Prevalence of Potentially Inappropriate Apixaban Prescribing Within a Single-Centre Tertiary Hospital.

Introduction Atrial fibrillation (AF) affects 2.4% of the English population. Direct oral anticoagulants (DOACs) are often used to reduce stroke risk. DOACs require dose adjustments according to creatinine clearance (CrCl). We evaluated DOAC prescribing in AF in an acute UK cardiology ward and evaluated whether eGFR can be used as an alternative to CrCl. Methods We examined all DOAC discharge prescriptions on the cardiology ward at NSECH, Cramlington from Nov 2015-Nov 2016. We retrospectively recorded DOAC dose, serum creatinine and eGFR pre-discharge. Weight was obtained from hospital paper records for those patients with eGFR reflecting a degree of renal impairment. We reviewed notes for patients prescribed apixaban or dabigatran at full dose with eGFR 35 and those prescribed rivaroxaban or edoxaban at full dose with eGFR 45. For those, CrCl was calculated using the Cockcroft-Gault equation. Summary product characteristics (SPC) dosing guidelines were used to define appropriate dosing. Results We identified 225 DOAC prescriptions for AF in 168 patients. Whilst the majority of DOAC prescriptions were appropriate, this study identified 11% (25) of discharge DOAC prescriptions for AF did not follow SPC guidelines (figure 1). Full dose DOAC was prescribed inappropriately in 3% (8). The other 8% (16) had inappropriate dose reduction. 55 discharges were identified as reflecting a degree of renal impairment. Comparison of CrCl and eGFR in those 55 discharges found 22% (12) would have over-estimated renal function had eGFR been used to make drug dosing decisions, leading to incorrect prescriptions of the full dose. Similarly renal function would have been under-estimated by eGFR in 13% (7 out of 55) of cases using eGFR alone which would have led to inappropriate reduced dose DOAC. Conclusion and implications This study reminds clinicians to remain vigilant about DOAC dose modifications. We demonstrated the importance of the CrCl for patients with impaired renal function as the eGFR provides an inaccurate estimate that may lead to inappropriate DOAC dosing. Inappropriate dose reduction appeared more common than inappropriate full dose. This is in keeping with published literature form a US cohort.1 Failure to reduce DOAC doses may increase bleeding without additional efficacy. Inappropriate dose reductions are often carried out to mitigate bleeding risks but is associated with overall worse outcomes.1 Our findings were from a unit with 7 day cardiologist input and dosing errors may be even more frequent in the non-specialist environment. We addressed this by designing educational material for the hospital teams (figure 2). Reference . Yao X, Shah ND, Sangaralingham LR, et al. Non-vitamin k antagonist oral anticoagulant dosing in patients with atrial fibrillation and renal dysfunction. J Am Coll Cardiol2017;69:2779–2790.

Introduction Patients with confirmed venous thromboembolism (VTE) are often managed with oral anticoagulation. There have been reports of prescribing, particularly dose-related, administration, and dispensing errors associated with direct oral anticoagulants (DOACs), with error rate ranging from 5.3% to 37.3% (1). The evidence on the appropriate prescribing of DOACs post completion of VTE treatment period is lacking as most studies review prescribing errors in patients with atrial fibrillation. Aim To evaluate prescribing practice of DOACs for patients with confirmed VTE following a discharge from a large teaching hospitals Trust in the North of England. Methods This retrospective audit covered a period from 1st April 2020 to 31st March 2021. Electronic medical records of adult patients with confirmed VTE, admitted to a large Teaching hospitals Trust, and newly prescribed DOAC on discharge were included. Extracted pseudo-anonymised data was analysed descriptively using Microsoft Excel. Creatinine clearance (CrCl) was calculated using the Cockcroft-Gault equation for patients with recorded weight. Results The initial list of patients diagnosed with VTE included 1119 entries, which after cleansing was reduced to 502 unique patients meeting the eligibility criteria. The mean age (±standard deviation) was 66±16 years (range 20-99) and 52% (n=260) were male. Documented diagnosis included PE (85%, n=428), DVT (10%, n=49), DVT with PE (4%, n=21), and no clear diagnosis (<1%, n=4). The weight was recorded and CrCl was possible to calculate for 67% (n=334). Out of these, 98% (n=328) had appropriate doses for their level of renal function. Treatment duration was clearly documented for 81% (n=406) patients and 22% (n=108) were planned for a long-term prophylaxis on discharge. Out of all patients, 37% (n=187) had treatment stopped after completing the treatment period (3 or 6 months), 23% (n=113) continued treatment dose following completion of treatment period without other comorbidity warranting the treatment dose to continue, 21% (n=104) were changed to recommended prophylaxis dose, 15% (n=76) were excluded due to missing data or dying within six months of admission, and 4% (n=22) had atrial fibrillation and continued on an appropriate dose. Conclusion Our study highlighted that potentially inappropriate treatment dose use after completing the planned treatment period (3 or 6 months) was prevalent in nearly a quarter of patients. The potentially unnecessary continuation of treatment dose of DOAC can increase the risk of bleeding events, add to medicine expenditure costs, and contribute to waste in the healthcare system. Education of prescribers in primary and secondary care on VTE treatment and prophylaxis management, harnessing the pharmacist’s role in primary and secondary care, and including explicit dosing and duration of DOAC use in hospital discharge letters could improve patient safety and reduce non-recommended DOAC use. The main strengths of the study included the use of patients’ routine data and a relatively large sample size. The data generalisability and analysis were limited by the accuracy of the electronic patients’ care records and using data from one NHS Trust.

