. Impact of race and obesity on arterial endothelial dysfunction associated with sleep apnea: Results from the Heart SCORE study. Int J Cardiol 2015; 201:476-8. [PMID: 26313870 DOI: 10.1016/j.ijcard.2015.08.098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 08/01/2015] [Accepted: 08/09/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Oladipupo Olafiranye
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Kevin E Kip
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Zachary Rhinehart
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Suresh R Mulukutla
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aryan Aiyer
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Strollo
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven E Reis
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Hickey GW, Nguyen D, Pasupala D, Khanna M, Anaraki SA, Rhinehart Z, Batal O, Markowitz J, Malhotra S, Soman P. YIELD OF MYOCARDIAL PERFUSION IMAGING IN ACUTE CHEST PAIN PATIENTS WITH NEGATIVE ECG AND BIOMARKERS. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)61247-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Patel SM, Jones M, Qin D, Rhinehart Z, Smith A. AN ANALYSIS OF CARDIOGENIC SHOCK & CARDIAC ARREST IN APICAL BALLOONING SYNDROME (TAKOTSUBO/ STRESS CARDIOMYOPATHY): EVALUATING CLINICAL CHARACTERISTICS AND OUTCOMES. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60830-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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