Incidence and Management of Clozapine-Induced Myocarditis in a Large Tertiary Hospital.

OBJECTIVE: Clozapine, an antipsychotic reserved for management of treatment-resistant schizophrenia, is associated with severe adverse effects, including myocarditis. This study aims to determine the incidence of clozapine-induced myocarditis at a large tertiary hospital compared to what is reported in the literature. METHODS: Medical records of adult patients admitted to psychiatry units receiving clozapine between January 1, 2010, and July 31, 2016, were retrospectively reviewed. Cases of clozapine-induced myocarditis were defined as having elevated C-reactive protein (CRP) or detectable troponin and at least 1 sign or symptom of myocarditis, in the absence of alternative plausible aetiologies. The primary outcome was incidence of clozapine-induced myocarditis during the study period. Secondary outcomes included rate and description of the management of clozapine-induced myocarditis. RESULTS: In total, 316 patients were screened; 10 patients met the case definition for clozapine-induced myocarditis. The incidence of this adverse drug reaction over the study period was 3.16%. Reduced left ventricular ejection fraction was observed in 60% of cases, and electrocardiography changes were noted in 60% of cases. Clozapine was discontinued in all cases. Rechallenge was performed in 2 patients; recurrent CRP elevation resulted in discontinuation in each case. Medications for management of myocarditis were used in 50% of cases. Although 2 patients required transfer to critical care, the in-hospital mortality rate was 0%. CONCLUSIONS: The incidence of clozapine-induced myocarditis at the study hospital was consistent with the higher range reported in the literature. Further research is necessary to elucidate risk factors, definitive diagnostic criteria, and effective management of clozapine-induced myocarditis.

Development and Application of an Attribute-Based Taxonomy on the Benefits of Oral Anticoagulant Switching in Atrial Fibrillation: A Delphi Study.

INTRODUCTION: Patients with atrial fibrillation (AF) often switch between oral anticoagulants (OACs). It can be hard to know why a patient has switched outside of a clinical setting. Medication attribute comparisons can suggest benefits. Consensus on terms and definitions is required for inferring OAC switch benefits. The objectives of the study were to generate consensus on a taxonomy of the potential benefits of OAC switching in patients with AF and apply the taxonomy to real-world data. METHODS: Nine expert clinicians (seven clinical pharmacists, two cardiologists) with at least 3 years of clinical and research experience in AF participated in a Delphi process. The experts rated and commented on a proposed taxonomy on the potential benefits of OAC switching. After each Delphi round, ratings were analyzed with the RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness method. Median ratings, disagreement index, and comments were used to modify the taxonomy. The resulting taxonomy from the Delphi process was applied to a cohort of patients with AF who switched OACs in a population-based administrative health dataset from 1996 to 2019 in British Columbia, Canada. RESULTS: The taxonomy was finalized in two Delphi rounds, reaching consensus on five switch benefit categories: safety, effectiveness, convenience, economic considerations, and drug interactions. Safety benefit (a switch that could lower the risk of adverse drug events) had three subcategories: major bleeding, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding. Effectiveness benefit had four subcategories: stroke and systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), and all-cause mortality. Real-world OAC switches revealed that more OAC switches had convenience (72.6%) and drug interaction (63.0%) benefits compared to effectiveness (SSE 22.0%, ischemic stroke 11.1%, MI 3.1%, all-cause mortality 10.1%), safety (major bleeding 24.3%, GI bleeding 10.6%, ICH 48.5%), and economic benefits (12.1%). CONCLUSIONS: The Delphi-based taxonomy identified five criteria for the beneficial effects of OAC switching, aiding in characterizing real-world OAC switching.

Comparison of a Fully Weight-Based Protocol with a Non-Weight-Based Dosage Titration Protocol for IV Unfractionated Heparin: A Before-and-After Study.

