1
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Trachtenberg B, Cowger J. HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support. J Card Fail 2023; 29:479-502. [PMID: 36828256 DOI: 10.1016/j.cardfail.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/24/2023]
Abstract
The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.
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Affiliation(s)
- Barry Trachtenberg
- Houston Methodist Heart and Vascular Center, Methodist J.C. Walter Transplant Center.
| | - Jennifer Cowger
- Medical Director, Mechanical Circulatory Support Program, Codirector, Cardiac Critical Care, Henry Ford Advanced Heart Failure Program.
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2
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Batran RA, Sabri NA, Ali I, Fahmy SF. Cost-Effectiveness of the Pharmacist-Managed Warfarin Therapy vs. Standard Care for Patients With Mechanical Mitral Valve Prostheses: An Egyptian Healthcare Perspective. Front Cardiovasc Med 2022; 9:889197. [PMID: 35911528 PMCID: PMC9327740 DOI: 10.3389/fcvm.2022.889197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
Background Despite warfarin therapy had been used for decades for patients with mechanical mitral valve prostheses (MMVPs), serious and life-threatening complications are still reported worldwide with a significant economic burden. This study is aimed at assessing the clinical and the cost-effectiveness of adopting pharmacist-managed warfarin therapy (PMWT) services for optimizing warfarin treatment in Egypt. Methods A prospective randomized trial in which 59 patients with MMVPs were randomly assigned to receive the PMWT services or the standard care and followed up for 1 year. The primary outcome was percentage time in the therapeutic range (TTR). For the cost-effectiveness analysis, a Markov cohort process model with nine mutually exclusive health states was developed from a medical provider’s perspective. A lifetime horizon was applied. All costs and outcomes were discounted at 3.5% annually. Results The study results revealed a significantly higher median TTR in the intervention group as compared to the control group; 96.8% [interquartile range (IQR) 77.9–100%] vs. 73.1% (52.7–95.1%), respectively, p = 0.008. A significant association between standard care and poor anticoagulation control (p = 0.021) was demonstrated by the multivariate regression analysis. For the cost-effectiveness analysis, the total cumulative quality-adjusted life-years (QALYs) and total costs per patient were 21.53 and 10.43; 436.38 and 1,242.25 United States dollar (USD) in the intervention and the control groups, respectively, with an incremental cost-effectiveness ratio (ICER) of −72.5796 for the intervention group. Conclusion The PMWT strategy was proven to provide a significantly better anticoagulation control and to be a cost-saving approach in Egyptian patients with MMVPs. Nevertheless, the dominance of this strategy is sustained by maintaining the therapeutic International Normalized Ratio (INR) control within the recommended range. Our findings will benefit Egyptian policy-makers who may seek novel health strategies for better resource allocation. Clinical Trial Registration [ClinicalTrials.gov], identifier [NCT04409613].
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Affiliation(s)
- Radwa Ahmed Batran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Nagwa Ali Sabri
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
- *Correspondence: Nagwa Ali Sabri, , orcid.org/0000-0002-2611-4853
| | - Ihab Ali
- Department of Cardiothoracic Surgery, Cardiothoracic Surgery Academy, Ain Shams University, Cairo, Egypt
| | - Sarah Farid Fahmy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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3
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Birk SE, Ingemi A, Bourassa P, Neumann K, Pine C, Seigh M, Cassa H, Sullivan M, Baran DA, Herre JM, Yehya A. Protocol-based anticoagulation management for mechanical circulatory support patients can be safe and efficient. Int J Artif Organs 2022; 45:564-570. [PMID: 35441556 DOI: 10.1177/03913988221093089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Achieving optimal anticoagulation remains a significant challenge in managing patients on left ventricular assist device (LVAD) support. Maintaining tight control of anticoagulation can be time-consuming but essential in preventing serious complications such as pump thrombosis and bleeding. OBJECTIVES The efficacy and safety of a nurse coordinator-driven outpatient protocol (NCDOP) was evaluated for managing anticoagulation for LVAD patients. METHODS A retrospective analysis was performed as part of a single-center quality improvement project. The primary outcome was time in therapeutic range (TTR), a measure of anticoagulation target efficacy before and after the implementation of the protocol. RESULTS Among 47 patients, who served as their own control, there was no significant change in TTR or proportion of hospitalizations following institution of the protocol. Pre-NCDOP, there were six major bleeding and two thrombotic events, and none during the post-NCDOP period. CONCLUSIONS A NCDOP is a reliable method to manage anticoagulation in LVAD patients and facilitates efficient care delivery. Future multicenter studies with larger patient cohorts are warranted to expand on the findings outlined in this manuscript.
