Faculty Bibliography
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64
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
Direct oral anticoagulants versus warfarin in people living with human immunodeficiency virus
Human immunodeficiency virus (HIV) is associated with increased rates of cardiovascular disease and vascular events, and people living with HIV (PLWH) may often have indications for therapeutic anticoagulation. However, the ideal anticoagulant in PLWH remains unknown. This retrospective cohort evaluated the tolerability and effectiveness of oral anticoagulants in PLWH. The primary outcome was tolerability, defined as a composite of bleeding and/or discontinuation rates. The secondary outcomes included recurrent thromboembolism, bleeding, and discontinuations, independently. There were 92 patients included for analysis, 48 in the direct oral anticoagulant (DOAC) arm and 44 in the warfarin arm. There were 35 (38%) PLWH that did not tolerate oral anticoagulation therapy in the total cohort. Among these, 19 received a DOAC and 16 received warfarin. There were 16 (17%) PLWH that experienced a bleeding event: six in the DOAC arm and 10 in the warfarin arm. There were 15 (16%) PLWH that experienced recurrent thromboembolism, with similar rates between DOAC versus warfarin (10, 21% vs 5, 11%, respectively; p = 0.11). The most commonly prescribed HIV regimens were protease inhibitor and integrase inhibitor-based regimens. Overall, anticoagulation-related outcomes with either a DOAC or warfarin were poor in our cohort of PLWH, with high rates of bleeding, discontinuations, and recurrent thromboembolism. Further studies are necessary to validate and assess reasons for poor tolerability.
PMID: 34293995
ISSN: 1758-1052
CID: 5005752
Catheter-Directed Thrombolysis for Neonatal IVC and Bilateral Renal Vein Thrombosis: A Case Report
Renal vein thrombosis is the most common non-catheter-associated venous thromboembolism event in neonates, accounting for up to 20% of cases. Although mortality rates are lower than a variety of other forms of pediatric thrombosis, renal vein thrombi are associated with significant short-term and long-term sequelae. This report presents the case of a full-term neonate presenting with bilateral renal vein thrombosis with inferior vena cava involvement treated with catheter-directed thrombolysis. This case report intends to highlight the value of a multidisciplinary approach to pediatric venous thromboembolism and to outline relevant procedural details and current laboratory and imaging monitoring of catheter-directed thrombolysis.
PMID: 32569035
ISSN: 1536-3678
CID: 4492822
To DOAC or Not to DOAC for Left Ventricular Thrombi-What Is the Dose?
PMID: 33471023
ISSN: 2380-6591
CID: 4799462
Evaluation of Direct Oral Anticoagulants Versus Warfarin for Intracardiac Thromboses
ABSTRACT/UNASSIGNED:Intracardiac thrombus (ICT) formation is a common complication of several cardiovascular diseases. Warfarin is recommended for treatment of ICT by guidelines based on observational studies occurring prior to the advent of non-vitamin K antagonist direct oral anticoagulants (DOACs). We aim to evaluate the current prescribing patterns at our institution and to compare the efficacy and safety profiles of warfarin versus DOACs for ICT.This is a retrospective review of adult patients treated with oral anticoagulation for ICT between May 2013 and December 2019. Our primary endpoint was complete thrombus resolution. Secondary outcomes included time to resolution of thrombus, treatment failure, and duration of therapy. Safety endpoints included stroke and systemic embolism (SSE) and bleeding events.A total of 123 patients were included (DOAC n=61; warfarin n=62). At baseline, more patients in the DOAC group had anemia (6 [10%] vs 0 [0%], p=0.013) and alcohol use disorder (6 [10%] vs 0 [0%], p = 0.013). Complete thrombus resolution occurred in 50 (82%) and 46 (74%) patients in the DOAC and warfarin groups, respectively (p = 0.298). There was a shorter time to thrombus resolution in the DOAC group versus the warfarin group (63 days [IQR 40, 138] vs 123 days [IQR 86, 244], p = 0.003). There were no differences found in SSE or bleeding between the groups (DOAC 11 [19%] vs warfarin 17 [28%], p = 0.213). For patients with an ICT, treatment with a DOAC for at least 3 months may be a comparable alternative to warfarin in terms of safety and efficacy.
PMID: 33560043
ISSN: 1533-4023
CID: 4814782
Comparison of Outcomes of Enoxaparin Bridge Therapy in HeartMate II versus HeartWare HVAD Recipients
BACKGROUND/UNASSIGNED:There is a lack of robust data evaluating outcomes of enoxaparin "bridge" therapy in left ventricular assist device (LVAD) patients. METHODS/UNASSIGNED:We performed a retrospective study of HeartMate II (HM II) and HeartWare HVAD recipients that received therapeutic enoxaparin as "bridge" therapy to describe bleeding and thrombotic events and compare outcomes between devices. The primary endpoint was the incidence of bleeding within 30 days of "bridge" episode. Major bleeding was defined by INTERMACS criteria. RESULTS/UNASSIGNED:= .02). We observed 3 (1%) thromboembolic events in 2 (4%) patients with an HVAD device. On multivariate analysis, the presence of a HM II device was associated with a 4-fold increased risk of bleeding. CONCLUSION/UNASSIGNED:We found the use of enoxaparin "bridge" therapy to be associated with a higher incidence of bleeding in patients with a HM II device compared with an HVAD device. Assessment of device- and patient-specific factors should be evaluated to minimize bleeding events.
PMID: 33844604
ISSN: 1940-4034
CID: 4845762