Background: Unfractionated heparin (UFH) is used for the prevention and treatment of arterial or venous thromboembolism. The dosage for IV infusion of UFH is generally based on the patient's weight, with adjustment to a specific target for activated partial thromboplastin time (aPTT). In May 2019, the UFH protocols at the study institution were changed from being fully weight-based (i.e., for both initial dosing and subsequent dosage titrations) to weight-based initial dosing and non-weight-based dosage titrations, but the relative effectiveness of these 2 approaches was not known. Objectives: The primary objective was to compare the effectiveness in achieving therapeutic aPTT with the fully weight-based and non-weight-based dosage titration protocols. The secondary objective was to compare the effectiveness of the non-weight-based dosage titration protocol with that of the previous fully weight-based one for patients with low-target aPTT. Methods: A single-centre, retrospective, observational before-and-after study was conducted for patients receiving therapeutic UFH for any indication. Patients in the "before" group (fully weight-based protocol) were treated from January 2015 to October 2016, and those in the "after" group (non-weight-based titration) from January to October 2020. Results: From a total of 1969 charts screened, 137 patients treated according to the fully weight-based protocols and 130 patients treated according to the non-weight-based titration protocols were included. In terms of the co-primary objective, the median number of dosage adjustments to achieve therapeutic anticoagulation was 1 in both groups (p = 0.48), and the proportion of patients with therapeutic anticoagulation at 24 h was similar (96.2% [125/130] with the non-weight-based titration protocols versus 99.3% [136/137] with the fully weight-based protocols; p = 0.09). Among patients treated according to the low-target UFH protocols, those with the non-weight-based titration protocol were less likely to have therapeutic anticoagulation at first measurement of aPTT than those with the fully weight-based protocol (37.9% [25/66] versus 44.6% [41/92], p = 0.033). Conclusions: This retrospective, observational, before-and-after study showed that the effectiveness of the non-weight-based dosage titration protocols in achieving therapeutic aPTT was similar to that of fully weight-based UFH protocols.

Contexte: L'héparine non fractionnée (HNF) est utilisée pour la prévention et le traitement de la thromboembolie artérielle ou veineuse. La posologie de la perfusion par IV d'HNF se base généralement sur le poids du patient, avec un ajustement à un objectif précis du temps moyen de céphaline activée (TCA). En mai 2019, les protocoles d'HNF de l'établissement à l'étude sont passés d'une approche entièrement basée sur le poids (à la fois pour la posologie initiale et les titrages posologiques ultérieurs) à une posologie initiale basée sur le poids, et à des titrages posologiques non basés sur le poids. Cependant, l'efficacité relative de ces 2 approches était inconnue. Objectifs: L'objectif principal de l'étude consistait à comparer dans quelle mesure les protocoles entièrement basés sur le poids et les protocoles de titrage non basés sur le poids étaient efficaces pour atteindre le TCA thérapeutique. L'objectif secondaire consistait quant à lui à comparer l'efficacité du protocole de titrage de dose non basé sur le poids au protocole précédent entièrement basé sur le poids chez les patients ayant une faible cible de TCA. Méthodes: Une étude monocentrique, rétrospective, observationnelle avant-après a été menée chez des patients recevant de l'HNF thérapeutique, toutes indications confondues. Les patients du groupe « Avant ¼ (protocole entièrement basé sur le poids) ont été traités de janvier 2015 à octobre 2016, et ceux du groupe « Après ¼ (protocole de titrage de dose non basé sur le poids) de janvier à octobre 2020. Résultats: À partir de 1969 dossiers examinés, 137 patients traités selon les protocoles entièrement basés sur le poids et 130 patients traités selon les protocoles d'ajustement posologique non basés sur le poids ont été inclus. En ce qui concerne l'objectif co-principal, le nombre médian d'ajustements posologiques pour obtenir une anticoagulation thérapeutique était de 1 dans les deux groupes (p = 0,48), et la part de patients ayant une anticoagulation thérapeutique à 24 h était similaire (96,2 % [125/130] avec les protocoles non basés sur le poids contre 99,3 % [136/137] avec ceux entièrement basés sur le poids [p = 0,09]). Parmi les patients traités selon les protocoles HNF à faible cible, ceux avec le protocole de titrage non basé sur le poids étaient moins susceptibles de connaître une anticoagulation thérapeutique à la première mesure du TCA que ceux avec le protocole entièrement basé sur le poids (37,9 % [25/66] contre 44,6 % [41/92], p = 0,033). Conclusions: Cette étude rétrospective et observationnelle avant-après a montré que l'efficacité des protocoles d'ajustement posologique non basés sur le poids pour obtenir un TCA thérapeutique était similaire à celle des protocoles d'HNF entièrement basés sur le poids.

