Use of Contraindicated Antiplatelet Medications in the Setting of Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

Background: Several antiplatelet medications used during and after percutaneous coronary intervention (PCI) are contraindicated for specific patient groups. A broad assessment of contraindicated medication use and associated clinical outcomes is not well described.

Methods And Results: Using national Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data for all PCI between 2007 and 2013, we evaluated patients with contraindications to commonly used antiplatelet medications during and after PCI, defined in accordance with package inserts.

Triple Oral Antithrombotic Therapy in Atrial Fibrillation and Coronary Artery Stenting: Searching for the Best Combination.

Patients with atrial fibrillation (AF) who are treated with oral anticoagulants often have concurrent coronary artery disease. Triple oral antithrombotic therapy (TOAT) is often necessity to prevent stent thrombosis or myocardial infarction associated with percutaneous coronary intervention or acute coronary syndrome in patients with comorbid coronary artery disease and AF. Although the use of TOAT (aspirin, clopidogrel, and warfarin) has excellent efficacy against thrombotic complications, this comes on the expense of increased bleeding risk.

Renal function in atrial fibrillation patients switched from warfarin to a direct oral anticoagulant.

All available direct oral anticoagulants (DOACs) are at least partially eliminated by the kidneys. These agents are increasingly being used as alternatives to warfarin for stroke prevention in patients with atrial fibrillation. The aim of this study was to identify changes in renal function and associated DOAC dosing implications in a multicenter cohort of atrial fibrillation patients switched from warfarin to DOAC treatment.

Use of decision aids for shared decision making in venous thromboembolism: A systematic review.

Background: Optimal care of patients with venous thromboembolism requires the input of patient preferences into clinical decision-making. However, the availability and impact of decision aids to facilitate shared decision making in care of venous thromboembolism is not well known.

Objectives: To assess the availability, clinical impact and outcomes associated with the use of decision aids in patients with or at risk for venous thromboembolism.

Reimagining Anticoagulation Clinics in the Era of Direct Oral Anticoagulants.

Anticoagulation clinics were initially developed to provide safe and effective care for warfarin-treated patients with atrial fibrillation, venous thromboembolism, and mechanical valve replacement. Traditionally, these patients required ongoing laboratory monitoring and warfarin dose adjustment by expert providers. With the introduction of direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban), many have questioned the need for anticoagulation clinic.

Cancer-Associated Venous Thromboembolism.

Cancer patients are at high risk for venous thromboembolism (VTE) which is considered the second leading cause of death among this population. Both cancer and cancer treatment increase this risk. Since the risk of VTE is not the same in all cancer patients, it is important to understand what factors increase the risk of incident and the risk of recurrent VTE in this patient population.

Cost-Effectiveness of Dabigatran (150 mg Twice Daily) and Warfarin in Patients ≥ 65 Years With Nonvalvular Atrial Fibrillation.

Dabigatran has been shown to be superior to warfarin for stroke prevention in nonvalvular atrial fibrillation (NVAF) but with higher out-of-pocket costs for patients. Although dabigatran has been shown to be cost effective from a societal perspective, cost implications for individual patients and insurers are not well described. We aimed to assess cost perspectives of each payer (Medicare and patient) in relation to administration, monitoring, and adverse outcomes for dabigatran and warfarin in patients with and without prescription drug coverage.

National Trends in Ambulatory Oral Anticoagulant Use.

Background: Four direct oral anticoagulants (DOACs) have been brought to market for the treatment of nonvalvular atrial fibrillation and venous thromboembolism. Many forces, including numerous positive trial results, emerging safety concerns, marketing, and promotion, may shape DOAC adoption by providers. However, relatively little is known regarding their ambulatory utilization compared with warfarin, as well as the degree to which they have decreased under-treatment of atrial fibrillation.

The changing characteristics of atrial fibrillation patients treated with warfarin.

It has been suggested that direct oral anticoagulants are being preferentially used in low risk atrial fibrillation (AF) patients. Understanding the changing risk profile of new AF patients treated with warfarin is important for interpreting the quality of warfarin delivery through an anticoagulation clinic. Six anticoagulation clinics participating in the Michigan Anticoagulation Quality Improvement Initiative enrolled 1293 AF patients between 2010 and 2014 as an inception cohort.

Venous thromboembolism: Predicting recurrence and the need for extended anticoagulation.

Initial treatment for venous thromboembolism (VTE) includes the acute and intermediate phases, usually lasting for 3 months. The choice to extend therapy beyond the initial 3-month window involves assessing a combination of risk factors for VTE recurrence and bleeding, along with weighing patient preferences. In some cases, such as VTE provoked by a reversible surgical risk factor, the recurrence risk is sufficiently low that most patients should not receive extended therapy.

Engaging with quality improvement in anticoagulation management.

Anticoagulants are highly effective at preventing thrombosis across a variety of clinical indications. However, their use can also lead to devastating effects, including major bleeding and death. Anticoagulation providers strive to balance the benefits of anticoagulant therapy with the risks of major bleeding.

Perioperative management of oral anticoagulants: a focus on target-specific oral anticoagulants.

