2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Assessing the utility of pre-course assessment and voluntary pre-work in two required integrated pharmacotherapy courses.

BACKGROUND AND PURPOSE: Self-assessment and self-learning are essential skills for student pharmacists. Data demonstrating the association between these skills in pharmacy courses are limited. The aim of this study was to evaluate the impact of providing pre-course review and administering a pre-course assessment on performance in two required integrated pharmacotherapy (IP) courses - IP: Pulmonology and IP: Cardiology. EDUCATIONAL ACTIVITY AND SETTING: This study included second-year student pharmacists enrolled in fall semester IP: Pulmonology and IP: Cardiology from 2019 to 2021. Voluntary pre-course review materials and pre-course assessments were added in fall 2021. Overall course grades and examination scores between each year were analyzed. Student perceptions of the pre-course assessment were also captured. FINDINGS: Of the 454 students analyzed, there was no difference in median overall IP: Pulmonology grades (85.93%, 86.67%, 86.29%; P = .63) or IP: Cardiology grades (80.25%, 78.3%, 79.96%; P = .41) for 2019, 2020, and 2021, respectively. IP: Pulmonology Exam 1 scores were statistically higher in 2021. For IP: Cardiology, Exam 1 and Final Exam scores were statistically higher in 2020 compared to 2019 and Exam 3 scores were significantly higher in 2021 than 2019. Pre-course assessment scores had a statistically significant, positive association with overall course grade. Half of the students surveyed agreed that completing the course prep work was an effective approach to learning. SUMMARY: Although overall course grades did not differ between years, pre-course assessment scores correlated with overall course grade. Thus, voluntary pre-course assessments could provide early identification of poor performance.

Key Points for Pharmacists From the ACC Expert Consensus Decision Pathway for Patients Hospitalized With Heart Failure.

Heart failure (HF) is a complex condition, and its clinical course often includes periods of decompensation that represent a deterioration in clinical status. During these periods, patients may experience worsening HF symptoms requiring hospitalization. Heart failure that necessitates hospitalization increases the risk of mortality and rehospitalization. In order to help facilitate appropriate care of patients hospitalized with HF, the American College Cardiology (ACC) published an expert consensus decision pathway (ECDP) that focuses on a multidisciplinary approach. The ECDP is divided into multiple nodes and pharmacists play integral roles in each one. There are many opportunities for pharmacists to optimize medical therapy, reinforce adherence, and provide medication and disease state education throughout hospitalization. This review article will highlight inpatient medication management of HF for hospital pharmacists.

A Call to Action for a Programmatic Approach to Addressing Health Disparities and Cultural Competency in Pharmacy Education.

Pharmacy has recognized the importance of education in health disparities and cultural competency (HDCC) for two decades. More recently, there has been emphasis on incorporating equity, diversity, and inclusion (EDI) in pharmacy programs. While many institutions identify a need to incorporate a programmatic approach to HDCC education to meet the growing needs of a diverse population, pharmacy curricula continue to lack a holistic, programmatic approach. More than ever, Doctor of Pharmacy (PharmD) students should graduate with the knowledge, values, and skills to provide culturally appropriate care for a diverse patient population. This commentary advocates for a holistic, programmatic approach to integrating HDCC education and serves as a call to action for curricular development. It is hoped that this commentary will also set the foundation for additional scholarly work and recommendations regarding a programmatic approach.

The role of inflammation in the pathogenesis and treatment of arrhythmias.