Patients' Beliefs About Their Cardiovascular Medications After Acute Coronary Syndrome: A Prospective Observational Study.

Background: Adherence to secondary preventive pharmacotherapy after an acute coronary syndrome (ACS) is generally poor and is associated with recurrent cardiovascular events. Patients' beliefs about their medications are a strong predictor of intentional nonadherence. Methods: This prospective, observational study assessed adult patients' beliefs about their post-ACS medications, using the Beliefs About Medicines Questionnaire (BMQ), and adherence, using the Medication Adherence Report Scale (MARS-5) at St. Paul's Hospital in Vancouver, Canada during May-December, 2022. The BMQ and MARS-5 were administered in-hospital and at 4 weeks after discharge. Outcomes included difference in BMQ necessity-concerns differential (BMQ-NCD) from hospitalization to 4-week follow-up and factors associated with the BMQ-NCD. Results: Forty-seven participants completed the 4-week follow-up. The mean age was 64 years, and 83% were male. Most presented with a non-ST-segment-elevation ACS. No difference occurred in BMQ-NCD (7.3 vs 6.6, P = 0.29) or MARS-5 scores from discharge to 4 weeks (22.8 vs 23.7, P = 0.06); however, the BMQ specific-necessity subscale score decreased significantly (20.3 vs 18.8, P = 0.002). South Asian and Middle Eastern ethnic origins, compared to European, were associated with a higher BMQ-NCD. Part-time employment and male sex were associated with a lower BMQ-NCD. Conclusions: Participants held favourable beliefs about their post-ACS medications, which were largely unchanged from hospitalization to 4 weeks postdischarge, except for beliefs about the necessity of taking their medications. Those of European descent, those with part-time employment, and males had the lowest BMQ-NCD. Self-reported adherence was high. Ongoing reassessment of patients' beliefs about the necessity of taking their post-ACS medications may be warranted to mitigate further decline in BMQ-NCD.

Contexte: L'adhésion à une pharmacothérapie préventive secondaire après la survenue d'un syndrome coronarien aigu (SCA) est généralement faible et associée à des manifestations cardiovasculaires récurrentes. Les croyances du patient au sujet de ses médicaments représentent un facteur prédictif majeur de la non-adhésion intentionnelle. Méthodologie: Cette étude observationnelle prospective avait pour objectif d'évaluer les croyances des patients au sujet des médicaments à prendre après la survenue d'un SCA, au moyen du questionnaire BMQ (Beliefs About Medicines), ainsi que l'adhésion thérapeutique, à l'aide de l'échelle de rapport sur l'adhésion aux médicaments MARS-5 (Medication Adherence Report Scale), à l'hôpital St. Paul de Vancouver, au Canada, de mai à décembre 2022. Les questionnaires BMQ et MARS-5 ont été administrés pendant l'hospitalisation, puis 4 semaines après le congé de l'hôpital. Les résultats comprenaient la différence du score BMQ-NCD (necessity-concerns differential ­ écart nécessité-inquiétudes), entre l'hospitalisation et le suivi à 4 semaines, et les facteurs associés au score BMQ-NCD. Résultats: Au total, 47 participants ont terminé l'étude, jusqu'au suivi à 4 semaines. L'âge moyen était de 64 ans, et 83 % des sujets étaient de sexe masculin. La plupart des sujets présentaient un SCA sans élévation du segment ST. Aucune variation du score BMQ-NCD (7,3 vs 6,6; p = 0,29) ou MARS-5 (22,8 vs 23,7; p = 0,06) n'a été observée entre le congé de l'hôpital et le suivi à 4 semaines; cependant, le score BMQ spécifique à la nécessité avait significativement diminué (20,3 vs 18.8; p = 0,002). Les origines ethniques sud-asiatiques et moyen-orientales étaient associées à des scores BMQ-NCD plus élevés que les origines européennes. L'occupation d'un emploi à temps partiel et le sexe masculin étaient associés à des scores BMQ-NCD inférieurs. Conclusions: Les participants entretenaient des croyances favorables envers leurs médicaments à prendre après la survenue d'un SCA, qui sont demeurées largement les mêmes entre l'hospitalisation et le suivi, 4 semaines après le congé de l'hôpital, à l'exception des croyances au sujet de la nécessité de prendre les médicaments. Les sujets d'origine européenne, ceux occupant un emploi à temps partiel et les sujets masculins ont eu les scores BMQ-NCD les plus faibles. L'adhésion thérapeutique autosignalée était élevée. Des réévaluations constantes des croyances des patients au sujet de la nécessité de prendre leurs médicaments après la survenue d'un SCA pourraient être justifiées afin d'éviter que les scores BMQ-NCD diminuent davantage.