Although warfarin has historically been the dominant oral anticoagulant, newer target-specific oral anticoagulants (TSOACs) have been introduced in the marketplace in the past few years. Dabigatran, rivaroxaban, and apixaban, collectively referred to as TSOACs, have undergone extensive testing in comparison with warfarin and other anticoagulants for a variety of conditions. Compared with warfarin, the shorter time to peak effect, shorter half-life, and fewer drug-drug interactions have helped make the TSOACs attractive alternatives to warfarin for the prevention and treatment of thromboembolic disease associated with orthopedic surgery and atrial fibrillation as well as for the treatment of venous thromboembolism.

AREDS Formula, Warfarin, and Bleeding: A Case Report from the Michigan Anticoagulation Quality Improvement Initiative.

Importance. The anticoagulant warfarin has been shown to interact with other medications, vitamin K containing foods, and over-the-counter products. These interactions may inhibit or potentiate the effect of warfarin, resulting in serious clotting or bleeding events.

The predictive ability of the CHADS2 and CHA2DS2-VASc scores for bleeding risk in atrial fibrillation: the MAQI(2) experience.

Introduction: Guidelines recommend the assessment of stroke and bleeding risk before initiating warfarin anticoagulation in patients with atrial fibrillation. Many of the elements used to predict stroke also overlap with bleeding risk in atrial fibrillation patients and it is tempting to use stroke risk scores to efficiently estimate bleeding risk. Comparison of stroke risk scores to bleeding risk scores to predict bleeding has not been thoroughly assessed.

Warfarin use in atrial fibrillation patients at low risk for stroke: analysis of the Michigan Anticoagulation Quality Improvement Initiative (MAQI(2)).

To more accurately quantify the proportion of anticoagulated patients with atrial fibrillation (AF) that may be inappropriately treated with warfarin for stroke prevention. Patients with AF have an increased risk of stroke, which is lowered by the use of warfarin. However there is likely more potential harm than benefit in patients that do not have additional stroke risk factors.

Effect of dabigatran on referrals to and switching from warfarin in two academic anticoagulation management services.

Dabigatran was expected to replace warfarin for stroke prevention in patients with nonvalvular atrial fibrillation (AF) who are warfarin naive, difficult to maintain in therapeutic range, or at risk of warfarin-related bleeding complications. We hypothesized that the number of patients with nonvalvular AF referred to Anticoagulation Management Services would decrease sharply and that most would switch from warfarin to dabigatran. We evaluated the number of patients with nonvalvular AF referred to 2 large services, Anticoagulation Management Service 1 and Anticoagulation Management Service 2, 12 months before and after market entry of dabigatran.

Management of oral anticoagulation in patients undergoing minor dental procedures.

Approximately 4.2 million patients in the United States are taking warfarin, making it the 11th most prescribed drug. Warfarin is primarily used for treatment of venous thromboembolic disease and stroke prevention in patients with atrial fibrillation and mechanical heart valves.

Use of warfarin for venous thromboembolism prophylaxis following knee and hip arthroplasty: results of the Michigan Anticoagulation Quality Improvement Initiative (MAQI2).

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are associated with high rates of venous thromboembolism (VTE). Anticoagulants, such as warfarin, are commonly used to prevent VTE in such patients. The practice and effectiveness of warfarin in real world populations is not well documented.

Venous thromboembolism: a collaborative quality improvement model for practitioners, hospitals, and insurers.

Venous thromboembolism (VTE) carries significant morbidity and mortality and affects a large portion of hospitalized patients. VTE prophylaxis is rated by the Agency for Healthcare Research and Quality as the most effective of 79 patient safety practices it assessed in 2001. Since 1997, Blue Cross Blue Shield of Michigan/Blue Care Network (BCBSM/BCN) have partnered with Michigan hospitals and providers in statewide registry-based collaborative quality improvement initiatives (CQI) aimed at improving the safety and quality of surgical and medical care; many of these collaborative have a particular focus on VTE prevention.

National trends in venous disease.

Background: The national burden of venous disease and use of ultrasound (US) in the outpatient and emergency department (ED) settings has not been well described. The objective of this study is to describe venous disease in the outpatient and ED settings nationally as well as to characterize the use of US for diagnosis of venous disease, including phlebitis.

Methods: Data from the 1997 to 2006 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) were compiled, and complex sampling methods were used to describe the number of outpatient and ED visits for adults given a diagnosis of venous disease or phlebitis by ICD-9 coding.

Anticoagulation: where we are and where we need to go.

Although a commonly prescribed medication, warfarin has unique pharmacologic properties that make dosing challenging for many primary care physicians. When a patient's international normalized ratio (INR) is out of the therapeutic range, they are at increased risk for thrombotic or hemorrhagic complications. We have reviewed the current literature for quality improvement techniques to minimize adverse outcomes and improve anticoagulation care.

Dual antiplatelet agent failure: a new syndrome or clinical nonentity?

Background: Aspirin resistance is a well-documented laboratory finding, but the effects of clinical aspirin (ASA) failure on patients with acute coronary syndrome (ACS) have been debated. Likewise, there is recognition of clopidogrel resistance, but the clinical effects of clopidogrel failure are not well understood. We sought to determine the 6-month outcomes of patients who developed an ACS while on ASA or dual antiplatelet agents.