Assessment of immunosuppression induction with basiliximab compared to antithymocyte-globulin in adult heart transplant patients.

BACKGROUND: Patients undergoing heart transplants are at risk of rejection which can have significant morbidity and mortality. Induction immunosuppression at the time of transplant reduces the early risk and has additional benefits. The induction agent of choice within our program was changed from rabbit antithymocyte-globulin (rATG) to basiliximab, so it was necessary to evaluate whether this had any impact on patient outcomes. OBJECTIVES: Our primary objective was to describe rejection, infection, and other outcomes in adult heart transplant patients at the University of Alberta Hospital in Edmonton, Canada. METHODS: This study was a nonrandomized, retrospective cohort study. RESULTS: Sixty-three patients were included with median ages 50 years versus 54 years. More female patients received rATG (20% vs. 42.4%). The most common indication for transplant in both cohorts was ICM (63.3% vs. 57.6%). Patients who received rATG had significantly higher PRA (0% vs. 43%, p < .001). Acute rejection episodes were similar between basiliximab and rATG at 3 months (16.7% vs. 15.1%; p = 1.0) and 6-months (30.0% vs. 18.1%; p = .376). Infections were not statistically different with basiliximab compared to rATG at 3-months, 43.3% vs. 63.6% and at 6-months 60.0% vs. 66.7%). There were no fatalities in either group. CONCLUSIONS: Our study did not demonstrate differences in rejection with basiliximab compared to rATG. Mortality did not differ, but basiliximab-treated patients had fewer infections and infection-related hospitalizations than those treated with rATG. Larger studies with longer durations are needed to more completely describe the differences in rejection and infectious outcomes.

Switching to Clopidogrel in Patients With Acute Coronary Syndrome Managed With Percutaneous Coronary Intervention Initially Treated With Prasugrel or Ticagrelor: Systematic Review and Meta-analysis.

Objective: To evaluate the effects of switching from ticagrelor or prasugrel to clopidogrel in acute coronary syndrome (ACS) patients managed with percutaneous coronary intervention on major adverse cardiovascular events (MACEs) and bleeding. Data Sources: We searched MEDLINE, EMBASE, CENTRAL, bibliographies of relevant articles, and clinicaltrials.gov for eligible articles published from inception to January 27, 2019. Study Selection and Data Extraction: We included randomized controlled trials (RCTs) and cohort and case-control studies that reported on ≥1 outcome of interest. Primary outcomes were MACE and major bleeding, and the secondary outcome was any bleeding. Data Synthesis: From 483 articles, we included 7 relevant studies (2 RCTs, 5 cohort studies) at high/unclear risk of bias. Random-effects meta-analysis revealed inconclusive effects on MACE (hazard ratio [HR] = 1.00, 95% CI = 0.59-1.68; I2 = 82%), major bleeding (HR = 0.51; 0.19-1.35; I2 = 91%), and any bleeding (HR = 0.64; 0.38-1.07; I2 = 85%). Similar nonsignificant results were obtained in secondary analyses evaluating risk ratios. Relevance to Patient Care and Clinical Practice: Ticagrelor and prasugrel, are now considered preferred therapy over clopidogrel in patients with ACS. Switching from these potent P2Y12 inhibitors to clopidogrel is commonly performed to reduce bleeding risk, other adverse effects, or costs. Current best-available evidence is inconclusive regarding the effects of switching to clopidogrel on the risk of MACE and bleeding. Overall, studies were underpowered to detect clinically important differences. Conclusions: Until adequately powered trials demonstrate an advantage to switching to clopidogrel from prasugrel or ticagrelor, clinicians may consider this approach as clinically indicated on an individual, case-by-case basis.

Prevention and management of statin adverse effects: A practical approach for pharmacists.

Statin-associated adverse effects, primarily muscle-related symptoms, occur in up to approximately one-third of patients in clinical practice. Recently, a Canadian Consensus Working Group outlined 6 key principles to assess and manage patients with goal-inhibiting statin intolerance, defined as a syndrome characterized by symptoms or biomarker abnormalities that prevent the long-term use of and adherence to indicated statin therapy, which includes a trial of at least 2 statins and precludes reversible causes of statin adverse effects. These principles ensure patients are appropriately receiving a statin and aware of both the benefits and risks of therapy. As well, they address factors that may increase the risk of statin-associated myopathy. A thorough assessment of patients' clinical and laboratory history should be performed in any patient presenting with muscle symptoms on statin therapy, followed by a systematic dechallenge/rechallenge approach. In practice, most patients with statin intolerance due to muscle symptoms will be able to tolerate another statin. This is of particular importance because of the relative paucity of compelling evidence demonstrating a cardiovascular benefit with nonstatin therapies. Pharmacists are ideally situated to provide patient education, recommend changes to therapy and monitor patients with goal-inhibiting statin intolerance.

