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ABSTRACT: OBJECTIVE:To provide recommendations for optimized anticoagulant therapy in the inpatient setting and outline broad elements that need to be in place for effective management of anticoagulant therapy in hospitalized patients; the guidelines are designed to promote optimization of patient clinical outcomes while minimizing the risks for potential anticoagulation-related errors and adverse events.DATA SOURCES:The medical literature was reviewed using MEDLINE (1946-January 2013), EMBASE (1980-January 2013), and PubMed (1947-January 2013) for topics and key words including, but not limited to, standards of practice, national guidelines, patient safety initiatives, and regulatory requirements pertaining to anticoagulant use in the inpatient setting. Non-English-language publications were excluded. Specific MeSH terms used include algorithms, anticoagulants/administration and dosage/adverse effects/therapeutic use, clinical protocols/standards, decision support systems, drug monitoring/METHODS: Because of this document's scope, the medical literature was searched using a variety of strategies. When possible, recommendations are supported by available evidence; however, because this paper deals with processes and systems of care, high-quality evidence (eg, controlled trials) is unavailable. In these cases, recommendations represent the consensus opinion of all authors and are endorsed by the Board of Directors of the Anticoagulation Forum, an organization dedicated to optimizing anticoagulation care. The board is composed of physicians, pharmacists, and nurses with demonstrated expertise and experience in the management of patients receiving anticoagulation therapy.DATA SYNTHESIS:Recommendations for delivering optimized inpatient anticoagulation therapy were developed collaboratively by the authors and are summarized in 8 key areas: (1) process, (2) accountability, (3) integration, (4) standards of practice, (5) provider education and competency, (6) patient education, (7) care transitions, and (8) outcomes. Recommendations are intended to inform the development of coordinated care systems containing elements with demonstrated benefit in improvement of anticoagulation therapy outcomes. Recommendations for delivering optimized inpatient anticoagulation therapy are intended to apply to all clinicians involved in the care of hospitalized patients receiving anticoagulation therapy. CONCLUSIONS:Anticoagulants are high-risk medications associated with a significant rate of medication errors among hospitalized patients. Several national organizations have introduced initiatives to reduce the likelihood of patient harm associated with the use of anticoagulants. Health care organizations are under increasing pressure to develop systems to ensure the safe and effective use of anticoagulants in the inpatient setting. This document provides consensus guidelines for anticoagulant therapy in the inpatient setting and serves as a companion document to prior guidelines relevant for outpatients.
Annals of Pharmacotherapy 04/2013; · 2.13 Impact Factor
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Renato D Lopes,
Richard C Becker,
L Kristin Newby,
Eric D Peterson,
Elaine M Hylek,
Robert Giugliano,
Christopher B Granger,
Kenneth W Mahaffey,
Antonio C Carvalho,
Otavio Berwanger, [......],
Gilson Soares Feitosa-Filho,
Marcia M Barbosa,
Maria da Consolacao V Moreira,
Renato A K Kalil,
Marildes Freitas,
Joao Carlos de Campos Guerra,
Marcio Vinicius Lins Barros,
Thiago da Rocha Rodrigues,
Antonio C Lopes, David A Garcia
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ABSTRACT: To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Fifth International Symposium of Thrombosis and Anticoagulation was held in Belo Horizonte, Minas Gerais, Brazil, on October 18-19, 2012. This scientific program was developed by clinicians for clinicians and was promoted by three major clinical research institutes: the Brazilian Clinical Research Institute, the Duke Clinical Research Institute of the Duke University School of Medicine, and Hospital do Coração Research Institute. Comprising 2 days of academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.
