Qualitative Analysis of Patient Decisional Needs for Medications to Treat Heart Failure.

BACKGROUND: The development of tools to support shared decision-making should be informed by patients' decisional needs and treatment preferences, which are largely unknown for heart failure (HF) with reduced ejection fraction (HFrEF) pharmacotherapy decisions. We aimed to identify patients' decisional needs when considering HFrEF medication options. METHODS: This was a qualitative study using semi-structured interviews. We recruited patients with HFrEF from 2 Canadian ambulatory HF clinics and clinicians from Canadian HF guideline panels, HF clinics, and Canadian HF Society membership. We identified themes through inductive thematic analysis. RESULTS: Participants included 15 patients and 12 clinicians. Six themes and associated subthemes emerged related to HFrEF pharmacotherapy decision-making: (1) patient decisional needs included lack of awareness of a choice or options, difficult decision timing and stage, information overload, and inadequate motivation, support and resources; (2) patients' decisional conflict varied substantially, driven by unclear trade-offs; (3) treatment attribute preferences-patients focused on both benefits and downsides of treatment, whereas clinicians centered discussion on benefits; (4) quality of life-patients' definition of quality of life depended on pre-HF activity, though most patients demonstrated adaptability in adjusting their daily activities to manage HF; (5) shared decision-making process-clinicians' described a process more akin to informed consent; (6) decision support-multimedia decision aids, virtual appointments, and primary-care comanagement emerged as potential enablers of shared decision-making. CONCLUSIONS: Patients with HFrEF have several decisional needs, which are consistent with those that may respond to decision aids. These findings can inform the development of HFrEF pharmacotherapy decision aids to address these decisional needs and facilitate shared decision-making.

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.

Anticoagulant Prescribing Patterns in New-Onset Atrial Fibrillation After Cardiac Surgery.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with an increased risk of thromboembolic stroke. Recommendations regarding the optimal anticoagulant, timing of initiation, and duration of therapy remain uncertain. METHODS: Administrative databases were used to include adult patients who presented with POAF after cardiac surgery between January 1, 2015, and December 31, 2020. Key exclusion criteria included preexisting atrial fibrillation, mechanical valve replacement, or anticoagulant prescription fill within 6 months before the index admission. RESULTS: A total of 3214 of patients were included, and 878 (27.3%) were prescribed an oral anticoagulant (OAC) on discharge, with 536 (61%) prescribed warfarin and 342 (39%) prescribed a direct OAC. More than half of the patients (56.1%) stopped their OAC by 6 months. There was no difference in stroke or systemic embolism at 30 days, 3 months, or 6 months between those with and without anticoagulation prescribed. However, those on any OAC had higher rates of any bleeding at all time points. CONCLUSIONS: A minority of patients who presented with POAF after cardiac surgery were prescribed OAC, with warfarin being the most common agent. OAC initiation was associated with increased bleeding risk, warranting special consideration when assessing a patient's risk of stroke with the increased risk of bleeding, particularly in the postoperative period.

Direct oral anticoagulants for atrial fibrillation in early postoperative valve repair or bioprosthetic replacement.

OBJECTIVE: Despite increased use of direct oral anticoagulants (DOACs), limited evidence guides their use in the early postoperative period after bioprosthetic valve implantation in patients with atrial fibrillation. Our objective was to describe the efficacy and safety of DOACs and warfarin in the first 3 months after surgical bioprosthetic valve replacement or repair in patients with atrial fibrillation. METHODS: This was a retrospective, registry-informed cohort study of surgical patients who underwent bioprosthetic valve replacement or repair, had concomitant atrial fibrillation and received oral anticoagulation at discharge. The primary efficacy outcome was a composite of death, ischemic stroke, transient ischemic attack, and systemic embolism; the primary safety outcome was a composite of major bleeding. Key secondary outcomes were comparative analyses of primary outcomes, temporal anticoagulation prescribing patterns, and 30-day readmission rates. RESULTS: A total of 1743 patients were included. Of the 570 patients in the DOAC group, 17 (2%) met the composite efficacy outcome and 55 (10%) met the composite safety outcome. Of the 1173 patients receiving warfarin, 41 (3%) and 114 (10%) met the composite efficacy and safety outcomes, respectively. Comparative secondary analysis was not statistically significant for either the efficacy (adjusted odds ratio, 0.85; 95% confidence interval, 0.46-1.55, P = .59) or safety (adjusted odds ratio, 0.94; 95% confidence interval, 0.66-1.34, P = .76) outcomes. The 30-day readmission rates were similar between both groups. CONCLUSIONS: Our results suggest DOACs may be safe and effective alternatives to warfarin in the early postoperative period after valve repair or surgical bioprosthetic replacement. Confirmation awaits adequately powered prospective studies.

