Faculty Bibliography
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59
Association Between COVID-19 Booster Vaccination and Omicron Infection in a Cohort of Players and Staff in the National Basketball Association [Comment]
PMID: 36472599
ISSN: 1538-3598
CID: 5378662
Real world prescribing practices of apixaban or rivaroxaban lead-in doses for the treatment of venous thromboembolism in hospitalized patients
The oral factor Xa inhibitors (OFXAi) apixaban and rivaroxaban are increasingly utilized for the treatment of venous thromboembolism (VTE) with recommended initial higher dose 7- and 21-day lead-in regimens, respectively. In patients receiving initial parenteral anticoagulation, it remains unknown if the full recommended higher dose OFXAi lead-in regimens are warranted, or if days can be subtracted. We aimed to describe when clinicians may deviate from recommended lead-in durations and evaluate clinical outcomes in these scenarios. This is a retrospective, observational study of patients 18 years or older who were treated with rivaroxaban or apixaban for acute pulmonary embolism (PE) or symptomatic proximal deep vein thrombosis (DVT) that received parenteral anticoagulation for at least 24 h before transitioning to the OFXAi. Among our cohort of 171 patients with acute VTE who received parenteral anticoagulation for a median of 48 h, 134 (78%) were prescribed a full OFXAi lead-in and 37 (22%) were prescribed a reduced lead-in. Patients in the reduced lead-in group were older with more cardiac comorbidities and antiplatelet use. There were four recurrent thromboembolic events within 3 months, two in the reduced lead-in group and two in the full lead-in group (5% vs. 2%, p = 0.206). Bleeding within 3 months occurred in 9 (5%) patients, with 6 events occurring in the reduced lead-in group and 3 events in the full lead-in group (16% vs. 2%, p = 0.004). Prescribing patterns of OFXAi lead-in therapy duration are variable in patients receiving initial parenteral anticoagulation. Larger cohorts are needed to better define the safety and efficacy of lead-in reduction.
PMID: 35381944
ISSN: 1573-742x
CID: 5204872
Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants and Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase [Comment]
PMID: 35727285
ISSN: 1538-3598
CID: 5281922
To Occlude or Not to Occlude the Left Atrial Appendage in Women
PMID: 35171202
ISSN: 2380-6591
CID: 5163482
Antithrombotic management for Impella® temporary ventricular assist devices: An analysis of an academic health-system experience
The use of acute mechanical circulatory support (MCS) has increased over the last decade. For patients with left-ventricular failure, an Impella® (Abiomed, Danvers, MA) may be used to improve cardiac output. The purpose of this study is to describe Impella® anticoagulation patterns and evaluate the safety and effectiveness of our protocol. This is a retrospective review of all adult patients who required at least 24 h of Impella® support and received a heparin-based purge solution. In total, 109 patients were included in the final analysis. The most common indication for Impella® device insertion was cardiogenic shock (76%) with the remaining patients receiving a device for a high-risk procedures; typically coronary artery bypass grafting or percutaneous coronary intervention. A total of 9 thrombotic events occurred among 8 (7%) patients and 50 bleeding events occurred among 43 (39%) patients, with the most common classification being BARC 3a (60%). A univariate analysis revealed that patients were more likely to bleed if they were less than 65 years old, had an indication of cardiogenic shock for Impella®, inserted the device peripherally, were on dual antiplatelet therapy, or had an intra-aortic balloon pump prior to Impella® insertion, the latter of which was confirmed with a multivariate analysis (OR 2.5 [1.072-5.830]; p = 0.034). For those monitored by anti-Xa, the presence of two or more values greater than 0.40 IU/mL was a risk factor for bleeding (p = 0.037). Our study identifies risk factors for bleeding in patients receiving temporary MCS with an Impella®.
PMID: 35285339
ISSN: 1724-6040
CID: 5183762
To Cool or Not to Cool for Brugada Syndrome [Meeting Abstract]
ISI:000890856903084
ISSN: 0009-7322
CID: 5523752
Antithrombotic Stewardship: Assessing Use of Computerized Clinical Decision Support Tools to Enhance Safe Prescribing of Direct Oral Anticoagulants in Hospitalized Patients
Prescribing patterns for oral anticoagulants in patients with nonvalvular atrial fibrillation and venous thromboembolism is shifting from vitamin K antagonists, such as warfarin to the direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, and apixaban. Although many hospital systems have implemented clinical decision support or enhanced monitoring for patients prescribed warfarin, there is limited evidence to suggest similar levels of enhanced monitoring for DOACs. The antithrombotic stewardship team at our institution developed guidelines and implemented computerized clinical decision support (CCDS) tools to enhance medication and patient safety related to the DOACs. We sought to assess the safety and effectiveness of these CCDS tools available to clinicians upon DOAC prescription in hospitalized patients. We performed a retrospective review of 121 patients who received at least two doses of a DOAC from January 2013 to July 2014. We assessed dosing of the DOAC according to the CCDS provided upon order entry. Adherence to CCDS was 80% (n = 24), 75% (n = 46), and 87% (n = 27) in the dabigatran, apixaban, and rivaroxaban group, respectively. Our data demonstrate that implementing CCDS for DOACs into the electronic medical record may ensure safe prescribing of high-risk medications.
