Optimal Timing for Resumption of Anticoagulation After Intracranial Hemorrhage in Patients With Mechanical Heart Valves.

BACKGROUND: Anticoagulation in patients with intracranial hemorrhage (ICH) and mechanical heart valves is often held for risk of ICH expansion; however, there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation remains uncertain. METHODS AND RESULTS: We retrospectively studied patients with ICH and mechanical heart valves from 2000 to 2018. The primary outcome was a composite end point of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of reinitiation of anticoagulation classified as early (resumed up to 7 days after ICH), late (≥7 and up to 30 days after ICH), and never if not resumed or resumed after 30 days post-ICH. We included 184 patients with ICH and mechanical heart valves (65 anticoagulated early, 100 late, 19 not resumed by day 30 post-ICH). Twelve patients had AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation was 12.7 days. Composite outcomes occurred in 12 patients resumed early (18.5%), 14 resumed late (14.0%), and 4 never resumed (21.1%). There was no increased hazard of the composite outcome (hazard ratio [HR], 1.1 [95% CI, 0.2-6.0]), AIS, or worsening or new ICH among patients resumed early versus late. There was no difference in the composite among patients never resumed versus resumed. Patients who never resumed anticoagulation had significantly more severe ICH (median Glasgow Coma Scale: 10.6, 13.9, and 13.9 among those who resumed never, early, and late, respectively; P=0.0001), higher in-hospital mortality (56.5%, 0%, and 0%, respectively; P<0.0001), and an elevated 30-day AIS risk (HR, 15.9 [95% CI, 1.9-129.7], P=0.0098). CONCLUSIONS: In this study of patients with ICH and mechanical heart valves, there was no difference in 30-day thrombotic and hemorrhagic brain-related outcomes when anticoagulation was resumed within 7 versus 7 to 30 days after ICH. Withholding anticoagulation >30 days was associated with severe baseline ICH, higher in-hospital case fatality, and elevated AIS risk.

Rising to the challenge: Pharmacy residents on the front lines during COVID-19 pandemic.

PURPOSE: To provide pharmacy residents' perspective on how the department of pharmacy at a large academic medical center prepared and managed the surge in admissions of patients with coronavirus disease 2019 (COVID-19), to describe how residents were trained for intensive care unit (ICU) staffing, and to provide recommendations on how residency programs nationally could navigate a second wave of COVID-19 admissions or other disaster response situations. SUMMARY: The majority of postgraduate year 1 (PGY1) pharmacy residents at the institution were trained for ICU staffing and deployed throughout the hospital to ICU units converted to dedicated COVID-19 ICUs to assist in patient care. The training process included live videoconference lectures about relevant ICU topics and on-site experiences with critical care clinical pharmacists. Based on their experience in training for and participating in ICU care of patients with COVID-19, the pharmacy residents recommend considering additional cross-training of residents, integration of additional clinical education, creation of opportunities for resident involvement in telehealth, advancement of residents' roles in emergency responses, building robust mental health services, and continued advocacy for the advancement of pharmacists' and pharmacy residents' scope of practice. CONCLUSION: The onset of the COVID-19 pandemic caused the institution to reevaluate the allocation of resources, and the department of pharmacy elected to deploy PGY1 pharmacy residents with previous ICU experience to assist in caring for an ICU patient census that had doubled. This experience will be valuable in preparing for another potential wave of COVID-19 cases and a surge in admissions of other groups of patients who deferred care due to the pandemic.