The pathogenesis of arrhythmias is complex and multifactorial. The role of inflammation in the pathogenesis of both atrial and ventricular arrhythmias (VA) has been explored. However, developing successful pharmacotherapy regimens based on those pathways has proven more of a challenge. This narrative review provides an overview of five common arrhythmias impacted by inflammation, including atrial fibrillation (AF), myocardial infarction, arrhythmogenic cardiomyopathy, cardiac sarcoidosis, and QT prolongation, and the potential role for anti-inflammatory therapy in their management. We identified arrhythmias and arrhythmogenic disease states with the most evidence linking pathogenesis to inflammation and conducted comprehensive searches of United States National Library of Medicine MEDLINE® and PubMed databases. Although a variety of agents have been studied for the management of AF, primarily in an effort to reduce postoperative AF following cardiac surgery, no standard anti-inflammatory agents are used in clinical practice at this time. Although inflammation following myocardial infarction may contribute to the development of VA, there is no clear benefit with the use of anti-inflammatory agents at this time. Similarly, although inflammation is clearly linked to the development of arrhythmias in arrhythmogenic cardiomyopathy, data demonstrating a benefit with anti-inflammatory agents are limited. Cardiac sarcoidosis, an infiltrative disease eliciting an immune response, is primarily treated by immunosuppressive therapy and steroids, despite a lack of primary literature to support such regimens. In this case, anti-inflammatory agents are frequently used in clinical practice. The pathophysiology of arrhythmias is complex, and inflammation likely plays a role in both onset and duration, however, for most arrhythmias the role of pharmacotherapy targeting inflammation remains unclear.

Utilization of EKOS in Patients With Pulmonary Embolism.

Objective: Current guidelines recommend utilization of catheter-directed thrombolysis systems for management of patients with submassive pulmonary embolism (PE) who have relative contraindications to systemic thrombolysis. Evidence from previous trials have demonstrated the short-term efficacy and safety of one of these systems, the EkoSonic Endovascular System (EKOS). The objective of this study was to evaluate the long-term efficacy and safety of EKOS in submassive PE. Methods: This single-center, retrospective study evaluated subjects ≥18 years old with submassive PE and baseline right ventricular to left ventricular (RV/LV) diameter ratio ≥1. The primary outcome evaluated change in RV/LV diameter ratio from baseline to first follow-up. The secondary outcomes evaluated need for further intervention after EKOS, major bleeding within 72 hours and 6 months, all-cause mortality at 6 months, and all-cause 30-day readmission rate. Results: Overall, 41 subjects received EKOS for submassive PE. Of the 26 subjects evaluated for the primary outcome, the RV/LV diameter ratio decreased by an average of 0.56 (P < 0.05). Of the 41 subjects evaluated for the secondary outcomes, 1 subject required pulmonary embolectomy after EKOS intervention, 1 major bleed occurred within 72 hours, 1 major bleed occurred within 6 months, 1 subject died within 6 months, and 3 subjects were readmitted within 30 days. Conclusions: Intervention with EKOS further reduced right heart strain and resulted in few complications compared with previous trials providing evidence that EKOS is effective and safe long-term for management of submassive PE. Use should be considered in patients with relative contraindications to systemic thrombolytic therapy.

Inclusion of Health Disparities, Cultural Competence, and Health Literacy Content in US and Canadian Pharmacy Curriculums.

Objective. To determine how US and Canadian pharmacy schools include content related to health disparities and cultural competence and health literacy in curriculum as well as to review assessment practices.Methods. A cross-sectional survey was distributed to 143 accredited and candidate-status pharmacy programs in the United States and 10 in Canada in three phases. Statistical analysis was performed to assess inter-institutional variability and relationships between institutional characteristics and survey results.Results. After stratification by institutional characteristics, no significant differences were found between the 72 (50%) responding institutions in the United States and the eight (80%) in Canada. A core group of faculty typically taught health disparities and cultural competence content and/or health literacy. Health disparities and cultural competence was primarily taught in multiple courses across multiple years in the pre-APPE curriculum. While health literacy was primarily taught in multiple courses in one year in the pre-APPE curriculum in Canada (75.0%), delivery of health literacy was more varied in the United States, including in a single course (20.0%), multiple courses in one year (17.1%), and multiple courses in multiple years (48.6%). Health disparities and cultural competence and health literacy was mostly taught at the introduction or reinforcement level. Active-learning approaches were mostly used in the United States, whereas in Canada active learning was more frequently used in teaching health literacy (62.5%) than health disparities and cultural competence (37.5%). Few institutions reported providing professional preceptor development.Conclusion. The majority of responding pharmacy schools in the United States and Canada include content on health disparities and cultural competence content and health literacy to varying degrees; however, less is required and implemented within experiential programs and the co-curriculum. Opportunities remain to expand and apply information on health disparities and cultural competence content and health literacy content, particularly outside the didactic curriculum, as well as to identify barriers for integration.

