AM Versus PM Postoperative Administration of Warfarin With a Mechanical Mitral Valve.

Background: Currently, there are no guidelines regarding the optimal daily timing of inpatient warfarin administration. Objective: The purpose of this study was to determine whether dosing warfarin in the morning will have a significant impact on therapeutic international normalized ratio (INR) achievement compared with evening administration in mechanical mitral valve patients initiated on warfarin following cardiac surgery. Methods: This was a single-center, pre- and post-retrospective cohort conducted between 2014 and 2018. One-hundred fifty-four adult patients who underwent a mechanical mitral valve replacement or alternative cardiac surgery with a history of a mechanical mitral valve were enrolled. The primary outcome was achievement of therapeutic INR at any time point after initiation of warfarin. Pre-intervention administration timing was 6 pm and post-intervention timing was 10 am. Results: Baseline characteristics including age, sex, and race were similar between the 2 groups (P = NS for each characteristic). Therapeutic INR achievement was significantly improved at all time points following 10 am warfarin administration compared with 6 pm (hazard ratio = 1.69; P = .005). Mean time-to-therapeutic INR was 7.37 days in the post-intervention group and 8.39 days in the pre-intervention group (P = .073). There were no significant differences in INR >4, bleeding, or thrombotic complications between groups. Conclusion and Relevance: This retrospective analysis suggests that there may be a postoperative benefit in therapeutic INR achievement in mechanical valve patients when dosing warfarin in the morning compared with evening administration. Large-scale studies should be conducted to further elucidate the potential benefit across more heterogeneous populations.

Ticagrelor Use in a Patient With a Documented Clopidogrel Hypersensitivity.

OBJECTIVE: To report the use of ticagrelor in a patient with a documented hypersensitivity reaction to clopidogrel. CASE SUMMARY: A 64-year-old woman presented with non-ST-segment elevation myocardial infarction (NSTEMI) with a history significant for a hypersensitivity reaction to clopidogrel and was medically managed. Based on the patient's past medical history and current evidence available, the determination was made to use ticagrelor in this patient. Ticagrelor was administered without reaction during the hospital stay and on assessment at 2 and 4 weeks postdischarge. DISCUSSION: Hypersensitivity occurs in approximately 1% of patients receiving clopidogrel. Although the risk of hypersensitivity reaction to clopidogrel is low, evidence to support alternative antiplatelets in this setting is relatively limited. Prasugrel has a similar structure to clopidogrel and, therefore, may cross-react. Furthermore, prasugrel is not recommended in the medical management of NSTEMI. Ticagrelor is a newer P2Y12 inhibitor that contains a cyclopentyltriazolopyrimidine structure. Because of the difference in structure, a lower theoretical risk of cross-reactivity with the thienopyridines would be anticipated. However, there are no reports to date that investigate the use of this agent in patients with a documented thienopyridine allergy. CONCLUSIONS: The current case report describes the use of ticagrelor in a patient with documented hypersensitivity to clopidogrel. In this patient, ticagrelor was well tolerated during hospital admission and at 2 and 4 weeks postdischarge following administration.

Fabrication of An Inexpensive but Effective Colonoscopic Simulator.

Because of increasing requirements for simulator training before actual clinical endoscopies, the demand for realistic, inexpensive endoscopic simulators is increasing. We describe the steps involved in the design and fabrication of an effective and realistic mechanical colonoscopic simulator.

Pharmacotherapy of Vasospastic Angina.

Vasospastic angina is a diagnosis of exclusion that manifests with signs and symptoms, which overlap with obstructive coronary artery disease, most often ST-segment elevation myocardial infarction. The pharmacotherapy that is available to treat vasospastic angina can help ameliorate angina symptoms. However, the etiology of vasospastic angina is ill-defined, making targeted pharmacotherapy difficult. Most patients receive pharmacotherapy that includes calcium channel blockers and/or long-acting nitrates. This article reviews the efficacy and safety of the pharmacotherapy used to treat vasospastic angina. High-dose calcium channel blockers possess the most evidence, with respect to decreasing angina incidence, frequency, and duration. However, not all patients respond to calcium channel blockers. Nitrates and/or alpha1-adrenergic receptor antagonists can be used in patients who respond poorly to calcium channel blockers. Albeit, evidence for use of nitrates and alpha1-adrenergic receptor antagonists in vasospastic angina is not as robust as calcium channel blockers and can exacerbate adverse effects when added to calcium channel blocker therapy. Despite having a clear benefit in patients with obstructive coronary artery disease, the benefit of beta-adrenergic receptor antagonists, statins, and aspirin remains unclear. More data are needed to elucidate whether or not these agents are beneficial or harmful to patients being treated for vasospastic angina. Overall, the use of pharmacotherapy for the treatment of vasospastic angina should be guided by patient-specific factors, such as tolerability, adverse effects, drug-drug, and drug-disease interactions.