Evaluation of Online Written Medication Educational Resources for People Living With Heart Failure.

Background: Patient educational resources on heart failure (HF) medications may improve patient understanding, which is critical for informed decision-making and patient self-efficacy. The purpose of our study was to evaluate the quality and readability of written medication educational resources available online. Methods: Two investigators searched Google, Yahoo, and Bing for written patient educational resources that addressed at least one HF medication. We assessed educational quality using the Ensuring Quality Information for Patients (EQIP) tool (range 0 [worst] to 100 [best]), and we evaluated readability using the Flesch-Kincaid Grade Level. Results: From 693 identified webpages, 39 HF medication educational resources met study eligibility. Among included resources, the median Ensuring Quality Information for Patients score was 61% (interquartile range 54%-68%), with 2 (5%) rated as high quality (score ≥ 75%). The median Flesch-Kincaid Grade Level was 8 (interquartile range 8-12), with 4 (10%) resources meeting the recommended 6th-grade reading level. Conclusions: Most HF medication educational resources available on the Internet are of acceptable educational quality, but could readily be improved. Most resources were beyond the recommended reading grade level for educational resources, limiting their utility for patients with a low literacy level.

Contexte: Les ressources éducatives destinées aux patients au sujet des médicaments contre l'insuffisance cardiaque (IC) pourraient améliorer la compréhension des patients, ce qui est essentiel pour la prise de décisions éclairées et pour le sentiment d'autoefficacité des patients. L'objectif de notre étude était d'évaluer la qualité et la lisibilité des ressources médicales éducatives écrites en ligne. Méthodologie: Deux membres de l'équipe de recherche ont utilisé Google, Yahoo et Bing pour repérer les ressources éducatives écrites destinées aux patients et portant sur au moins un médicament contre l'IC. La qualité éducative des ressources a été évaluée avec l'outil « Ensuring Quality Information for Patients ¼ (EQIP), qui fournit avec un score allant de 0 (pire) à 100 (meilleur), et la lisibilité a été évaluée avec le test « Flesch-Kincaid Grade Level ¼. Résultats: Sur 693 pages Web repérées, 39 ressources éducatives sur les médicaments contre l'IC répondaient aux critères de notre étude. Pour les ressources évaluées, le score médian sur l'échelle EQIP était de 61 % (intervalle interquartile de 54 % à 68 %), et deux d'entre elles (5 %) ont obtenu un score indiquant une qualité élevée (score ≥ 75 %). Le résultat médian au test Flesch-Kincaid Grade Level était de 8 années de scolarité (intervalle interquartile de 8 à 12), et quatre ressources (10 %) respectaient le niveau de lecture recommandé, qui correspond à une 6e année de scolarité. Conclusions: La plupart des ressources éducatives en ligne sur les médicaments contre l'IC sont d'une qualité éducative acceptable, mais des améliorations sont possibles. La plupart des ressources corres-pondent à un niveau de lecture plus élevé que ce qui est recommandé pour la rédaction de ressources éducatives, ce qui limite leur utilité pour les patients qui ont un faible niveau de littératie.

P2Y12 inhibitor adherence trajectories in patients with acute coronary syndrome undergoing percutaneous coronary intervention: prognostic implications.

AIMS: Post-acute coronary syndrome (ACS) P2Y12 inhibitor non-adherence is common and associated with greater risk of major adverse cardiovascular events (MACEs). Non-adherence can follow different trajectories from an inability to initiate, implement, or continue therapy for the intended duration. We aimed to evaluate P2Y12 inhibitor adherence trajectories among ACS patients treated with percutaneous coronary intervention (PCI), their frequency, and association with MACE. METHODS AND RESULTS: We conducted a cohort study of adults discharged alive after PCI for ACS (2012-16) using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry linked with administrative data. The primary outcome was P2Y12 inhibitor adherence trajectory in the year after PCI assessed using group-based trajectory modelling. We used logistic regression and Cox proportional-hazards regression to assess associations of trajectories with risk factors and MACE, respectively. We included 12 844 patients (mean age 62.4 years, 23.6% female). Five trajectories were identified: early consistent non-adherence (11.0%), rapid decline (7.7%), delayed initiation (6.0%), gradual decline (20.5%), and persistent adherence (54.8%). Compared with persistent adherence, rapid decline [hazard ratio (HR) 1.23, 95% confidence interval (CI) 1.01-1.49] and delayed initiation (HR 1.41, 95% CI 1.12-1.78) were associated with higher MACE in the overall cohort, whereas early consistent non-adherence was associated with higher MACE only in the subgroup receiving a drug-eluting stent (HR 2.44, 95% CI 1.60-3.71). CONCLUSION: After PCI for ACS, patients followed one of five distinct P2Y12 inhibitor adherence trajectories. Rapid decline and delayed initiation were associated with a higher risk of MACE, whereas early consistent non-adherence was only associated with higher MACE risk in patients with a drug-eluting stent.