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Affiliation(s)
- Sarah E Birk
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | | | | - Karl Neumann
- Sentara Norfolk General Hospital, Norfolk, VA, USA
| | - Carly Pine
- Sentara Norfolk General Hospital, Norfolk, VA, USA
| | - Mindy Seigh
- Sentara Norfolk General Hospital, Norfolk, VA, USA
| | - Hannah Cassa
- Sentara Norfolk General Hospital, Norfolk, VA, USA
| | | | - David A Baran
- Eastern Virginia Medical School, Norfolk, VA, USA.,Sentara Norfolk General Hospital, Norfolk, VA, USA
| | - John M Herre
- Eastern Virginia Medical School, Norfolk, VA, USA.,Sentara Norfolk General Hospital, Norfolk, VA, USA
| | - Amin Yehya
- Eastern Virginia Medical School, Norfolk, VA, USA.,Sentara Norfolk General Hospital, Norfolk, VA, USA
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4
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Nguyen VN, Stevens CA, Brambatti M, Smith M, Braun OO, Mariski M, Pretorius VG, Adler ED, Feist AA. Improved Time in Therapeutic Range with International Normalized Ratio Remote Monitoring for Patients with Left Ventricular Assist Devices. ASAIO J 2022; 68:363-368. [PMID: 34225278 DOI: 10.1097/mat.0000000000001489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Despite advances in therapy, bleeding and thromboembolic events are frequent complications in patients with left ventricular assist device (LVAD) support. Maintaining warfarin in therapeutic range has been shown to be more challenging in this patient population compared to other indications. Patients with LVADs on warfarin typically are within goal international normalized ratio (INR) range 36-57% of the time, compared to about 65% for other indications. The goal of this study was to evaluate if an INR remote monitoring system along with the implementation of a standardized warfarin management protocol improves warfarin time in therapeutic range (TTR) for patients with LVADs. This single-center, retrospective, observational study included 78 patients with LVADs that were followed at our academic center from January 2015 to October 2017. In October 2016, we updated our warfarin management protocol and implemented a remote monitoring system with patients' weekly INR results monitored. The primary objective of the study was to determine the difference between TTRs in remote monitoring versus standard monitoring. We found that the average TTR was significantly higher in the remote monitoring group compared to the standard monitoring cohort (61.1% vs. 40.0%, p < 0.005). However, bleeding, thrombotic incidence, and hospital readmission rates were similar between the two patient cohorts. Remote monitoring improved warfarin TTR significantly in this study and may have the potential to improve anticoagulation-related outcomes in patients with LVADs.