Familial hypercholesterolemia: Review of diagnosis, screening, and treatment.

OBJECTIVE: To summarize the pathophysiology, epidemiology, screening, diagnosis, and treatment of familial hypercholesterolemia (FH). QUALITY OF EVIDENCE: A PubMed search was conducted (inception to July 2014) for articles on pathophysiology, screening, diagnosis, and management of FH, supplemented with hand searches of bibliographies of guidelines and reviews. A supporting level of evidence for each recommendation was categorized as level I (randomized controlled trial or systematic review of randomized controlled trials), level II (observational study), or level III (expert opinion). The best available evidence is mostly level II or III. MAIN MESSAGE: Familial hypercholesterolemia affects 1 in 500 Canadians. Risk of a coronary event is high in these patients and is underestimated by risk calculators (eg, Framingham). Clinicians should screen patients according to guidelines and suspect FH in any patient with a premature cardiovascular event, physical stigmata of hypercholesterolemia, or an elevated plasma lipid level. Physicians should diagnose FH using either the Simon Broome or Dutch Lipid Network criteria. Management of heterozygous FH includes reducing low-density lipoprotein levels by 50% or more from baseline with high-dose statins and other lipid-lowering agents. Clinicians should refer any patient with homozygous FH to a specialized centre. CONCLUSION: Familial hypercholesterolemia represents an important cause of premature cardiovascular disease in Canadians. Early identification and aggressive treatment of individuals with FH reduces cardiovascular morbidity and mortality.

A randomized trial of a community-based approach to dyslipidemia management: Pharmacist prescribing to achieve cholesterol targets (RxACT Study).

BACKGROUND: Dyslipidemia is an important risk factor for cardiovascular disease but is suboptimally managed. Pharmacists are accessible primary care professionals and with expanded scopes of practice (including prescribing), could identify and manage patients with dyslipidemia. We sought to evaluate the effect of pharmacist prescribing of dyslipidemia medications on the proportion of participants achieving target LDL-cholesterol (LDL-c) levels. METHODS: We conducted a randomized controlled trial in 14 community pharmacies in Alberta, Canada. We enrolled adults with uncontrolled dyslipidemia as defined by the 2009 Canadian Dyslipidemia Guidelines. Intervention was pharmacist-directed dyslipidemia care, including assessment of cardiovascular risk, review of LDL-c, prescribing of medications, health behaviour interventions and follow-up every 6 weeks for 6 months. Usual care patients received their lipid results and a pamphlet on cardiovascular disease and usual care from their physician and pharmacist. Primary outcome was the proportion of participants achieving their target LDL-c (<2 mmol/L or ≥50% reduction) at 6 months between groups. RESULTS: We enrolled 99 patients with a mean (SD) age of 63 (13) years, 49% male and baseline LDL-c of 3.37 mmol/L (0.98). Proportion of patients achieving LDL-c target was 43% intervention versus 18% control (p = 0.007). Adjusted odds of achieving target LDL-c were 3.3 times higher for the intervention group (p = 0.031), who also achieved greater reduction in LDL-c (1.12 mmol/L, SE = 0.112) versus control (0.42 mmol/L, SE = 0.109), for an adjusted mean difference of 0.546 mmol/L (SE = 0.157), p < 0.001. CONCLUSION: Pharmacist prescribing resulted in >3-fold more patients achieving target LDL-c levels. This could have major public health implications.

Pharmacist-Led Follow-Up Program for Rural Patients with Acute Coronary Syndrome: The PLURAL-ACS Pilot Program.

Background: Patients living in rural settings have poorer access to care and more frequent readmissions after treatment for acute coronary syndrome (ACS) than patients in urban settings. It is unclear what types of medication-related issues are encountered by this cohort and whether pharmacist-led care could resolve them. Objectives: To describe the issues related to cardiac medications encountered by rural patients after treatment for ACS and the impact of a pharmacist-led virtual follow-up pilot program in this population. Methods: A quality improvement initiative was developed whereby a cardiology pharmacist provided follow-up to post-ACS rural patients in Alberta, Canada, between March and May 2022. For each patient, the pharmacist identified and resolved cardiac medication-related issues through regular telephone visits over a 30-day period following hospital discharge. The primary outcome was the number of cardiac medication-related issues identified. Secondary outcomes included the types of medication-related issues identified and actions taken by the pharmacist to resolve them. Results: During the 15-week program, 40 patients received care, and 139 virtual visits were completed. The median time spent per visit was 60 (interquartile range [IQR] 50-80) minutes. In total, 255 cardiac medication-related issues (6 per patient, IQR 3.75-8.25) were identified, of which 233 (91%) were resolved by the pharmacist. Prescription errors, adverse effects, and drug therapy optimization were the most common issues identified on days 1, 10, and 30, respectively. The pharmacist commonly undertook patient counselling (n = 126, 54%) and medication prescribing (n = 63, 27%) to address medication-related issues. Conclusions: A substantial number of cardiac medication-related issues were identified and resolved through a pharmacist-led virtual follow-up program in rural post-ACS patients. These findings could assist in the development of future follow-up programs to improve care for this high-risk population.