Direct-Acting Oral Anticoagulant Choice for Stroke Prevention in Obese Patients With Atrial Fibrillation.

Anticoagulation with direct-acting oral anticoagulants (DOACs) is recommended over warfarin for stroke prevention in patients with atrial fibrillation (AF). The efficacy of DOACs over warfarin in obese patients with AF is less defined and may carry the potential for subtherapeutic anticoagulation and reduced efficacy. The best available evidence to guide DOAC use in obese patients with AF is from analysis of obese subgroups of all the major landmark DOAC trials. From these subgroup analyses of the RE-LY, ARISTOTLE, ENGAGE-AF TIMI 48, and ROCKET-AF trials, DOAC use in obese patients demonstrated efficacy similar or superior to warfarin for stroke reduction. Major bleeding rates were similar or higher with DOACs compared with warfarin in these obese subgroup analyses. Meta-analysis of the above major clinical trials concluded that DOACs were more effective compared with warfarin for stroke prevention in obese patients (up to a body mass index [BMI] of 50 kg/m2) and had lower incidence of major bleeding. The totality of evidence supports that DOACs are as effective, if not superior, to warfarin in obese patients with AF. We propose an algorithm, based on the available evidence and current guidelines, to guide the use of DOACs based on severity of obesity. Any DOAC can be used in obese patients with BMI < 40 kg/m2. In patients with a BMI of 40-50 kg/m2, warfarin should be used, but apixaban or edoxaban can be considered. In obese patients with a BMI > 50 kg/m2, warfarin should be used.

Factors Affecting Delay in Filling Prescriptions for Dual Antiplatelet Therapy After Coronary Stenting.

Dual antiplatelet therapy (DAPT) is critical in preventing stent thrombosis after percutaneous coronary intervention (PCI). Delays in DAPT after PCI have been associated with stent thrombosis, reinfarction, and death. Cases of death, stent thrombosis, and reinfarction at our institution have been attributed to patient delays in accessing DAPT on discharge after PCI. We sought to determine the proportion of patients that delay filling their discharge prescription for DAPT after PCI and factors that influence delays in DAPT prescription-filling. We reviewed all patients who received PCI at St Paul's Hospital from April 1, 2015 to April 1, 2016 and determined the date of the first prescription filling of a P2Y12 antiplatelet agent after hospital discharge. The primary outcome was proportion of patients who delay filling their DAPT discharge prescription. Logistic regression analysis was performed to determine the relationship of various factors with delays in DAPT-filling. Six hundred fifty-one patients were included in the final analysis. Age, sex, and provincial drug coverage status were not associated with delays in DAPT prescription-filling. Distance of patient's residence to St Paul's Hospital was associated with a significant delay in DAPT prescription filling (adjusted odds ratio, 1.90; 95% confidence interval, 1.11-3.22). Hospital discharge processes to ensure timely access to DAPT after PCI should be established.

