Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: Where Are We Now?

OBJECTIVE: To synthesize the literature and provide guidance to practitioners regarding double therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) requiring percutaneous coronary intervention (PCI). DATA SOURCES: PubMed and MEDLINE (January 2000 to February 2018) were searched using the following terms: atrial fibrillation, myocardial infarction, acute coronary syndrome, percutaneous coronary intervention, anticoagulation, dual-antiplatelet therapy, clopidogrel, aspirin, ticagrelor, prasugrel, and triple therapy. STUDY SELECTION AND DATA EXTRACTION: The results included randomized and nonrandomized clinical trials and meta-analyses. Each study was reported based on study design, population, intervention, comparator, and key cardiovascular (CV) and bleeding outcomes. DATA SYNTHESIS: A total of 15 studies were included in the review. The majority of studies evaluating DT and TT utilized clopidogrel and warfarin as components of the regimen, although there are emerging data with newer agents. Evidence purporting DT regimens to be equally effective in preventing CV events and improved safety profiles compared with TT regimens included populations with relatively low risk for recurrent CV events, and many of these studies were observational in nature. Overall, current evidence as well as American and European guidelines support the use of TT in patients with AF who require PCI for the least possible amount of time, depending on patient-specific factors involving bleeding and thrombosis. CONCLUSIONS: In the majority of patients with AF who require PCI, TT should be used for the shortest period of time possible. DT regimens may be used in patients requiring PCI who have low risk for thrombosis and/or high bleeding risk.

Impact of a problem-based learning elective on performance in non-problem-based learning required courses.

BACKGROUND AND PURPOSE: Use of problem-based learning (PBL) in health professions education has limited data supporting improved exam performance and confidence in problem solving, primarily within courses converted to a PBL format. This study aimed to demonstrate a similar benefit in simultaneous and subsequent required, non-PBL courses that involved critical thinking. EDUCATIONAL ACTIVITY AND SETTING: This retrospective cohort study included students who were enrolled in the pharmacotherapeutics and case studies/laboratory course sequences in the second and third professional (P3) years. We compared performance across both course sequences of students who took a PBL elective course in the fall of the P3 year (PBL students) and students who did not take the elective course (non-PBL students). FINDINGS: There was a statistically significant difference favoring PBL students in performance in both the therapeutics and case/lab courses offered simultaneously with the PBL elective. There was no significant difference noted between PBL and non-PBL student performance in the subsequent therapeutics and case/lab courses; however, results within individual cohorts differed strikingly from the aggregate analysis. Performance in the PBL elective had no impact on the outcomes of the study. SUMMARY: This study demonstrated an overall benefit for students who participated in a PBL course on performance in simultaneous, critical thinking courses that did not incorporate PBL. However, the aggregate did not show a difference in performance in subsequent critical thinking, non-PBL courses. Further studies are needed to elucidate the true benefit of the PBL approach in other non-PBL courses that require advanced clinical reasoning.

Describing pharmacy student participation in an international, interprofessional medical mission trip as part of an advanced pharmacy practice experience (APPE).

BACKGROUND AND PURPOSE: Several schools of pharmacy across the United States have taken steps to incorporate international medical mission trips into the doctor of pharmacy (PharmD) curriculum. This study aims to describe the impact of advanced pharmacy practice experience (APPE)-level student pharmacists on an interprofessional team during an international medical mission trip to Jamaica. EDUCATIONAL ACTIVITY AND SETTING: The Jamaica Medical Mission (JMM) trip is an annual event involving healthcare professionals from several disciplines across multiple universities and healthcare systems. At this institution, the JMM trip is included as part of a rural health elective APPE rotation. Students electing to participate in this rotation are provided with the opportunity to serve as active participants on an interprofessional healthcare team in underserved and under-resourced communities throughout Jamaica. The JMM trip that took place during June 2016 included healthcare professionals and students in the fields of medicine, dentistry, optometry, nursing, and pharmacy. A total of five pharmacist preceptors and 10 pharmacy students attended the JMM trip in June 2016. Approximately three to five clinic sites per day were conducted simultaneously on each of the seven clinic days at various locations throughout Jamaica. The interprofessional healthcare teams provided free medical care, including physical exams and access to prescription and non-prescription medications. FINDINGS: The interprofessional healthcare team saw a total of 1014 patients and dispensed 1879 prescriptions during the seven clinic days. A total of 811 clinical recommendations were made by student pharmacists and/or pharmacy preceptors. Of these recommendations, 561 (69%) were made by student pharmacists without pharmacy preceptor prompting, 103 (13%) were made by the student pharmacist with preceptor prompting, and 147 (18%) were made by pharmacy preceptors. Over 70% of recommendations made by student pharmacists without pharmacy preceptor prompting were accepted by prescribers. DISCUSSION AND SUMMARY: This study sought to describe the impact of APPE-level student pharmacists on an interprofessional team during an international medical mission trip. Our findings demonstrate that APPE-level student pharmacists were capable of making a substantial number of clinical recommendations without preceptor prompting. The number of recommendations made by students without preceptor prompting were consistently greater than the number of recommendations made with preceptor prompting throughout the trip. Future studies should address student competence in achieving learning objectives associated with international, interprofessional APPE rotations.