Use Of Antithrombotic Medication Research Articles

Use of Performance Indicators for Assessment of Quality of Care of Acute Stroke Patients in a Health Insurance Hospital in Alexandria

Performance indicators are usually one component of an overall strategy for quality improvement in health care. However, their use depends on adequate documentation in medical records. The aim of this study is to assess the quality of care provided to hospitalized stroke patients in Health Insurance hospital in Alexandria using performance indicators, and to determine the feasibility of abstraction of indicator data based on the level of documentation in medical records. Data elements for ten performance indicators were abstracted through retrospective review of randomly selected 170 records of acute stroke patients [out of 850 discharges] during the year 2003-2004. Results indicated that documentation in medical records was adequate for computing five of the ten performance indicators, namely, use of antithrombotic medication within 48 hours of hospitalization, prescription of anticoagulant therapy for patients with atrial fibrillation, prescription of antithrombotic on discharge, lipid profile during hospitalization, and plan for rehabilitation, with figures ranging between 71.2% and 14.5%. Due to the deficiency of recorded data, it was not possible to reliably compute the following five indicators: deep vein prophylaxis, tissue plasminogen activator considered, screen for dysphagia, stroke education, and adult smoking cessation advice. It was concluded that management of stroke patients needs to be better documented, along with more provider education for proper management of stroke.

Management of early rheumatoid arthritis

<h3>Objective:</h3> To characterize the frequency of and risk factors for out-of-hospital sudden neurologic deaths. <h3>Methods:</h3> During the initial 25 months (February 1, 2011–March 1, 2013) of the San Francisco Postmortem Systematic Investigation of Sudden Cardiac Death Study, we captured incident WHO criteria sudden cardiac deaths (SCDs) through active surveillance of consecutive out-of-hospital deaths, which must be reported to the medical examiner by law. All cases were referred for full autopsy with detailed examination of the heart and cranial vault, toxicology, and histology. A multidisciplinary committee adjudicated a final cause of death. <h3>Results:</h3> Of 352 incident SCDs, 335 (95%) underwent systematic evaluation including full autopsy. Of these 335 cases, 18 (5.4%) were sudden neurologic deaths (mean age 60.6 years [SD 17.6, range 27–87]; 67.7% female), which accounted for 14.9% of the 121 noncardiac sudden deaths. The risk of sudden neurologic death compared to non-neurologic SCD was lower in male and white participants (<i>p</i> &lt; 0.01). Neurologic causes included intracranial hemorrhage (8), sudden unexpected death in epilepsy (6, including 2 with juvenile myoclonic epilepsy), aneurysmal subarachnoid hemorrhage (2), acute ischemic stroke (1), and aspiration from Huntington disease (1). Most deaths were unwitnessed (16; 89%) with asystole at presentation (17; 94%). Prior stroke/TIA was not associated with risk of stroke (odds ratio [OR] 1.4 [95% confidence interval (CI) 0.18–11.8], <i>p</i> = 0.73), but antithrombotic medication use was (OR 3.9 [95% 1.01–15.5], <i>p</i> = 0.05). <h3>Conclusions:</h3> Sudden neurologic death is an important cause of out-of-hospital apparent SCDs. Low prevailing autopsy rates may result in systematic misclassification of apparent SCDs and underestimation of the incidence of sudden neurologic death.

The risk of hemorrhagic complications in hospital in-patients who fall while receiving antithrombotic therapy