Evaluation of the safety and tolerability of spironolactone in patients with heart failure and chronic kidney disease.

BACKGROUND: Spironolactone reduces morbidity and mortality in patients with heart failure (HF) with reduced ejection fraction (EF) and decreases hospitalizations in HF with preserved EF. To minimize the risk of hyperkalemia, patients must have an estimated glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2 and potassium < 5.0 mEq/L prior to initiation; however, spironolactone is prescribed outside these parameters. The objective of this study was to evaluate the safety and tolerability of spironolactone in patients with HF and chronic kidney disease (CKD). METHODS: This single-center, retrospective cohort study evaluated patients ≥ 18 years with HF and CKD stages 3-5 who received ≥ 48 h of spironolactone therapy and were hospitalized from February 2018 to August 2019. The primary outcome was incidence of hyperkalemia (potassium ≥ 5.5 mEq/L). RESULTS: Overall, 121 patients were evaluated: 52.1% (n = 63) had an EF > 40% and 47.9% (n = 58) had an EF ≤ 40% with 69.4% (n = 84) CKD stage 3, 24.8% (n = 30) stage 4, and 5.8% (n = 7) stage 5. Spironolactone was initiated prior to admission (PTA) for 54.5% (n = 66) of patients, while 45.5% (n = 55) of orders were initiated during hospitalization. Eight patients (6.6%) experienced inpatient hyperkalemia-all with PTA spironolactone. Patients who experienced inpatient hyperkalemia had a numerically lower eGFR that was not statistically significant (35.40 vs. 38.22 mL/min/1.73 m2; p = 0.730). Patients with CKD stage 3 (n = 4) had numerically higher rates of inpatient hyperkalemia than stages 4 (n = 1) or 5 (n = 3) (50%, 12.5%, and 37.5% respectively; p < 0.05). CONCLUSION: Spironolactone may be safe to initiate in hospitalized patients with HF and CKD; however, appropriateness of therapy must be assessed upon admission to the hospital. Larger studies are needed for conclusive results.

Predictors of Student Failure or Poor Performance on Advanced Pharmacy Practice Experiences.

Objective. To determine factors predictive of student failure or poor performance on advanced pharmacy practice experiences (APPEs) at a single pharmacy program. Methods. This retrospective cohort evaluated students entering the Doctor of Pharmacy (PharmD) program from 2012-2014 at St. Louis College of Pharmacy. Students who received a grade of F for one or more APPEs (failure group) were compared to all other students (non-failure group). A secondary evaluation compared students with a C or F on one or more APPEs (poor performers) to all other students (non-poor performers). Data were collected on didactic and experiential performance, identifiable professionalism issues from introductory pharmacy practice experiences (IPPEs), and academic honor code violations. Univariable and multivariable logistic regressions were performed to determine factors associated with APPE failure and poor performance. Results. A total of 669 students were analyzed. Twenty-eight students (4.2%) failed one or more APPEs and 81 students (12.1%) were identified as poor performers (grade of C or F). For the primary outcome, professional grade point average (GPA) of less than 2.7, practicum failure, IPPE professionalism issue(s), and pharmacotherapy course failure were identified for inclusion in the multivariable analysis. The IPPE professionalism issue(s) (HR 4.8 [95% CI 1.9-12.4]) and pharmacotherapy course failure (HR 4.2 [95% CI, 1.6-11.1]) were associated with APPE failure on multivariable regression. On the secondary analysis, the same variables were identified for multivariable regression, with professional GPA of less than 2.7 (HR 2.7 [95% CI 1.5-5]), IPPE professionalism issue(s) (HR 3.9 [95% CI 2.2-6.9]), and pharmacotherapy course failure (HR 2.0 [95% CI 1.1-3.7]) associated with poor performance. Conclusion. Poor academic performance and/or identified unprofessional behavior while completing IPPEs are associated with APPE failure and poor performance. Interventions should be aimed at identifying at-risk students and addressing risk factors prior to APPEs.