PMID: 30252771
ISSN: 1549-8425
CID: 3315992
To Deprescribe or Not to Deprescribe Aspirin-A Clear Indication Is the Challenge
PMID: 34459847
ISSN: 2168-6114
CID: 5011632
Antixa heparin dosing protocol evaluation at a large academic medical center [Meeting Abstract]
Background : The activated partial thromboplastin time (aPTT) and anti-factor Xa (anti-Xa) test are often used as surrogate markers of heparin's effects, though anti-Xa may be preferred due to less variability and closer relation to heparin's activity in the body. The antithrombotic and hemostatic therapy oversight group at NYU Langone Health (NYULH) implemented a nurse-titrated protocol, utilizing anti-Xa to titrate and monitor time in therapeutic range with heparin. Aims : To evaluate adherence to the nurse-driven continuous infusion unfractionated heparin protocol and assess time to therapeutic anti-Xa, median time in therapeutic range, and clinical outcomes including bleeding and thrombotic events. Methods : This was a retrospective chart review. Adult patients (>18 years old) who received heparin based on nurse-driven titration protocol between March 2019 and June 2019 at NYULH were included. Patients that received heparin for less than 24 hours, had an interruption in heparin for more than 12 hours, or received a direct oral anticoagulant (DOAC) prior to heparin initiation were excluded. Data collection included baseline characteristics, relevant concomitant medications, heparin administration including bolus dose, infusion rate, length of therapy, time within therapeutic range, bleeding events, and thrombotic events. The primary outcome was adherence to the protocol. Secondary outcomes included time within therapeutic range, thrombotic or bleeding events. Results : Adherence to the protocol, defined as deviation of not more than 25% of protocol elements, including but not limited to adequate bolus dose, correct body weight used, time to first anti-Xa, and correct adjustment (units/kg) in heparin dose based on anti-Xa was observed 85% of the time, with the majority of dose titrations occurring by nursing, per protocol in 82% of patients. Therapeutic anti-Xa levels were achieved at a median of 30 hours into IV UFH therapy. Conclusions : It remains a challenge to achieve a stable goal anti-Xa level within 24 hours of heparin initiation
EMBASE:636404148
ISSN: 2475-0379
CID: 5044692
Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19
BACKGROUND:Thrombosis and inflammation may contribute to morbidity and mortality among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation would improve outcomes in critically ill patients with Covid-19. METHODS:In an open-label, adaptive, multiplatform, randomized clinical trial, critically ill patients with severe Covid-19 were randomly assigned to a pragmatically defined regimen of either therapeutic-dose anticoagulation with heparin or pharmacologic thromboprophylaxis in accordance with local usual care. The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. RESULTS:The trial was stopped when the prespecified criterion for futility was met for therapeutic-dose anticoagulation. Data on the primary outcome were available for 1098 patients (534 assigned to therapeutic-dose anticoagulation and 564 assigned to usual-care thromboprophylaxis). The median value for organ support-free days was 1 (interquartile range, -1 to 16) among the patients assigned to therapeutic-dose anticoagulation and was 4 (interquartile range, -1 to 16) among the patients assigned to usual-care thromboprophylaxis (adjusted proportional odds ratio, 0.83; 95% credible interval, 0.67 to 1.03; posterior probability of futility [defined as an odds ratio <1.2], 99.9%). The percentage of patients who survived to hospital discharge was similar in the two groups (62.7% and 64.5%, respectively; adjusted odds ratio, 0.84; 95% credible interval, 0.64 to 1.11). Major bleeding occurred in 3.8% of the patients assigned to therapeutic-dose anticoagulation and in 2.3% of those assigned to usual-care pharmacologic thromboprophylaxis. CONCLUSIONS:In critically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin did not result in a greater probability of survival to hospital discharge or a greater number of days free of cardiovascular or respiratory organ support than did usual-care pharmacologic thromboprophylaxis. (REMAP-CAP, ACTIV-4a, and ATTACC ClinicalTrials.gov numbers, NCT02735707, NCT04505774, NCT04359277, and NCT04372589.).
PMCID:8362592
PMID: 34351722
ISSN: 1533-4406
CID: 4980752