Does Direct Helicopter Retrieval Improve Survival of Severely Injured Trauma Patients From Rural Western Australia?

Evaluation of an Ambulatory Emergency Care Centre at a tertiary hospital in Perth, Western Australia

Heart failure (HF) represents a major and growing public health problem because of its prevalence, incidence, morbidity, mortality, and economic costs. The prevalence of HF is 2% to 3% of the general population.1 Five million Americans are affected, with >550 000 cases diagnosed each year.2 The mortality rate from severe HF remains >60% within 5 years of diagnosis, and 50% of hospitalized patients with HF require readmission within 6 months of discharge. In the US estimated costs amount to > $35 billion per year.3 Although several therapies (eg, β-blockers, angiotensin-converting enzyme [ACE] inhibitors, and cardiac resynchronization therapy) have been proven effective in improving HF outcomes, many unanswered questions about optimal treatment remain. One area of ongoing uncertainty is the appropriate role for antithrombotic therapy in patients with HF. Observational data suggest that patients with HF have an increased venous thromboembolism (VTE) risk (deep venous thromboembolism [DVT], pulmonary embolism [PE], peripheral arterial thromboembolism, and stroke).4 These epidemiological findings are supported by multiple mechanisms that can contribute to a hypercoagulable state in patients with HF. Despite this increased risk of VTE, the role of antithrombotic therapy remains unclear. In this article, we provide an overview of epidemiology, pathophysiology, clinical trial data, and therapeutic recommendations for prevention of thromboembolism in HF. We searched PubMed for articles published between 1958 and 2010 using the following search terms: epidemiology of heart failure , thromboembolism and heart failure , thrombogenesis and heart failure , anticoagulation in heart failure , antiplatelet agent and heart failure , aspirin and heart failure , bleeding risk and anticoagulation , and aspirin and angiotensin-converting enzyme inhibitors . We also studied abstracts from national and international cardiovascular meetings to identify unpublished studies using the key words anticoagulation and dilated cardiomyopathy . Data from published observational studies and secondary …

ObjectivesInappropriate dosing of direct oral anticoagulants (DOACs) may increase the risk of thromboembolism or bleeding in patients with atrial fibrillation (AF). The inappropriate use of these medications presents a significant clinical challenge. Our study aimed to analyze the current utilization of rivaroxaban and edoxaban among Chinese patients with AF, as well as the factors influencing the use of nonstandard doses.MethodsThis study evaluated patients diagnosed with AF between January 2017 and December 2023. Descriptive analyses were performed to summarize the characteristics of the study population. Inappropriate dosing was identified based on the guidelines. Multivariate analysis was performed to identify factors associated with inappropriate dosing in these patients.ResultsA total of 1,066 patients diagnosed with AF, comprising 852 individuals treated with rivaroxaban and 214 individuals treated with edoxaban, were included. Their median age was 69 years, and 58.7% of them were males. Among them, 573 patients (53.8%) received inappropriate dosages. Among the patients prescribed rivaroxaban, 503 (59.0%) were underdosed and eight (0.9%) were overdosed. Among the patients prescribed edoxaban, 49 patients (22.9%) were underdosed and 13 patients (6.1%) were overdosed. Multivariate analysis identified independent factors associated with inappropriate medication dosing, including advanced age [adjusted odds ratio (OR) 1.031, 95% confidence interval (CI) 1.010–1.052], combined use of antiplatelet drugs (adjusted OR 1.649, 95% CI 1.111–2.447), and reduced use of dronedarone (adjusted OR 0.332, 95% CI 0.126–0.877).ConclusionsThe incidence of inappropriate DOAC dosing in Chinese patients with AF was high. Advanced age, the concurrent use of antiplatelet medications, and the nonuse of dronedarone have been identified as independent factors associated with inappropriate dosing.