BackgroundThe use of antithrombotic agents and falls are independently associated with an increased risk of hemorrhagic injury. However, few studies have delineated the risk of fall-related hemorrhagic complications in persons who are taking antithrombotic therapy. The objective of this study was to compare the rates of fall-related hemorrhagic injury in hospital in-patients who are taking and not taking antithrombotic therapy.MethodsA 4-year retrospective chart review of consecutive patients who fell during admission to a 500-bed tertiary-care teaching hospital was conducted. Major hemorrhagic injuries including subdural hematomas and major bleeding/cuts, patients' use of antithrombotic medication (warfarin, aspirin, clopidogrel and heparin) and their anticoagulation status at the time of their fall were recorded.ResultsA total of 2635 falls in 1861 patients were reviewed. Approximately 10% of falls caused major hemorrhagic injury. One fall resulted in a subdural hematoma. Persons taking warfarin were less likely to suffer a fall-related major hemorrhagic injury compared with persons not taking antithrombotic therapy (warfarin, 6%; no therapy, 11%; p = 0.01). Logistic regression showed that fall-related major hemorrhagic injury was associated with female gender (odds ratio 1.6; 95% CI 1.3, 2.1), use of aspirin (odds ratio 1.4; 95% CI 1.1, 1.8) and use of clopidogrel (odds ratio 2.2; 95% CI 1.1, 4.8), but not with the use of warfarin or heparin, or the intensity of anticoagulation.ConclusionsIn this study, compared with persons taking no antithrombotic therapy, those taking warfarin had lower rates of fall-related hemorrhagic injuries. The absolute rate of the development of fall-related intracranial hemorrhagic injury such as subdural hematomas was low, even in persons taking warfarin. These counter-intuitive results may be due to selection bias, and suggest that physicians are very conservative in selecting patients for warfarin therapy, choosing only those who are sufficiently healthy to be at much lower than average risk of suffering fall-related hemorrhagic injuries. This phenomenon may lead to physicians overestimating the potential for fall-related major hemorrhagic injury in persons taking antithrombotic therapy, with the possible denial of warfarin therapy to many of those who would benefit. This perception may contribute to the care gap between the number of patients who would theoretically derive overall benefit from warfarin therapy and those who are actually receiving it.

National trends in antiarrhythmic and antithrombotic medication use in atrial fibrillation.

Atrial fibrillation is the most common cardiac arrhythmia associated with significant medical complications. We examined trends in the medical therapy of atrial fibrillation in the United States from 1991 through 2000. Data from 1355 visits among patients with atrial fibrillation were obtained from the National Ambulatory Medical Care Survey, a nationally representative assessment of office-based practice. We assessed trends in medication use for ventricular rate control (digoxin, beta-blockers, and calcium channel blockers), sinus rhythm maintenance (class IA, IC, and III antiarrhythmics), and thromboembolism prevention (oral anticoagulants and aspirin). Overall rate control medication use decreased from 72% of visits in 1991-1992 to 56% in 1999-2000 (P =.01 for trend) due to declining digoxin use (64% to 37%, P<.001 for trend). beta-Blocker and calcium channel blocker use remained unchanged. Although there was no change in overall sinus rhythm medication use over time, amiodarone hydrochloride use increased from 0.2% to 6.4% (P<.001 for trend), while quinidine use decreased from 5.0% to 0.0% (P =.01 for trend). Oral anticoagulant use increased (28% to 41%, P =.01 for trend), with the greatest increase in patients aged 80 years and older (14% to 48%, P<.001 for trend). Despite this, only 46.5% of patients at high risk for stroke were taking anticoagulants in 1999-2000. Digoxin use in atrial fibrillation decreased over time, without concomitant increases in beta-blocker or calcium channel blocker use. Amiodarone replaced quinidine as the dominant sinus rhythm medication. Although oral anticoagulant use increased over time, particularly in the oldest patients, fewer than half of the patients at high risk for stroke were anticoagulated.

Mortality and rate of stroke or embolism in atrial fibrillation during long-term follow-up in the embolism in left atrial thrombi (ELAT) study.