Flecainide is well-tolerated and effective in patient with atrial fibrillation at 12 months: a retrospective study.

INTRODUCTION: Current atrial fibrillation (AF) guidelines recommend flecainide as a first-line rhythm control option in patients without structural heart disease. While there is proven efficacy in clinical trials and guideline support, it is hypothesized that flecainide may be underutilized due to negative outcomes in the CAST trial and that adverse effects are less common than previously perceived. METHODS: This retrospective chart review evaluated patients ⩾18 years initiated on flecainide for AF from August 2011 to October 2016 by a cardiology provider at the study site. Exclusion criteria included: <5 days of flecainide therapy, AF due to a reversible cause, and inadequate documentation. The primary outcome was efficacy of flecainide at maintaining symptomatic control at 6 and 12 months. Secondary outcomes included characterization of alterations in rhythm control strategies and documented normal sinus rhythm per electrocardiogram at 6 and 12 months. RESULTS: Of the 326 patients identified, 144 patients were included. After 6 and 12 months, 102 patients (70.8%) and 89 patients (61.8%) of the 144 were symptomatically controlled. Atenolol use (p = 0.024), female sex (p = 0.006), hypertension (p = 0.040), and dronedarone failure (p = 0.012) were associated with flecainide discontinuation at 6 months. At 12 months, only previous propafenone failure (p = 0.032) was significant. Of the 144 patients, 16 (11.1%) reported adverse effects with dizziness, hot flashes, bradycardia, and headache (1.4% each) being the most common. CONCLUSION: Flecainide is a well-tolerated medication, even at 12 months, with very minor adverse effects. These results support the utility of flecainide in guideline recommended patient populations.

Assessment of a multi-institution integration of cultural competency activities.

INTRODUCTION: To meet educational standards and provide effective patient care, student pharmacists must be well-prepared to interact with a diverse patient population. Thus, the objective was to assess the effectiveness of four different active learning strategies in enhancing the cultural competency (CC) of student pharmacists at multiple institutions. METHODS: Across two years, eight colleges/schools of pharmacy integrated two sets of CC activities with different student cohorts (first-third professional year) that were designed to address different aspects of CC. Pre- and post-activity, a modified electronic version of the Clinical Cultural Competency Questionnaire (CCCQ) that included the addition of activity-specific questions was distributed to students. RESULTS: A total of 1009 students participated in these activities across eight colleges of pharmacy. The integration of activities resulted in significant increases in most items on three of the four subscales of the CCCQ (knowledge, skills, and encounters/situations). Items on the attitude subscale remained the same. Students also felt the activities were beneficial in addressing their intent. CONCLUSIONS: Faculty were able to incorporate these activities throughout their respective curricula with minimal time commitment and resources. The activities improved student perceptions of their CC knowledge, skills, and ability to handle encounters and situations. These activities may be useful for other institutions as they determine the best approach to improve student CC and prepare them for practice.

Evaluating the safety and tolerability of inpatient sacubitril/valsartan initiation in a community hospital.