Switching Between ß-Blockers: An Empiric Tool for the Cardiovascular Practitioner.

ß-Blockers are a cornerstone of therapy for cardiovascular disease, but their clinical benefits are not consistent across the class and specific agents are preferred for certain indications. Further, when prescribed, a patient's clinical status might change, requiring the cardiologist to switch to an alternate agent. Examples of such scenarios include the development or a worsening of chronic noncardiac diseases (eg, hyperthyroidism, renal failure), new cardiac-related disease (eg, heart failure, atrial fibrillation), or practical/safety issues (eg, pregnancy, cost, side effects). However, guidelines on how to best switch to a different ß-blocker are lacking. Additionally, most hospital-based formularies and guidelines do not provide recommendations around common challenges, like medication intolerance or adjustments for acute illness. We present a practical approach to switching between commonly prescribed ß-blockers, which considers drug interchangeability for various indications, rationale for switching, necessary initial adjustments to dose/frequency, and differences in target/maximal doses.

Comparison of Preventive Cardiovascular Pharmacotherapy in Surgical vs Percutaneous Coronary Revascularization.

BACKGROUND: Data suggest that patients who undergo coronary artery bypass grafting (CABG) have a lower rate of secondary preventive cardiovascular pharmacotherapy use compared with patients who undergo percutaneous coronary intervention (PCI). This study sought to assess the rate of use of preventive pharmacotherapy at discharge in patients who underwent CABG vs PCI post-acute coronary syndrome (ACS). METHODS: A prospective cohort study was conducted at St Paul's Hospital in Vancouver, Canada. Patients aged ≥ 18 years who presented with an ACS and underwent CABG or PCI between January and November 2018 were included. Data on preventive pharmacotherapy use and reasons for justified nonuse (eg, intolerance, contraindication) were collected. RESULTS: A total of 275 patients were included. Mean age was 65 years, and 83% were male. Overall, 141 patients (51%) underwent CABG and 134 patients (49%) underwent PCI. All patients received acetylsalicylic acid, but more patients who underwent CABG received 325 mg (vs 80-81 mg) compared to PCI (25% vs 1%, P < 0.01). Use of P2Y12 inhibitors was higher in patients who underwent PCI (primarily ticagrelor) compared with patients who underwent CABG (primarily clopidogrel) (99% vs 26%, P < 0.01). All patients who underwent CABG received a ß-blocker vs 96% of patients who underwent PCI (P = 0.017). Use of angiotensin-modulating agents was higher in patients who underwent PCI (98% vs 65%, P < 0.01). Statin use was similar between groups (99% vs 99%, P = 0.96), but more patients who underwent PCI received maximum-dose therapy (89% vs 64%, P < 0.01). CONCLUSIONS: Use of acetylsalicylic acid, ß-blockers, and statins in patients post-ACS was high regardless of revascularization strategy, whereas P2Y12 inhibitors and angiotensin-modulating agents were underused in patients who underwent CABG even after adjusting for justified nonuse.