Journal of Thrombosis and Thrombolysis 03/2013; · 1.48 Impact Factor
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ABSTRACT: BACKGROUND Patients who not only survive a warfarin-associated gastrointestinal tract bleeding (GIB) event but also have an ongoing risk for thromboembolism present 2 clinical dilemmas: whether and when to resume anticoagulation. The objective of this study was to determine the incidence of thrombosis, recurrent GIB, and death, as well as the time to resumption of anticoagulant therapy, during the 90 days following a GIB event. METHODS In this retrospective, cohort study using administrative and clinical databases, patients experiencing GIB during warfarin therapy were categorized according to whether they resumed warfarin therapy after GIB and followed up for 90 days. Variables describing the management and severity of the index GIB were also collected. Kaplan-Meier curves were constructed to estimate the survival function of thrombosis, recurrent GIB, and death between the "resumed warfarin therapy" and "did not resume warfarin therapy" groups, with Cox proportional hazards modeling to adjust for potentially confounding factors. RESULTS There were 442 patients with warfarin-associated index GIB included in the analyses. Following the index GIB, 260 patients (58.8%) resumed warfarin therapy. Warfarin therapy resumption after the index GIB was associated with a lower adjusted risk for thrombosis (hazard ratio [HR], 0.05; 95% CI, 0.01-0.58) and death (HR, 0.31; 95% CI, 0.15-0.62), without significantly increasing the risk for recurrent GIB (HR, 1.32; 95% CI, 0.50-3.57). CONCLUSIONS The decision to not resume warfarin therapy in the 90 days following a GIB event is associated with increased risk for thrombosis and death. For many patients who have experienced warfarin-associated GIB, the benefits of resuming anticoagulant therapy will outweigh the risks.
Archives of internal medicine 09/2012; · 11.46 Impact Factor
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ABSTRACT: When a patient with atrial fibrillation (AF) interrupts oral anticoagulation to undergo an invasive procedure, the clinician must answer two questions: for how long should the anticoagulant be stopped before the procedure, and should a "bridging" strategy be used with a shorter-acting agent? These questions are extremely important to the clinician who wants neither to use too much anticoagulation around procedures and cause unnecessary bleeding nor use too little and result in stroke. Based on decades of use of warfarin, the provider is left to choose an approach based on a subjective sense of the likely risks and benefits based on patient and procedural factors (Table 1). These decisions must be based on surprisingly little reliable evidence(1,2).(SELECT FULL TEXT TO CONTINUE).
Circulation 06/2012; 126(3):255-7. · 14.74 Impact Factor
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Circulation 06/2012; 125(23):2944-7. · 14.74 Impact Factor
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Circulation 04/2012; 125(16):e614; author reply e616. · 14.74 Impact Factor
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Renato D Lopes,
Richard C Becker,
L Kristin Newby,
Eric D Peterson,
Elaine M Hylek,
Christopher B Granger,
Mark Crowther,
Tracy Wang,
Antonio C Carvalho,
Otavio Berwanger, [......],
Jorge Pinto Ribeiro,
Eduardo Darze,
Renato A K Kalil,
Marianna Andrande,
Fabio Villas Boas,
Jadelson Andrade,
Ana Thereza Rocha,
Robert A Harrington,
Antonio C Lopes, David A Garcia
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ABSTRACT: To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Fourth International Symposium of Thrombosis and Anticoagulation was held in Salvador, Bahia, Brazil, from October 20-21, 2011. This scientific program was developed by clinicians for clinicians and was promoted by three major clinical research institutes: the Brazilian Clinical Research Institute, the Duke Clinical Research Institute of the Duke University School of Medicine, and Hospital do Coração Research Institute. Comprising 2 days of academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.
Journal of Thrombosis and Thrombolysis 03/2012; 34(1):143-63. · 1.48 Impact Factor
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Stroke 12/2011; 43(1):271-9. · 5.73 Impact Factor
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ABSTRACT: Ms TS is a 66-year-old woman who receives warfarin for prevention of systemic embolization in the setting of hypertension, diabetes, and atrial fibrillation. She had a transient ischemic attack about 4 years ago when she was receiving aspirin. Her INR control was excellent; however, over the past few months it has become erratic, and her average dose required to maintain an INR of 2.0 to 3.0 appears to have decreased. She has had back pain over this same period and has been taking acetaminophen at doses at large as 650 mg four times daily, with her dose varying based on her symptoms. You recall a potential interaction and wonder if (1) her acetaminophen use is contributing to her loss of INR control, and (2) does this interaction place her at increased risk of warfarin-related complications?
Blood 09/2011; 118(24):6269-73. · 9.90 Impact Factor
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Evidence-based medicine 07/2011; 16(6):187-8.