Background: Sacubitril/valsartan has been incorporated into guidelines based on the results of the PARADIGM-HF trial, which demonstrated reduced mortality in stable patients with heart failure with reduced ejection fraction (HFrEF). Sacubitril/valsartan is recommended in addition to other HF therapies in place of an angiotensin-converting-enzyme inhibitor or angiotensin-receptor-blocker. Objectives: To evaluate the safety and tolerability of sacubitril/valsartan initiation in a community hospital. Design/methods: This single-center, retrospective review evaluated patients that received ≥24 hours of sacubitril/valsartan therapy August 2015-March 2018. The primary outcome included the incidence of hypotensive events during hospitalization. Secondary outcomes included: incidence of inpatient acute kidney injury (AKI) and hyperkalemia, rates of inpatient discontinuation, and change in ejection fraction (EF) ≥30 days after initiation. Results: Of the 59 patients included, 21 (35.6%) experienced a hypotensive event. A total of 6 patients (10.2%) discontinued therapy while inpatient, which was more likely in patients that developed AKI (n = 3; p = 0.005) or those who experienced a hypotensive event (n = 5; p = 0.018). There was a significant difference in mean EF from baseline to ≥ 30 days post-initiation (24.8% vs. 33.2%; p = 0.018). Conclusion: Careful patient selection and monitoring for hypotension, AKI, and hyperkalemia can help increase successful outcomes and improve patient safety.

Evaluation of the Safety and Effectiveness of Direct-Acting Oral Anticoagulants in Patients with Atrial Fibrillation and Coexisting Valvular Heart Disease.

BACKGROUND: Current guidelines recommend direct-acting oral anticoagulants (DOACs) over warfarin in patients with atrial fibrillation (AF) and valvular heart disease (VHD) without a mechanical valve or moderate to severe mitral stenosis. However, real-world data to support the safety and efficacy of DOACs in this patient population are lacking. OBJECTIVE: Our objective was to assess the safety and effectiveness of DOACs in patients with AF and VHD. METHODS: This retrospective chart review evaluated patients aged ≥ 18 years with a diagnosis of AF and at least moderate VHD on echocardiogram. Patients were included if they received ≥ 1 month of DOAC therapy from December 2016 to December 2018. Patients were excluded if they received dual antiplatelet therapy or had additional indications for anticoagulation. The primary outcomes were incidence of stroke or systemic embolism (SSE) and major bleeding. RESULTS: In total, 200 patients were included (disease type: aortic, n = 50; mitral, n = 50; tricuspid, n = 50; multivalve, n = 50). Most patients received apixaban (n = 133 [66.5%]) followed by rivaroxaban (n = 50 [25%]) and dabigatran (n = 17 [8.5%]). No patients received edoxaban. The mean CHA2DS2-VASc score was 4.25 and was similar among DOAC cohorts (p = 0.380). The overall SSE rate was 3.5% and was highest for dabigatran (n = 3 [17.6%]) compared with the other DOACs (apixaban, n = 1 [0.8%]; rivaroxaban, n = 3 [6%]; p = 0.001). Rates were similar among different valve types (aortic, n = 3 [6%]; mitral, n = 1 [2%]; tricuspid, n = 2 [4%]; multivalve, n = 1 [2%]; p = 0.653). The overall rate of major bleeding was 5.5% and did not differ among the DOACs (apixaban, n = 5 [3.8%]; rivaroxaban, n = 4 [8%]; dabigatran, n = 2 [11.8%]; p = 0.264) or valve type (aortic, n = 3 [6%]; mitral, n = 2 [4%]; tricuspid, n = 2 [4%]; multivalve, n = 4 [8%]; p = 0.787). CONCLUSIONS: In patients with AF and VHD, rates of major bleeding were similar among the DOACs and valve types; however, more patients receiving dabigatran experienced SSE. Further studies are needed to validate these findings.

Evaluation of the effect of prior antiarrhythmic drug use on the success of atrial fibrillation catheter ablation.