CONTEXTE: Les données semblent indiquer que le taux de recours à une pharmacothérapie cardiovasculaire en prévention secondaire est plus faible chez les patients qui subissent un pontage aortocoronarien (PAC) que chez ceux qui subissent une intervention coronarienne percutanée (ICP). Les auteurs ont tenté d'évaluer le taux de recours à une pharmacothérapie préventive à la sortie de l'hôpital après un syndrome coronarien aigu (SCA) chez les patients ayant subi un PAC et chez ceux ayant subi une ICP. MÉTHODE: Une étude de cohorte prospective a été menée à l'hôpital St. Paul de Vancouver, au Canada. Ont été inclus les patients âgés de 18 ans ou plus ayant présenté un SCA traité par un PAC ou par une ICP entre janvier et novembre 2018. Des données sur le recours à une pharmacothérapie préventive et les raisons justifiant le non-recours à une telle thérapie (p. ex. intolérance, contre-indication) ont été recueillies. RÉSULTATS: Au total, 275 patients ont été retenus. Les sujets avaient en moyenne 65 ans, et 83 % d'entre eux étaient des hommes. Dans l'ensemble, 141 patients (51 %) ont subi un PAC et 134 (49 %), une ICP. Tous les patients ont reçu de l'acide acétylsalicylique, mais les patients ayant subi un PAC ont été plus nombreux à recevoir une dose de 325 mg plutôt qu'une dose de 80-81 mg que chez les patients ayant subi une ICP (25 % vs 1 %, p < 0,01). L'emploi d'inhibiteurs du récepteur P2Y12 était plus fréquent chez les patients ayant subi une ICP (principalement le ticagrélor) que chez les patients ayant subi un PAC (principalement le clopidogrel) (99 % vs 26 %, p < 0,01). Tous les patients qui ont subi un PAC ont aussi reçu un bêtabloquant, comparativement à 96 % des patients qui ont subi une ICP (p < 0,017). L'emploi d'agents modulateurs de l'angiotensine était plus fréquent chez les patients ayant subi une ICP (98 % vs 65 %, p < 0,01). L'emploi de statines était comparable dans les deux groupes (99 % vs 99 %, p = 0,96), mais un plus grand nombre de patients ayant subi une ICP ont reçu un traitement à la dose maximale (89 % vs 64 %, p < 0,01). CONCLUSIONS: Le recours à l'acide acétylsalicylique, aux bêtabloquants et aux statines chez les patients ayant subi un SCA était élevé quelle que soit la stratégie de revascularisation, tandis que les inhibiteurs du récepteur P2Y12 et les agents modulateurs de l'angiotensine étaient sous-utilisés chez les patients ayant subi un PAC, même lorsqu'on tenait compte des cas de non-utilisation justifiée.

The role of statin therapy in sepsis.

OBJECTIVE: To systematically review the evidence evaluating the role of statin therapy in sepsis. DATA SOURCES: MEDLINE, EMBASE, and PubMed were searched (1980-January 2007) for English-language clinical trials that evaluated the use of statins and the development and treatment of sepsis in human subjects. Search terms included statin, HMG-CoA reductase inhibitor, bacteremia, sepsis, septic shock, septicemia, and severe sepsis. In addition, pertinent references from identified articles were obtained. STUDY SELECTION AND DATA EXTRACTION: Only clinical trials with primary efficacy outcomes of mortality, incidence of sepsis, and severe sepsis were included. DATA SYNTHESIS: Seven retrospective and 2 prospective cohort studies were included in this review. One was excluded because the patient population was not experiencing sepsis. Three studies demonstrated a reduced mortality with statin use while 2 other studies did not demonstrate this mortality benefit. One study suggested increased mortality with statin use in sepsis. Three studies showed a reduced incidence of development of sepsis or sepsis-related outcomes, while one study did not. The observational and retrospective nature of these studies and the higher rate of cardiovascular comorbidities in the statin groups may have allowed for a confounding influence. The conflicting results and heterogeneity between the studies makes the observed association between statin use and incidence of sepsis and sepsis-related mortality inconclusive. The clinical benefit of statin therapy in sepsis remains to be determined. CONCLUSIONS: There is an association between statin use and a lower incidence of sepsis and sepsis-related mortality. However, a causal relationship between statin use and reduced sepsis-related mortality has not yet been established. Currently, statins cannot be recommended for sepsis prevention or treatment until controlled trials are performed.

Management of Supratherapeutic International Normalized Ratio without Bleeding after Warfarin Use: An Evaluation of Vitamin K Administration (SUPRA-WAR-K Study).