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Renato D Lopes,
Richard C Becker,
John H Alexander,
Paul W Armstrong,
Robert M Califf,
Mark Y Chan,
Mark Crowther,
Christopher B Granger,
Robert A Harrington,
Elaine M Hylek, [......],
Lars Wallentin,
Harvey D White,
Antonio C Carvalho,
Roberto R Giraldez,
Helio P Guimaraes,
Helena B Nader,
Renato A K Kalil,
Joyce M A Bizzachi,
Antonio C Lopes, David A Garcia
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ABSTRACT: To discuss and share knowledge around advances in the care of patients with thrombotic disorders, the Third International Symposium of Thrombosis and Anticoagulation was held in São Paulo, Brazil, from October 14-16, 2010. This scientific program was developed by clinicians for clinicians, and was promoted by four major clinical research institutes: the Brazilian Clinical Research Institute, the Duke Clinical Research Institute of the Duke University School of Medicine, the Canadian VIGOUR Centre, and the Uppsala Clinical Research Center. Comprising 3 days of academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.
Journal of Thrombosis and Thrombolysis 05/2011; 32(2):242-66. · 1.48 Impact Factor
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David A Garcia
Journal of Thrombosis and Thrombolysis 03/2011; 31(3):241. · 1.48 Impact Factor
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ABSTRACT: Monitoring patients on warfarin therapy is challenging. The tools highlighted here--from online forums and Web-based dosing calculators to patient education materials and self-monitors--can help.
The Journal of family practice 02/2011; 60(2):70-5. · 0.61 Impact Factor
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ABSTRACT: Atrial fibrillation is a supraventricular tachyarrhythmia with significant consequences in terms of morbidity and mortality. In light of the limitations of available pharmacologic treatment options (suboptimal efficacy plus safety and tolerability issues), atrial fibrillation management should be individualized based on patient characteristics and comorbidities that could influence response to specific management approaches. The importance of adequate anticoagulation should not be overlooked. This review provides a practical guide for primary care physicians, internists, and cardiologists on current management strategies for atrial fibrillation, based on recent guidelines and current clinical data.
The American journal of medicine 10/2010; 124(1):4-14. · 4.47 Impact Factor
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ABSTRACT: Atrial fibrillation is a common condition that increases the risk of stroke in many patients. Although warfarin has been shown to reduce the risk of stroke, many patients who might benefit from anticoagulation do not receive this therapy. Fear of bleeding is the most often cited reason. Several new anticoagulant medications are being studied to determine their efficacy and safety relative to warfarin. Unlike earlier trials that established the superiority of warfarin over placebo, recent trials in atrial fibrillation have enrolled a disproportionate number of patients already taking warfarin. This review suggests that the risk of both haemorrhage and stroke are highest when atrial fibrillation is newly diagnosed and during the initiation of anticoagulant medication. Randomised controlled trials designed to evaluate the safety and efficacy of new anti-thrombotic agents should include substantial numbers of patients without prior exposure to anticoagulation since these individuals are at the highest risk for bleeding and thromboembolism.
Thrombosis and Haemostasis 09/2010; 104(6):1099-105. · 5.04 Impact Factor
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David A Garcia
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ABSTRACT: Pulmonary embolism (PE) and deep vein thrombosis (DVT) are widely regarded as manifestations of a single disease, venous thromboembolism (VTE). An evidence-based approach to the treatment of acute VTE will be reviewed here. Currently available therapeutic options will be emphasized; possible future treatment approaches will be discussed briefly. The chronic management of VTE involves assessment of the risks and benefits of prolonged anticoagulation and is discussed in more detail elsewhere in this issue.
Current pharmaceutical design 01/2010; 16(31):3475-7. · 4.41 Impact Factor
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New England Journal of Medicine 07/2009; 360(23):2474; author reply 2475. · 53.30 Impact Factor
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David A Garcia
Evidence-based medicine 05/2009; 14(2):59.
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ABSTRACT: For patients on warfarin therapy, an international normalized ratio (INR) recall interval not exceeding 4 weeks has traditionally been recommended. Less frequent INR monitoring may be feasible in stable patients. We sought to identify patients with stable INRs (defined as having INR values exclusively within the INR range) and comparator patients (defined as at least one INR outside the INR range) in a retrospective, longitudinal cohort study. Occurrences of thromboembolism, bleeding, and death were compared between groups. Multivariate logistic regression models were used to identify independent predictors of stable INR control. There were 2504 stable and 3569 comparator patients. The combined rates of bleeding and thromboembolism were significantly lower in stable patients. Independent predictors of stable INR control were age older than 70 years and the absence of comorbid heart failure and diabetes. Stable patients were significantly less likely to have target INR of 3.0 or higher or chronic diseases. We hypothesize that many patients demonstrating stable INR control could be safely treated with INR recall intervals greater than the traditional 4 weeks.
Blood 05/2009; 114(5):952-6. · 9.90 Impact Factor
