The Role of Direct Oral Anticoagulants in Patients With Coronary Artery Disease.

Despite contemporary management, patients with coronary artery disease (CAD) remain at high risk for thrombotic events. Several randomized controlled trials have evaluated the use of direct oral anticoagulants (DOACs) in patients with CAD, including in the setting of acute coronary syndrome (ACS) and stable CAD, and in patients with concomitant atrial fibrillation. Trials of apixaban and dabigatran in patients with ACS demonstrate no benefit with an increased risk of bleeding. Conversely, rivaroxaban at a reduced dose of 2.5 mg twice daily reduced thrombotic events and all-cause mortality when added to dual antiplatelet therapy in patients with ACS. Similarly, the addition of low-dose rivaroxaban to acetylsalicylic acid reduced the risk of thrombotic events in patients with stable CAD. However, the addition of a DOAC to antiplatelet therapy increased the risk of major bleeding. In patients with atrial fibrillation undergoing percutaneous coronary intervention, dual-pathway or low-dose triple therapy regimens including dabigatran or rivaroxaban reduced bleeding risk compared to traditional warfarin-based triple therapy, although it remains unclear whether these regimens preserve antithrombotic efficacy. DOAC-based antithrombotic regimens prove useful in patients with CAD in various settings; however, careful selection of patients and regimens per trial protocols are critical to achieving net benefit.

Pharmacists as Care Providers for Stroke Patients: A Systematic Review.

BACKGROUND: Pharmacists have become an integral member of the multidisciplinary team providing clinical patient care in various healthcare settings. Although evidence supporting their role in the care of patients with other disease states is well-established, minimal literature has been published evaluating pharmacist interventions in stroke patients. The purpose of this systematic review is to summarize the evidence evaluating the impact of pharmacist interventions on stroke patient outcomes. METHODS: Study abstracts and full-text articles evaluating the impact of a pharmacist intervention on outcomes in patients with an acute stroke/transient ischemic attack (TIA) or a history of an acute stroke/TIA were identified and a qualitative analysis performed. RESULTS: A total of 20 abstracts and full-text studies were included. The included studies provided evidence supporting pharmacist interventions in multiple settings, including emergency departments, inpatient, outpatient, and community pharmacy settings. In a significant proportion of the studies, pharmacist care was collaborative with other healthcare professionals. Some of the pharmacist interventions included participation in a stroke response team, assessment for thrombolytic use, medication reconciliation, participation in patient rounds, identification and resolution of drug therapy problems, risk-factor reduction, and patient education. Pharmacist involvement was associated with increased use of evidence-based therapies, medication adherence, risk-factor target achievement, and maintenance of health-related quality of life. CONCLUSIONS: Available evidence suggests that a variety of pharmacist interventions can have a positive impact on stroke patient outcomes. Pharmacists should be considered an integral member of the stroke patient care team.

Short- versus standard-term dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent implantation: A meta-analysis.

BACKGROUND: Twelve months of dual antiplatelet therapy (DAPT) is recommended after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. However, certain clinical scenarios may require premature discontinuation of therapy (e.g. urgent surgical procedure, major bleeding). The objective of this systematic review and meta-analysis was to investigate clinically relevant outcomes associated with a shorter duration of DAPT after PCI with DES implantation. METHODS: A systematic search of Medline and Embase (inception to December 2015) was conducted. Included were randomized controlled trials that compared 6 months (or less) of DAPT (defined as acetylsalicylic acid 75-200mg daily and a P2Y12 inhibitor) to the standard of 12 months. Outcomes of interest included death (all-cause and cardiac), myocardial infarction (MI), definite/probable stent thrombosis, and bleeding (major and overall). An odds ratio (OR) and 95% confidence interval (CI) were calculated for each outcome using a random effects model. RESULTS: Six trials (five open-label, one double-blind) were included (N=13,900). Four studies investigated 6 months of DAPT, and two studies investigated 3 months. Median follow-up was 12 months. There was no statistically significantly difference between groups regarding all-cause death (OR 0.88, 95% CI 0.64-1.20), cardiac death (OR 1.00, 95% CI 0.64-1.55), MI (OR 1.16, 95% CI 0.87-1.56), and stent thrombosis (OR 1.22, 95% CI 0.70-2.15). Both major and any bleeding were significantly decreased with shorter-term DAPT (OR 0.58, 95% CI 0.34-0.98, and OR 0.62, 95% CI 0.47-0.81, respectively). CONCLUSIONS: Shorter duration (3-6 months) of DAPT, as compared to 12 months, was not associated with a higher risk of death, MI, or stent thrombosis, but a lower rate of major and overall bleeding.

What is the optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent implantation?

PURPOSE: Published evidence on varying durations of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with implantation of a drug-eluting stent (DES) is reviewed. SUMMARY: A systematic literature search identified 13 randomized controlled trials and eight meta-analyses evaluating patient outcomes of standard (12-month) versus shorter or longer courses of DAPT (aspirin and a P2Y12 inhibitor, usually clopidogrel) after PCI with DES implantation. Evaluated outcomes included cardiovascular (CV) events, stent thrombosis, bleeding events, and mortality. Overall, the available evidence indicates that DAPT for periods of 3-6 months was as effective as DAPT courses of 12 months or more in reducing rates of CV events and stent thrombosis and was associated with similar or lower rates of bleeding; however, the quality of that evidence was limited by methodological shortcomings, including open-label study designs and low overall event rates. Relative to 12-month DAPT, DAPT for longer periods (up to four years) was associated with decreased rates of CV events and stent thrombosis (the reduction in thrombosis risk was greatest in patients who received a first-generation DES) but also increased bleeding events; all-cause mortality appears to be similar or potentially higher with extended-duration DAPT. CONCLUSION: DAPT for a period of 12 months should continue to be the standard recommendation after PCI with DES implantation. Routine use of shorter- or longer-duration DAPT should be discouraged; if such therapy is considered, prescribing decisions should be based on individual patient risk factors.

Pharmacotherapy of heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) constitutes ~50% of all heart failure diagnoses and is associated with considerable morbidity and mortality. The treatment of HFpEF can be challenging due to a lack of evidence supporting the benefit of various drug therapies. In practice, treatment can be divided into acute and chronic management. Acute therapy for decompensated heart failure is similar for both HFpEF and heart failure with reduced ejection fraction. The mainstay of treatment is diuretics to reduce volume overload and improve dyspnea. Patients with an acute exacerbation of HFpEF and rapid atrial fibrillation (AF) should be rate controlled with negative chronotropic agents. For chronic therapy, patients with HFpEF should not be treated like patients with heart failure with reduced ejection fraction. Chronic management of HFpEF can be simplified by using three strategies based on applicability: treat precipitating conditions (e.g., hypertension, AF), control symptoms by maintaining euvolemia with diuretics, and avoid therapies that have been shown not to be beneficial unless another compelling indication exists. Nondrug interventions for HFpEF include salt and fluid restriction, regular physical activity, and referral to a heart function clinic, if appropriate.