Cardiac and cardiometabolic phenotyping of trastuzumab-mediated cardiotoxicity: a secondary analysis of the MANTICORE trial.

AIMS: An improved understanding of the pathophysiology of trastuzumab-mediated cardiotoxicity is required to improve outcomes of patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer. We aimed to characterize the cardiac and cardiometabolic phenotype of trastuzumab-mediated toxicity and potential interactions with cardiac pharmacotherapy. METHODS AND RESULTS: This study was an analysis of serial magnetic resonance imaging (MRI) and circulating biomarker data acquired from patients with HER2-positive early-stage breast cancer participating in a randomized-controlled clinical trial for the pharmaco-prevention of trastuzumab-associated cardiotoxicity. Circulating biomarkers (B-type natriuretic peptide, troponin I, MMP-2 and -9, GDF-15, neuregulin-1, and IGF-1) and MRI of cardiac structure and function and abdominal fat distribution were acquired prior to trastuzumab, post-cycle 4 and post-cycle 17. Ninety-four participants (51 ± 8 years) completed the study with 30 on placebo, 33 on perindopril, and 31 on bisoprolol. Post-cycle 4, global longitudinal strain deteriorated from baseline in both placebo (+2.0 ± 2.7%, P = 0.002) and perindopril (+0.9 ± 2.5%, P = 0.04), but not with bisoprolol (-0.2 ± 2.1%, P = 0.55). In all groups combined, extracellular volume fraction and GDF-15 increased post-cycle 4 (+1.3 ± 4.4%, P = 0.004; +130 ± 150%, P ≤ 0.001, respectively). However, no significant change in troponin I was detected throughout trastuzumab. In all groups combined, visceral and intermuscular fat volume increased post-cycle 4 (+7 ± 17%, P = 0.02, +8 ± 23%, P = 0.02, respectively), while muscle volume and IGF-1 decreased from post-cycle 4 to 17 (-2 ± 10%, P = 0.008, -18 ± 28%, P < 0.001, respectively). CONCLUSION: Trastuzumab results in impaired cardiac function and early myocardial inflammation. Trastuzumab is also associated with deleterious changes to the cardiometabolic phenotype which may contribute to the increased cardiovascular risk in this population.

Comparison of risk-scoring systems for heparin-induced thrombocytopenia in cardiac surgery patients.

OBJECTIVES: Several risk-scoring tools have been developed to exclude heparin-induced thrombocytopenia (HIT) in patients with thrombocytopenia, but these scores have not been reproduced or compared in the cardiac surgery population. The objective of this study was to validate and compare the modified 4T's (m4T) and Lillo-Le Louet (LLL) scores for HIT screening in the cardiac surgery population. METHODS: In this nested case-control study, we retrospectively calculated the m4T and the cardiac surgery-specific score by LLL for 18 cases (HIT-positive) and 54 matched controls (HIT-negative) using characteristics known at the time the HIT assay was ordered post-cardiac surgery and compared their performances by their c-statistic (area under the receiver operating characteristic curve), sensitivity and specificity. RESULTS: The median time from surgery to HIT assay order was 9.5 days (IQR 3.75-11.0) in the HIT-positive group and 2 days (IQR 2.0-3.0) in the HIT-negative group (p < 0.0001). The c-statistics for the m4T and the LLL scores were 0.76 (95% CI 0.64-0.85) and 0.63 (95% CI 0.51-0.74), respectively (p = 0.051). Sensitivity and specificity were 61% and 91% for the m4T, and 94% and 32% for the LLL score. CONCLUSION: Performance of the m4T and LLL scores in discriminating HIT-positive from HIT-negative patients was modest among patients post-cardiac surgery. However, differences between the sensitivities of these scores suggest that the LLL score may be a safer tool for ruling out HIT in this population.

Clinical Pharmacists' Knowledge of and Attitudes toward Older Adults.