BACKGROUND: For patients with supratherapeutic international normalized ratio (INR) and no evidence of bleeding, the 2012 guidelines of the American College of Chest Physicians discourage administration of vitamin K. At the study hospital, it was observed that vitamin K was frequently prescribed for patients with INR of 4.5 or higher and no bleeding. OBJECTIVES: To compare efficacy and safety outcomes between holding warfarin alone and holding warfarin with administration of vitamin K and to compare these outcomes among various doses and routes of vitamin K administration in non-critical care inpatients experiencing supratherapeutic INR without evidence of bleeding. METHODS: This single-centre retrospective chart review involved noncritical care inpatients with supratherapeutic INR (4.5-8.9) without evidence of bleeding. The primary outcomes were the change in INR 1 day after implementation of supratherapeutic INR management and the time to reach INR less than 3.0. The secondary outcomes were length of stay, frequency of warfarin resistance, incidence and duration of bridging anticoagulation, incidence of thromboembolism and major bleeding, and death. RESULTS: Regardless of vitamin K dose, the administration of vitamin K combined with holding warfarin, relative to holding warfarin alone, was associated with a greater INR decrease 1 day after the intervention (mean ± standard deviation -3.2 ± 1.9 versus -0.9 ± 1.0, p < 0.001) and a shorter time to reach INR below 3.0 (1.9 ± 1.0 days versus 2.6 ± 1.4 days, p = 0.003). No statistically significant differences in any other outcomes were observed. CONCLUSIONS: In hospitalized non-critical care patients with INR between 4.5 and 8.9 without evidence of bleeding, the combination of holding warfarin and administering vitamin K was associated with greater and faster decreases in INR than holding warfarin alone. No significant differences were found in clinically important outcomes. The practice of administering vitamin K in this population warrants further study and re-evaluation.

CONTEXTE: Dans ses lignes directrices de 2012, l'American College of Chest Physicians déconseille l'administration de vitamine K aux patients ayant des résultats de rapport international normalisé (RIN) suprathérapeutiques et ne présentant aucun saignement. À l'hôpital des auteurs, on a remarqué que l'on prescrivait fréquemment de la vitamine K aux patients répondant aux critères ci-dessus. OBJECTIFS: Comparer l'efficacité et l'innocuité entre un simple arrêt de la warfarine et l'arrêt de la warfarine combiné à l'administration de vitamine K, puis comparer ces résultats thérapeutiques selon différentes doses et voies d'administration de la vitamine K chez des patients hospitalisés qui ne sont pas en phase critique, qui ont un RIN suprathérapeutique et qui ne présentent aucun saignement. MÉTHODES: La présente étude menée dans un seul centre comportait une analyse des dossiers médicaux de patients hospitalisés n'étant pas en phase critique, ayant un RIN suprathérapeutique (4.5­8.9) et ne présentant aucun saignement. Les principaux paramètres d'évaluation étaient le changement du RIN un jour après la mise en œuvre de mesures pour corriger un RIN suprathérapeutique et le temps nécessaire pour atteindre un RIN de moins de 3,0. Les paramètres d'évaluation secondaires étaient la durée du séjour, la fréquence des cas de résistance à la warfarine, le nombre et la durée des relais anticoagulants, l'incidence des cas de thromboembolie et de saignement important et les cas de décès. RÉSULTATS: L'administration de vitamine K, peu importe la dose, combinée à l'arrêt de la warfarine comparativement au simple arrêt de la warfarine était associée à une réduction plus importante du RIN un jour après l'intervention (moyenne ± écart-type −3.2 ± 1,9 contre −0,9 ± 1,0, p < 0,001) et à un plus court délai pour atteindre un RIN de moins de 3,0 (1,9 ± 1,0 jour contre 2,6 ± 1,4 jours, p = 0.003). Aucune différence statistiquement significative n'a été observée pour le reste des paramètres d'évaluation. CONCLUSIONS: Chez les patients hospitalisés n'étant pas en phase critique, ayant un RIN entre 4,5 et 8,9 et ne présentant aucun saignement, l'arrêt de la warfarine combiné à l'administration de vitamine K a été associé à une réduction plus rapide et plus importante du RIN que le simple arrêt de la warfarine. On n'a observé aucune différence significative en ce qui touche aux résultats thérapeutiques cliniquement importants. L'administration de vitamine K pour cette population est une pratique qui nécessite de plus amples études et doit être évaluée à nouveau.