Contexte: L'accès des patients vivant en milieu rural aux soins est plus difficile et leur réadmission plus fréquente après un traitement pour le syndrome coronarien aigu (SCA) que les patients vivant en milieu urbain. On ne sait pas exactement quels types de problèmes liés aux médicaments rencontre cette cohorte et si les soins dispensés par les pharmaciens pourraient les résoudre. Objectifs: Décrire les problèmes liés aux médicaments cardiaques que rencontrent les patients vivant en milieu rural après un traitement pour le SCA et les effets d'un programme pilote de suivi virtuel dirigé par un pharmacien dans cette population. Méthodes: Une initiative d'amélioration de la qualité a été développée dans le cadre de laquelle un pharmacien en cardiologie a assuré le suivi des patients vivant en milieu rural après un SCA en Alberta, au Canada, entre mars et mai 2022. Pour chaque patient, le pharmacien a identifié et résolu les problèmes liés aux médicaments cardiaques grâce à des visites téléphoniques régulières sur une période de 30 jours après le congé de l'hôpital. Le critère de jugement principal était le nombre de problèmes identifiés liés aux médicaments cardiaques. Les critères de jugement secondaires comprenaient les types de problèmes liés aux médicaments identifiés et les mesures prises par le pharmacien pour les résoudre. Résultats: Au cours du programme de 15 semaines, 40 patients ont reçu des soins et 139 visites virtuelles ont été réalisées. La durée médiane de chaque visite était de 60 minutes (intervalle interquartile [IQR] 50­80). Au total, 255 problèmes liés aux médicaments cardiaques (6 par patient, IQR 3,75­8,25) ont été identifiés, dont 233 (91 %) ont été résolus par le pharmacien. Les erreurs de prescription, les événements indésirables et l'optimisation du traitement médicamenteux étaient les problèmes les plus fréquents les jours 1, 10 et 30, respectivement. Le pharmacien offrait généralement du counseling aux patients (n = 126, 54 %) et prescrivait des médicaments (n = 63, 27 %) pour résoudre les problèmes liés aux médicaments. Conclusions: Un nombre important de problèmes liés aux médicaments cardiaques ont été identifiés et résolus grâce à un programme de suivi virtuel dirigé par un pharmacien chez les patients vivant en milieu rural après un SCA. Ces résultats pourraient aider à élaborer de futurs programmes de suivi pour améliorer les soins dans cette population à haut risque.

Consideration and Application of Lipoprotein(a) in the Risk Assessment of Atherosclerotic Cardiovascular Disease Risk in Adults.

Lipoprotein(a) (Lp[a]) is an low-density lipoprotein (LDL)-like particle in which apolipoprotein (apo) B is covalently bound to a plasminogen-like molecule called apo(a). A High level of Lp(a) has been demonstrated to be an independent, causal, and prevalent risk factor for atherosclerotic cardiovascular disease (ASCVD), as well as aortic valve disease, through mechanisms that promote atherogenesis, inflammation, and thrombosis. With reliable and accessible assays, Lp(a) level has been established to be associated linearly with the risk for ASCVD. The 2021 Canadian Cardiovascular Society Dyslipidemia Guidelines recommend measuring an Lp(a) level once in a person's lifetime as part of the initial lipid screening. The aim of this review is to provide an update and overview of the utility and application of Lp(a) level in the assessment and treatment of adults at risk for ASCVD, consistent with this guideline recommendation.

La lipoprotéine(a), ou Lp(a), est une lipoprotéine de basse densité dans laquelle l'apolipoprotéine B est liée de manière covalente à une molécule semblable au plasminogène, l'apolipoprotéine(a). On a démontré qu'un taux élevé de Lp(a) est un facteur de risque indépendant, causal et fréquent d'athérosclérose cardiovasculaire (ASCV) et de valvulopathie aortique, en raison de mécanismes qui favorisent l'athérogénèse, l'inflammation et la thrombose. Des épreuves fiables et accessibles ont permis d'établir que le taux de Lp(a) était associé de façon linéaire à un risque d'ASCV. Dans ses lignes directrices de 2021 sur la prise en charge de la dyslipidémie, la Société cardiovasculaire du Canada recommande de mesurer le taux de Lp(a) une fois au cours de la vie d'une personne, dans le cadre du dépistage initial des lipides. Le présent article vise à fournir une mise à jour et un compte rendu de l'utilité et de l'application du taux de Lp(a) dans l'évaluation et le traitement des adultes présentant un risque d'ASCV, conformément à cette recommandation issue des lignes directrices.

