Evaluation of a transitional care pharmacist intervention in a high-risk cardiovascular patient population.

PURPOSE: The utility of a transitions-of-care (TOC) pharmacist intervention focused on improving the quality and safety of the medication process for high-risk cardiovascular patients was evaluated. METHODS: A quality-improvement initiative was developed for patients with heart failure or acute coronary syndrome followed longitudinally at a hospital's outpatient cardiovascular clinic. The TOC pharmacist intervention occurred either before a patient's outpatient cardiovascular clinic appointment or during a hospitalization. The major outcome analyzed was the number of unplanned hospital readmissions within 30 days. Additional endpoints evaluated included the time to healthcare utilization, number of medication discrepancies identified, percentage of therapeutic recommendations accepted by a provider, number of medication access issues resolved, patient cost savings, patient satisfaction, and mean time spent on an intervention by the pharmacist per patient encounter. RESULTS: A total of 118 patients received the TOC pharmacist intervention. A total of 516 medication discrepancies were identified and corrected, with 55.6% of discrepancies involving cardiovascular medications. A total of 244 recommendations for therapeutic optimization were provided, with an 81% provider acceptance rate and a 100% patient satisfaction rate. Fifty-five patients were provided with medication cost savings, and medication-access issues were resolved for 8 patients. A TOC pharmacist spent means of 98 and 73 minutes on patient education and coordination of care during inpatient and ambulatory encounters, respectively. The 30-day hospital readmission rate for patients with heart failure was reduced by 20%. CONCLUSION: A TOC pharmacist intervention improved the quality and safety of care across both inpatient and ambulatory settings for high-risk cardiovascular patients at our institution.

No-reflow is an independent predictor of death and myocardial infarction after percutaneous coronary intervention.

BACKGROUND: No-reflow occurring during percutaneous coronary intervention (PCI) has been associated with poor inhospital outcomes. The objectives of this analysis were to evaluate the occurrence of no-reflow as an independent predictor of adverse events and to determine whether treatment with intracoronary vasodilator therapy affected clinical outcomes. METHODS: We prospectively collected data from 4264 consecutive patients undergoing PCI, identifying those with no-reflow, and analyzed their treatments and clinical outcomes. RESULTS: No-reflow was identified in 135 of 4264 patients (3.2%). Baseline demographics were comparable, but patients with no-reflow were more likely to have acute myocardial infarction, unstable angina, and cardiogenic shock and to have undergone saphenous vein graft interventions. No-reflow was highly predictive of postprocedural myocardial infarction (17.7% vs 3.5% in patients without no-reflow, P <.001) and death (7.4% vs 2.0%, P <.001) and remained a strong independent predictor of death or myocardial infarction after multivariate analysis (odds ratio 3.6, P <.001). The administration of intracoronary verapamil, sodium nitroprusside, or both was not associated with a reduction in the rate of death or myocardial infarction (adjusted odds ratio of death or myocardial infarction 1.04, P =.945 for nitroprusside; and adjusted odds ratio of death or myocardial infarction 0.94, P =.91 for verapamil), despite an improvement in angiographic flow rates for patients treated with sodium nitroprusside. CONCLUSIONS: No-reflow is a strong independent predictor of inhospital mortality and postprocedural myocardial infarction. Administration of verapamil or sodium nitroprusside was not associated with improved inhospital outcomes in patients with no-reflow, although anterograde flow rates were improved in patients treated with sodium nitroprusside.

Comparison of the use of downstream tests after exercise treadmill testing by cardiologists versus noncardiologists.

Although exercise treadmill testing (ETT) is a useful initial test for patients with suspected cardiovascular (CV) disease, there is concern regarding the use of downstream imaging tests especially in the setting of equivocal or positive ETTs. Patients with no history of coronary artery disease who underwent ETT between 2009 and 2010 were prospectively included. Referring physicians were categorized as cardiologists and noncardiologists. Downstream tests included nuclear perfusion imaging, coronary computed tomography angiography, stress echocardiography, stress magnetic resonance, and invasive coronary angiography performed up to 6 months after the ETT. Patients were followed for CV death, myocardial infarction, and coronary revascularization for a median of 2.7 years. Among 3,656 patients, the ETT were negative in 2,876 (79%), positive in 132 (3.6%), and inconclusive in 643 (18%). Cardiologists ordered less downstream tests than noncardiologists (9.5% vs 12.2%, p=0.02), with less noninvasive tests (5.9% vs 10.4%, p<0.0001) and more invasive angiography (3.6% vs 1.8%, p<0.0001). After adjustment for confounding, patients evaluated by cardiologists were less likely to undergo additional testing after equivocal (odds ratio: 0.65, p=0.02) or positive ETT results (odds ratio: 0.39, p=0.02), whereas after negative ETT, the odds ratio was 1.7 (p=0.06). There was no difference in the rate of adverse CV events between patients referred by cardiologists versus noncardiologists. In conclusion, patients referred for ETT by cardiologists are less likely to undergo additional testing, particularly noninvasive tests, than those referred by noncardiologists. The lower rate of tests is driven by a lower rate of tests after positive or inconclusive ETT.

An algorithm for use of prasugrel (effient) in patients undergoing cardiac catheterization and percutaneous coronary intervention.

An algorithm for use of Prasugrel (Effient) in patients undergoing cardiac catheterization and percutaneous coronary intervention at the Brigham and Women's Hospital is presented. Our algorithm, which is in the process of being implemented, is consistent with published and generally accepted standards of care and is based on data from the pivotal Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38, which compared clopidogrel with prasugrel in acute coronary syndrome patients undergoing percutaneous coronary intervention. Areas of focus include analysis of the benefit of prasugrel over clopidogrel in acute coronary syndrome patients and appropriate selection of patients for prasugrel treatment.