Improving use of proton pump inhibitors with dual antiplatelet therapy in patients admitted with acute coronary syndrome.

Acute coronary syndrome (ACS) is one of the leading causes of morbidity and mortality with a major impact on healthcare resources and expenditure. Dual antiplatelet therapy (DAPT) is recommended for the treatment of ACS. DAPT is associated with an increased risk of gastrointestinal (GI) bleeding, which is seen in 1.2%-2.4% of patients on DAPT and associated with fivefold increase in mortality at 30 days and fourfold increase at 1 year. European Society of Cardiology guidelines recommend that patients on DAPT should also be prescribed a proton pump inhibitor (PPI) to reduce the risk of GI bleeding.We assessed compliance with this recommendation on the cardiology ward of our tertiary cardiac unit. At baseline, only 56% of patients on DAPT were coprescribed a PPI. We subsequently devised and delivered a service improvement project (three completed audit cycles) to improve concomitant prescription of PPI, with the aim of achieving 100% compliance with the guidelines. We introduced low-cost interventions that included educational sessions for junior doctors, cardiac nursing staff and pharmacists, as well as posters which served as visual prompts for discharging doctors. We also initiated a protocol that the pharmacy team clarify with the discharging doctor whether a patient on DAPT should also be on PPI, before the discharge summary is finalised.Consequently, 100% of patients on DAPT were coprescribed PPI within fourteen weeks of the onset of our intervention. This improvement was sustained across a subsequent cohort of junior doctors. Our interventions should help to reduce the risk of GI bleeding in this population.

A real-world experience of subcutaneous and transvenous implantable cardiac defibrillators-comparison with the PRAETORIAN study.

Background: PRAETORIAN is the first randomized controlled trial that demonstrated the noninferiority of subcutaneous ICD (S-ICD) in comparison with transvenous ICD (TV-ICD). We retrospectively reviewed electronic records of patients with ICD implanted over the past 6 years, with the primary objective to compare our real-world single tertiary center experience with the randomized data from the PRAETORIAN study. Methods: Seventy S-ICD patients were compared with 197 TV-ICD patients, from July 2014 to June 2020 retrospectively, over a median period of 1304 days (296-2451 days). Primary composite endpoints included inappropriate shocks and device-related malfunctions. Results: Patients with S-ICD implantation were younger than those who received TV-ICD (mean, 49.7 years vs 63.9 years, p < .001). About 31.4% of S-ICDs were implanted for secondary prevention, and 58.6% of S-ICD patients had ischemic cardiomyopathy (ICM) with a median left ventricular ejection fraction of 32.5% (range: 10-67%). S-ICDs and TV-ICD had statistically similar inappropriate shocks (4.3% vs 4.6%, p = .78), device-related complications (11.4% vs 9.1%, p = .93), and the overall primary endpoints (15.7% vs 13.7%, p = .68). The findings remained the same even after age and gender adjustments and time-dependent analysis. Conclusion: Although single-center experience with a small number of S-ICD patients, results of the PRAETORIAN study has been replicated in our real-world experience of S-ICD and TV-ICD implantations across diverse etiologies, indications, and age groups confirming the comparable performance of S-ICD and TV-ICD when implanted in selected patients.