Statins and progression of calcified aortic stenosis.

OBJECTIVE: To review the evidence evaluating the efficacy of statins in reducing the progression of calcified aortic stenosis (AS). DATA SOURCES: MEDLINE, EMBASE, and PubMed were searched (all up to November 2006) for studies evaluating the use of statins to reduce the progression of calcified AS. Search terms included statin, HMG CoA reductase inhibitor, calcified AS, valve stenosis, and calcified stenosis. Additional primary trials were located by searching references noted in review articles. STUDY SELECTION AND DATA EXTRACTION: Clinical trials published in the English language were selected for review. Primary efficacy outcomes evaluated were changes in aortic valve measurements, hemodynamic measures of AS, and change in measures of AS severity. DATA SYNTHESIS: Two prospective clinical trials and 5 retrospective studies were included in this review. All of the retrospective studies demonstrated that statin use was associated with a statistically significant delay in the progression of AS. One prospective observation trial showed benefit of statin use; however, a large, randomized, double-blind, prospective trial showed no benefit of statin use in decreasing the progression of AS. CONCLUSIONS: An association between statin use and a delay in AS progression has been observed in retrospective studies; however, prospective trials showed conflicting results. Currently, statins cannot be recommended for medical treatment of AS until larger trials are conducted.

Impact of PharmaNet-Based Admission Medication Reconciliation on Best Possible Medication Histories for Warfarin.

BACKGROUND: Inaccurate documentation of medication histories may lead to medication discrepancies during hospital admissions. Obtaining a best possible medication history (BPMH) for warfarin can be challenging because of frequent dosage changes and nonspecific directions of use (e.g., "take as directed"). On February 27, 2012, the study hospital implemented an admission medication reconciliation (MedRec) process using a form that compiled the most recent 6 months of outpatient prescription dispensing history from a provincial electronic database called PharmaNet. It was unclear whether admission MedRec had improved the process of obtaining warfarin BPMHs and the quality of their documentation. OBJECTIVE: To compare the rates of complete warfarin BPMH documentation before and after implementation of PharmaNet-based admission MedRec. METHODS: A single-centre, retrospective chart review was conducted using the health records of patients receiving warfarin who were admitted to the hospital's Internal Medicine service before and after implementation of admission MedRec. The study periods were October 1, 2009, to February 26, 2012, and February 27, 2012, to July 31, 2014, respectively. The primary outcome was the rate of complete warfarin BPMH documentation during each period. RESULTS: Data were recorded for 100 patients in the pre-implementation phase and 100 patients in the post-implementation phase. The rates of complete warfarin BPMH documentation were 65% and 84% in these 2 phases, respectively (p = 0.002). CONCLUSION: Implementation of PharmaNet-based admission MedRec was associated with a statistically significant increase in the rate of complete warfarin BPMH documentation.

La consignation inexacte des schémas thérapeutiques peut mener à des divergences au chapitre des médicaments durant l'hospitalisation. Il peut être difficile d'établir un meilleur schéma thérapeutique possible (MSTP) pour la warfarine à cause de fréquents changements de posologie et de modes d'emploi imprécis (par exemple, « usage connu ¼). Le 27 février 2012, l'hôpital où s'est déroulée l'étude a mis en place un processus de bilan comparatif des médicaments (BCM) à l'admission. Celui-ci emploie un formulaire dressant la liste des médicaments d'ordonnance délivrés aux patients externes au cours des six derniers mois selon PharmaNet, une base de données numérique provinciale. On ignorait si les BCM à l'admission avaient amélioré le processus d'obtention et la qualité de la consignation des MSTP liés à la warfarine.