WHAT IS KNOWN AND OBJECTIVE: Current guidelines recommend catheter ablation (CA) for atrial fibrillation (AF) refractory to at least one antiarrhythmic drug (AAD), but do not specify an adequate number of AADs to be trialed prior to considering ablation. The objective of this study was to evaluate the effect of CA success based on the number of AADs failed in patients with paroxysmal or persistent AF. METHODS: This retrospective cohort study evaluated patients with paroxysmal or persistent AF who underwent an initial CA at a community hospital. Patients with unknown AAD histories, those who did not achieve acute procedural success, or who were lost to follow-up or death unrelated to thromboembolic stroke within 6 months post-ablation were excluded. Catheter ablation success was defined as freedom from AF. The primary outcome was the incidence of AF or atrial flutter captured on an electrocardiogram or other recording device at 3, 6, 9 and 12 months after the procedure. RESULTS AND DISCUSSION: Overall, 99 out of 103 patients completed 1 year of follow-up. Of those patients, 34 of 99 (34.3%) experienced AF recurrence within 1-year post-ablation. There was no significant difference among the categories of number of failed AADs and the recurrence of AF within 12 months post-ablation for zero AADs, 1 AADs and ≥2 AADs (41.7%, 31.3% and 40%, respectively; P = 0.658). WHAT IS NEW AND CONCLUSION: The results of this study do not support preferentially performing CA on patients who have failed a certain number of AADs. Results are limited by the nature of the study design and a small sample size. Conclusive results would best be addressed by a prospective randomized trial.

A rare case of a gabapentin-induced cardiomyopathy.

WHAT IS KNOWN AND OBJECTIVE: Gabapentin, a γ-aminobutyric acid derivative, is used for the treatment of partial onset seizures, postherpetic neuralgia, diabetic neuropathy and a host of other neurological disorders. CASE DESCRIPTION: A 44-year-old woman with spinal stenosis was prescribed gabapentin for pain. Two months after initiating therapy, she was diagnosed with a new-onset non-ischaemic cardiomyopathy with an ejection fraction of 36% measured on a transthoracic echocardiogram. WHAT IS NEW AND CONCLUSION: A patient with suspected gabapentin-induced cardiomyopathy is reported. However, to date, gabapentin therapy has not been associated with risk of the developing a cardiomyopathy.

Evaluation of the impact of body mass index on warfarin requirements in hospitalized patients.

BACKGROUND: Despite well established empiric dose adjustments for drug and disease-state interactions, the impact of body mass index (BM) on warfarin remains unclear. The objective of this study is to evaluate warfarin requirements in hospitalized patients, stratified by BMI. METHODS: This retrospective review included two cohorts of patients: cohort A (patients admitted with a therapeutic international normalized ratio (INR)) and cohort B (newly initiated on warfarin during hospitalization). Exclusion criteria included: age under 18 years, pregnancy, INR (goal 2.5-3.5), and warfarin thromboprophylaxis post orthopedic surgery. The primary outcome was mean total weekly dose (TWD) of warfarin based on weight classification: underweight (BMI <18 kg/m2), normal/overweight (BMI 18-29.9 kg/m2), obese (BMI 30-39.9 kg/m2), and morbidly obese (BMI ⩾ 40 kg/m2). Data were extracted from two community hospitals in reverse chronologic order during July 2015-June 2013 until both study institutions evaluated 100 patients per cohort in each BMI classification or until all patients had been evaluated within the prespecified timeframe. RESULTS: A total of 585 patients were included in cohort A (26 underweight, 200 normal/overweight, 200 obese, 159 morbidly obese). There was a statistically significant difference in TWD as determined by one-way analysis of variance ( p < 0.05). A Tukey post hoc test revealed a statistically significantly higher TWD in morbidly obese (41.5 mg) compared with underweight (25.6 mg, p < 0.05), normal/overweight (28.8 mg, p < 0.05) and obese patients (32.4 mg, p < 0.05). In cohort B, 379 patients were evaluated (9 underweight, 166 normal/overweight, 152 obese, 52 morbidly obese). Overall, 191 patients had a therapeutic INR on discharge (88.9% underweight, 52.4% normal/overweight, 44.1% obese, 55.8% morbidly obese, p = 0.035). Of those, there was a statistically significant difference in TWD ( p = 0.021) with a higher TWD in the morbidly obese (41 mg) compared with underweight patients (24.4 mg, p = 0.017). CONCLUSIONS: Based on the results of this study, morbidly obese patients may require higher TWD to obtain and maintain a therapeutic INR.