BACKGROUND: Although pharmacy literature suggests that pharmacists have a positive attitude towards older adults, there is a paucity of studies that have measured pharmacists' knowledge or attitudes towards older people. The purpose of our study was to assess the knowledge and attitudes of hospital pharmacists toward older adults. METHODS: An electronic survey was distributed over two months to clinical hospital pharmacists across the province of Alberta, Canada. The survey was composed of two validated tools, the Palmore Facts of Aging Quiz (PFAQ) and Kogan's Attitude toward Old People Scale (KOPS). PFAQ is scored from 0 (poor knowledge) to 25 (high knowledge) and KOPS from 34 to 204, with higher than 119 indicating a positive attitude. RESULTS: A total of 153 pharmacists completed the survey (response rate of 24%). The mean age was 39 (SD 10.8) years; the average years practiced was 15 (SD 11), and the majority of respondents (n = 65) reported that >50% of patients in their practice were geriatrics. The mean correct responses on the PFAQ were 18.8 (SD 2.6). KOPS had a mean score of 156.8 (SD 14), with only one pharmacist score falling below 119, indicating a negative attitude. There was a statistically significant, positive correlation between attitudes and knowledge (r = 0.38, p < 0.05), as well as the increasing age of the respondents (r = 0.18, p = 0.03). The remaining measured categories (i.e., gender, years of pharmacy practice) had no significant effect. CONCLUSION: Clinical hospital pharmacists in Alberta have a positive attitude toward geriatric patients, as well as a satisfactory knowledge of older adults.

The evidence for pharmacist care in outpatients with heart failure: a systematic review and meta-analysis.

AIMS: Patients with heart failure (HF) have poor outcomes, including poor quality of life, and high morbidity and mortality. In addition, they have a high medication burden due to the multiple drug therapies now recommended by guidelines. Previous reviews, including studies in hospital settings, provided evidence that pharmacist care improves outcomes in patients with HF. Because most HF is managed outside of hospitals, we aimed to synthesize the evidence for pharmacist care in outpatients with HF. METHODS AND RESULTS: We conducted a systematic literature search in PubMed of randomized controlled trials (RCTs) and integrated the evidence on patient outcomes in a meta-analysis. We found 24 RCTs performed in 10 countries, including 8029 patients. The data revealed consistent improvements in medication adherence (independent of the measuring instrument) and knowledge, physical function, and disease and medication management. Sixteen RCTs were included in meta-analyses. Differences in all-cause mortality (odds ratio (OR) = 0.97 [95% CI, 0.84-1.12], Q-statistic, P = 0.49, I2  = 0%), all-cause hospitalizations (OR = 0.86 [0.73-1.03], Q-statistic, P = 0.01, I2  = 45.5%), and HF hospitalizations (OR = 0.89 [0.77-1.02], Q-statistic, P = 0.11, I2  = 0%) were not statistically significant. We also observed an improvement in the standardized mean difference for generic quality of life of 0.75 ([0.49-1.01], P < 0.01), with no indication of heterogeneity (Q-statistic, P = 0.64; I2  = 0%). CONCLUSIONS: Results indicate that pharmacist care improves medication adherence and knowledge, symptom control, and some measures of quality of life in outpatients with HF. Given the increasing complexity of guideline-directed medical therapy, pharmacists' unique focus on medication management, titration, adherence, and patient teaching should be considered part of the management strategy for these vulnerable patients.

CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction.

In this update of the Canadian Cardiovascular Society heart failure (HF) guidelines, we provide comprehensive recommendations and practical tips for the pharmacologic management of patients with HF with reduced ejection fraction (HFrEF). Since the 2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of HF, substantial new evidence has emerged that has informed the care of these patients. In particular, we focus on the role of novel pharmacologic therapies for HFrEF including angiotensin receptor-neprilysin inhibitors, sinus node inhibitors, sodium glucose transport 2 inhibitors, and soluble guanylate cyclase stimulators in conjunction with other long established HFrEF therapies. Updated recommendations are also provided in the context of the clinical setting for which each of these agents might be prescribed; the potential value of each therapy is reviewed, where relevant, for chronic HF, new onset HF, and for HF hospitalization. We define a new standard of pharmacologic care for HFrEF that incorporates 4 key therapeutic drug classes as standard therapy for most patients: an angiotensin receptor-neprilysin inhibitor (as first-line therapy or after angiotensin converting enzyme inhibitor/angiotensin receptor blocker titration); a ß-blocker; a mineralocorticoid receptor antagonist; and a sodium glucose transport 2 inhibitor. Additionally, many patients with HFrEF will have clinical characteristics for which we recommended other key therapies to improve HF outcomes, including sinus node inhibitors, soluble guanylate cyclase stimulators, hydralazine/nitrates in combination, and/or digoxin. Finally, an approach to management that integrates prioritized pharmacologic with nonpharmacologic and invasive therapies after a diagnosis of HFrEF is highlighted.