An evaluation of teaching physical examination to pharmacists.

BACKGROUND: Evolving scope of practice has led pharmacists to develop new skills traditionally performed by other members of the health care team, including physical examination (PE). A session to teach PE skills to pharmacists was created as part of a professional development program. The purpose of this study was to evaluate participants' perception of, barriers to and confidence in performing PE before and after the session. METHODS: A 2-hour session introduced participants to PE as part of a primary care professional development program. Surveys were administered before and after the session, and then 4 weeks later. Participants' confidence in performing PE was assessed using a 4-point unipolar scale questionnaire, and mean weighted responses were compared between the pre- and post-session surveys. RESULTS: Thirty-four pharmacists participated in the study. At baseline, 82.4% had never received formal PE education, but 38.2% performed PE in practice, including blood pressure measurement. Eighty-two percent of participants identified barriers to performing PE, the most common being lack of formal training. Participants' confidence with PE significantly increased between the pre- and post-session surveys, except for comfort with making drug therapy interventions based on PE findings. Forty-three percent of participants completed the 4-week follow-up survey, which demonstrated that the use of PE in practice remained unchanged. CONCLUSION: Prior to the session, most participants did not use PE in their practice, primarily due to a lack of formal training. The session significantly improved participants' confidence in PE, but this did not translate into short-term practice change.

2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults.

The 2021 guidelines primary panel selected clinically relevant questions and produced updated recommendations, on the basis of important new findings that have emerged since the 2016 guidelines. In patients with clinical atherosclerosis, abdominal aortic aneurysm, most patients with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy continues to be recommended. We have introduced the concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with nonstatin agents, and have identified the secondary prevention patients who have been shown to derive the largest benefit from intensification of therapy with these agents. For all other patients, we emphasize risk assessment linked to lipid/lipoprotein evaluation to optimize clinical decision-making. Lipoprotein(a) measurement is now recommended once in a patient's lifetime, as part of initial lipid screening to assess cardiovascular risk. For any patient with triglycerides ˃ 1.5 mmol/L, either non-high-density lipoprotein cholesterol or apolipoprotein B are the preferred lipid parameter for screening, rather than low-density lipoprotein cholesterol. We provide updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision tool to aid the decision to initiate statin therapy. There are new recommendations on the preventative care of women with hypertensive disorders of pregnancy. Health behaviour modification, including regular exercise and a heart-healthy diet, remain the cornerstone of cardiovascular disease prevention. These guidelines are intended to provide a platform for meaningful conversation and shared-decision making between patient and care provider, so that individual decisions can be made for risk screening, assessment, and treatment.

Secondary stroke prevention: practice patterns in a tertiary care stroke service.

BACKGROUND: Stroke and transient ischemic attack (TIA) have a high personal and financial cost to society and prevention is critical. Outside of registries in Ontario, there has been little effort to determine whether care gaps exist for secondary preventative care within Canada. The objective of this study was to evaluate inpatient medical team compliance to four secondary stroke prevention interventions: antithrombotic therapy, antihypertensive therapy, lipid lowering therapy and smoking cessation. METHODS: Adults admitted to the University of Alberta Hospital stroke service with a diagnosis of stroke or TIA between August 1st, 2005 and July 31st, 2006 were identified using International Classification of Diseases (10th Revision) codes. Two hundred charts were randomly selected for retrospective review. Compliance, defined as achievement of therapeutic targets or appropriate therapy for subtherapeutic targets, was assessed. RESULTS: Among 190 eligible patients (mean age 67 years, 55% male), 147 (77.4%) had a non-cardioembolic cerebral event while 43 (22.6%) had a cardioembolic cerebral event. We found high compliance for antithrombotic (92% [174/190]) and antihypertensive (95% [136/143]) agents, but suboptimal compliance for lipid lowering agents (68% [107/158]) and smoking cessation (27% [17/64]). CONCLUSIONS: There is room for improvement in early risk factor management for secondary prevention, even in specialized stroke centres. To optimize stroke preventative care, more interdisciplinary collaboration, investigation of reasons for suboptimal care, development of strategies to minimize care gaps and ongoing stroke care audits for quality improvement are needed.