Patients with atrial fibrillation (AF) have a higher mortality and risk of stroke/embolism than patients with sinus rhythm. The aim of the study was to assess the association of clinical and echocardiographic characteristics with mortality and stroke/embolism and the use of antithrombotic medication in the year 2000 in patients who participated 1990-1995 in the Embolism in Left Atrial Thrombi (ELAT) study. The study included 409 outpatients with nonrheumatic AF (62 +/- 12 years, 36% women, 39% intermittent AF). Patients with thrombi received anticoagulation, patients without thrombi aspirin until follow-up in 1995; thereafter, anticoagulation according to clinical risk factors was recommended. Primary events were death and secondary events were stroke/embolism. All patients were contacted during the year 2000. Mean follow-up was 102 months. Mortality was 4%/year; the cause of death was cardiac (n = 84), fatal stroke (n = 26), malignancy (n = 23), sepsis (n = 5), and unknown (n = 24). Multivariate analysis identified age (p < 0.0001), heart failure (p = 0.0013), and reduced left ventricular systolic function (p = 0.0353) as predictors of mortality. Stroke/embolism occurred in 83 patients, with a rate of 3%/year. Multivariate analysis identified age (p = 0.0006) and previous stroke (p = 0.0454) as predictors of stroke/embolism. In the year 2000, 51 (21%) of the 247 surviving patients received no antithrombotic medication, 88 received (36%) oral anticoagulants, 102 (41%) acetylsalicylic acid, and 6 (2%) low-molecular heparin. Therapy for heart failure and oral anticoagulation in AF should be seriously considered, especially in elderly patients and in those with previous stroke.

Transient ischaemic attacks

Each day, about 25 Australians experience a transient ischaemic attack of the brain or eye. These people need to be distinguished from those who suffer "funny turns" due to other causes because, as a group, they have a significant risk of stroke and other vascular events. This risk can be substantially reduced through control of vascular risk factors, use of long term antithrombotic medication and, in some cases, carotid endarterectomy. Strategies for stroke prevention need to involve both the "high risk" and population "mass" approach, which are complementary.

Predictors of hospital mortality in older patients with subdural hematoma.

To identify presenting characteristics of older patients with subdural hematoma who are unlikely to survive hospitalization. A retrospective cohort. All patients > or = 65 years of age hospitalized at a tertiary care center from 1985-1990 with the primary diagnosis of subdural hematoma. Chart review was performed to characterize presenting clinical characteristics, hospital course, and outcome at the time of hospital discharge. Of the 157 eligible patients, 42% (66/157) were > or = 80 years of age. Although 30% of patients had no recorded trauma, 54% experienced a fall before hospitalization. Twenty-six percent (47/157) of patients had been on antithrombotic therapy (14 on coumadin, two on heparin, 31 on antiplatelet agents, one on both coumadin and an antiplatelet agent). Sixty percent of patients had no focal neurologic findings, and the mean Glasgow Coma Score was 12.3 (+/- 3.6). The hematoma was considered chronic in 49% (77/157) of cases, based on time from antecedent trauma or on neuroimaging criteria. Midline shift by neuroimaging was present in 69%. Overall hospital mortality was 31% (48/157). Using logistic regression to control for other factors, level of consciousness (Glasgow Coma Score < = 7) (OR = 10.4), age > or = 80 (OR = 3.7), duration of hematoma considered acute (OR = 2.7), and craniotomy (OR = 2.6) were significantly associated with hospital mortality. Presence of focal symptoms, previous antithrombotic medication use, nature of trauma, comorbidity score, and presence of midline shift were not associated with hospital mortality. Among older patients with subdural hematoma, level of consciousness, extreme old age, duration of the hematoma, and nature of the intervention were significantly associated with hospital mortality. These factors should help physicians in clinical decision making and formulation of advance directives for geriatric patients with subdural hematoma.

Transient ischaemic attacks

Each day, about 25 Australians experience a transient ischaemic attack of the brain or eye. These people need to be distinguished from those who suffer “funny turns” due to other causes because, as a group, they have a significant risk of stroke and other vascular events. This risk can be substantially reduced through control of vascular risk factors, use of long term antithrombotic medication and, in some cases, carotid endarterectomy. Strategies for stroke prevention need to involve both the “high risk” and population “mass” approach, which are complementary.