Comparison of Medical Costs Avoided When New Oral Anticoagulants Are Used for the Treatment of Patients with Atrial Fibrillation and Venous Thromboembolism in the U.S

Effect of dexamethasone on direct Xa-inhibitor oral anticoagulant plasma levels in patients with COVID-19

Impact of Adding Aspirin to Direct Oral Anticoagulant Therapy without an Apparent Indication

Background/Introduction Oral anticoagulants are widely used for the treatment and second prevention of venous thromboembolism (VTE) and stroke prevention in atrial fibrillation (AF). VTE and AF are common diseases and these sometimes might coexist. However, there are few reports about the relationship between VTE and AF. Purpose We sought to evaluate the clinical characteristics and outcomes in VTE patients with AF. Methods The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 129 patients with AF (AF group) and 2898 patients without AF (non-AF group). We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups. Results The AF group was older (mean age: 75.3 vs. 66.8 years, P<0.001), and more often had co-morbidities such as hypertension (54.3% vs. 37.7%, P<0.001), diabetes mellitus (20.2% vs. 12.4%, P=0.01), chronic kidney disease (28.7% vs. 18.5%, P=0.004), heart failure (28.7% vs. 18.5%, P=0.004), history of stroke (20.2% vs. 8.4%, P<0.001), and history of major bleeding (12.4% vs. 7.4%, P=0.04) compared with the non-AF group, whereas there were no significant differences in the proportions of active cancer at diagnosis (18.6% vs. 23.2%, P=0.23) and pulmonary embolism at presentation (64.3% vs. 56.3%, P=0.07). The proportion of anticoagulation therapy beyond acute phase was not significantly different (94% vs. 93%, P=0.60), while the cumulative discontinuation rates of anticoagulation therapy was significantly lower in the AF group (26.9% vs. 43.4% at 3 years, Log-rank P=0.03). The cumulative 5-year incidences of recurrent VTE and major bleeding were not significantly different (Recurrent VTE: 7.6% vs. 10.6%, Log-rank P=0.89; Major bleeding: 18.6% vs. 11.8%, Log-rank P=0.07). After adjusting for potential confounders, the risks of the AF group relative to the non-AF group for recurrent VTE and major bleeding remained insignificant (HR 1.19, 95% CI 0.54–2.28, P=0.64; HR 1.28, 95% CI 0.73–2.06, P=0.37). The cumulative 5-year incidence of all-cause death was significantly higher in the AF-group (49.1% vs. 28.6%, Log-rank P<0.001). After adjusting for potential confounders, the risks of the AF group relative to the non-AF group for all-cause death remained significant (HR 1.63, 95% CI 1.23–2.15, P<0.001). The proportion of deaths due to cancer was lower in the AF group (30% vs. 55%, P<0.001), while the proportion of cardiac deaths was higher in the AF group (16.1% vs. 4.0%, P<0.001). The outcomes of VTE patients with AF Conclusions The risks for recurrent VTE between patients with AF and those without AF were not significantly different, although patients with AF received longer-term anticoagulation therapy, whereas the risks for major bleeding tended to be higher in patients with AF. Acknowledgement/Funding Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

Direct oral anticoagulants (DOACs) are used to prevent thrombosis in patients with nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). Despite their clinical benefits, some patients abandon their DOAC prescription. To retrospectively evaluate the association between patient out-of-pocket (OOP) costs and abandonment of the first DOAC prescription among patients with NVAF or VTE in the United States. Data from Symphony Health, an ICON plc Company, PatientSource (April 1, 2017, to October 31, 2020) were used to select patients with NVAF or VTE with an approved or abandoned claim for a DOAC (apixaban, dabigatran, rivaroxaban). OOP costs (2021 US dollars) of the index claim were described by abandonment status, and multivariable logistic regression models were used to evaluate the association between OOP costs of the index DOAC claim and abandonment. Analyses were performed in patients with NVAF and VTE separately. Among 753,755 patients with NVAF, 88.5% had an approved index DOAC claim and 11.5% had an abandoned index DOAC claim. Among 308,429 patients with VTE, 91.5% had an approved index DOAC claim and 8.5% had an abandoned index DOAC claim. Mean OOP costs of the index DOAC claim were lower in those with an approved than abandoned claim (NVAF approved vs abandoned: $79 vs $175; VTE approved vs abandoned: $65 vs $133). Among patients with NVAF, 21.4% of those with an approved claim and 9.1% of those with an abandoned claim had no OOP costs, 58.7% (approved) and 49.0% (abandoned) had OOP costs greater than $0 to less than $100, and 19.9% (approved) and 41.9% (abandoned) had OOP costs greater than or equal to $100; among patients with VTE, 27.8% (approved) and 15.6% (abandoned) had no OOP costs, 58.4% (approved) and 54.8% (abandoned) had OOP costs greater than $0 to less than $100, and 13.8% (approved) and 29.6% (abandoned) had OOP costs greater than or equal to $100. In multivariable models, the risk of abandonment increased by 21% (NVAF) and 17% (VTE) for each $100 in OOP costs (both P < 0.001). Relative to patients with no OOP costs, patients with OOP costs greater than $0 to less than $50 were 86% (NVAF) and 55% (VTE) more likely to abandon their index DOAC, patients with OOP costs greater than $50 to less than $100 were 80% (NVAF) and 111% (VTE) more likely to abandon their index DOAC, and patients with OOP costs greater than or equal to $100 were 332% (NVAF) and 244% (VTE) more likely to abandon their index DOAC (all P < 0.001). Among patients with NVAF or VTE, OOP costs of the first DOAC claim greater than or equal to $100 were associated with the highest risk of abandoning the first DOAC prescription.

Background: It is well-established that atrial fibrillation (AF) is associated with thrombus formation in the left atrium, which can lead to ischemic stroke. Case reports, autopsies, and transesophageal echo data have indicated that clot formation also occurs in the right atrium (i.e. right-side intracardiac thrombosis) of AF patients, which could lead to pulmonary embolism (PE). However, it is unclear whether this occurrence is common. Objective: Test the hypotheses that individuals with incident AF are at elevated risk of developing venous thromboembolism (VTE), and that the association will be stronger for those presenting with PE alone versus PE and deep vein thrombosis (DVT) or DVT alone. Methods: A total of 15,205 Atherosclerosis Risk in Communities (ARIC) study participants, aged 45-64 years, were followed from baseline (1987-1989) to 2011 for incidence of AF and VTE (median follow-up 19.8 years). Incident AF and VTE events were identified via active surveillance and defined by relevant hospital discharge ICD codes. VTE events were validated by medical record review. Multivariable-adjusted Cox proportional hazards regression models were used, with AF modeled as a time-dependent covariate. We also evaluated separately risk of PE without evidence of DVT, DVT without PE, and events presenting with both PE and DVT. Results: At baseline participants were on average 54 years old, 55% female and 26% black. In the absence of AF there were 678 VTE events, for an incidence rate of 2.6 per 1000 person-years. After an AF diagnosis there were 77 events, with an incidence rate of 7.1 per 1000 person-years. In multivariable-adjusted models, having AF (versus no AF) was associated with a greater risk of incident VTE; the HR (95% CI) was 2.10 (1.65-2.68) after adjustment for demographics, 1.82 (1.42-2.32) additionally accounting for numerous AF and VTE risk factors, and 1.97 (1.53-2.53) after further adjusting for time-dependent anticoagulant use. When we restricted to PE events without evidence of DVT there were 188 events in total, of which 19 occurred following a diagnosis of AF. The HR for AF (versus no AF) was 1.53 (0.92-2.56) in fully adjusted models. For DVT alone there were 384 events in total, of which 48 occurred after AF diagnosis; the HR for AF was 2.43 (1.77-3.33). Among the 116 events presenting with both DVT and PE, 10 occurred after AF diagnosis, and the HR for AF was 1.36 (0.67-2.75). Conclusions: Diagnosis with AF was associated with a nearly 2-fold increased risk of incident VTE. The association was not stronger when isolated to those with PE without DVT, suggesting that higher risk of VTE among AF patients may be due to either the coagulation abnormalities that accompany AF, or shared risk factors that were not fully accounted for in this analysis.

Arterial Thrombosis and Cancer: Implications for Screening and Risk Modification

Venous and Arterial Thrombosis Following Abemaciclib Therapy for Metastatic Breast Cancer