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Affiliation(s)
- Vi N Nguyen
- From the Department of Pharmacy, University of California San Diego, La Jolla, California
| | - Craig A Stevens
- From the Department of Pharmacy, University of California San Diego, La Jolla, California
| | - Michela Brambatti
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Monica Smith
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Oscar O Braun
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Mark Mariski
- From the Department of Pharmacy, University of California San Diego, La Jolla, California
| | - Victor G Pretorius
- Department of Surgery, University of California San Diego, La Jolla, California
| | - Eric D Adler
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Ashley A Feist
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California
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5
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Loyaga-Rendon RY, Kazui T, Acharya D. Antiplatelet and anticoagulation strategies for left ventricular assist devices. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:521. [PMID: 33850918 PMCID: PMC8039667 DOI: 10.21037/atm-20-4849] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Left ventricular assist devices (LVAD) have revolutionized the management of advanced heart failure. However, complications rates remain high, among which hemorrhagic and thrombotic complications are the most important. Antiplatelet and anticoagulation strategies form a cornerstone of LVAD management and may directly affect LVAD complications. Concurrently, LVAD complications influence anticoagulation and anticoagulation management. A thorough understanding of device, patient, and management, including anticoagulation and antiplatelet therapies, are important in optimizing LVAD outcomes. This article provides a comprehensive state of the art review of issues related to antiplatelet and anticoagulation management in LVADs. We start with a historical overview, the epidemiology and pathophysiology of bleeding and thrombotic complications in LVADs. We then discuss platelet and anticoagulation biology followed by considerations prior to, during, and after LVAD implantation. This is followed by discussion of anticoagulation and the management of thrombotic and hemorrhagic complications. Specific problems, including management of heparin-induced thrombocytopenia, anticoagulant reversal, novel oral anticoagulants, artificial heart valves, and noncardiac surgeries are covered in detail.
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Affiliation(s)
| | - Toshinobu Kazui
- Division of Cardiothoracic Surgery, University of Arizona, Tucson, AZ, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona, Tucson, AZ, USA
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6
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Spielmann H, Seemann M, Friedrich N, Tigges-Limmer K, Albert W, Semmig-Könze S, Spitz-Köberich C, Kugler C. Self-management with the therapeutic regimen in patients with ventricular assist device (VAD) support - a scoping review. Heart Lung 2021; 50:388-396. [PMID: 33621837 DOI: 10.1016/j.hrtlng.2021.01.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ventricular assist device (VAD) implantation has become an established treatment strategy for the increasing number of patients with advanced heart failure. Adequate patient self-management becomes essential to prevent adverse events, which could diminish expected outcomes and survival for patients on VAD support. OBJECTIVES The aim of this study was to provide an overview of the current state of evidence concerning self-management in VAD patients through a systematized search and mapping of the literature. METHODS Following the scoping review process, a comprehensive literature search (PubMed, PsychInfo), tabular synthesis of included articles, and data analysis of synthesized findings were performed. RESULTS Overall, twenty articles were included. Results describe the complexity of regular self-management tasks and give direction for specific self-management training. CONCLUSIONS This article represents the first comprehensive overview of available evidence suggesting the need for development and implementation of evidence-based, patient self-management curricula with therapeutic regimen for VAD patients.
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Affiliation(s)
- Hannah Spielmann
- University of Freiburg, Faculty of Medicine, Institute of Nursing Science, Germany.
| | - Maiken Seemann
- University of Freiburg, Faculty of Medicine, Institute of Nursing Science, Germany
| | - Nina Friedrich
- University of Freiburg, Faculty of Medicine, Institute of Nursing Science, Germany
| | | | | | | | | | - Christiane Kugler
- University of Freiburg, Faculty of Medicine, Institute of Nursing Science, Germany.
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7
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Katada Y, Yonezawa A, Utsumi M, Kitada N, Sato YK, Matsumura K, Sukeishi A, Nakagawa S, Imai S, Nakagawa T, Minakata K, Kanemitsu H, Minatoya K, Nomoto S, Matsubara K. Pharmacist-physician collaborative care for outpatients with left ventricular assist devices using a cloud-based home medical management information-sharing system: a case report. J Pharm Health Care Sci 2021; 7:5. [PMID: 33517903 PMCID: PMC7849089 DOI: 10.1186/s40780-020-00188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022] Open
Abstract
Background The standard anticoagulation therapy for patients implanted with left ventricular assist devices (LVADs) includes warfarin therapy. We developed a cloud-based home medical management information-sharing system named as LVAD@home. The LVAD@home system is an application designed to be used on iPad tablet computers. This system enables the sharing of daily information between a patient and care providers in real time. In this study, we reported cases of outpatients with LVADs using this system to manage anticoagulation therapy. Case presentation The patient, a man in his 40s with end-stage heart failure owing to non-ischemic dilated cardiomyopathy, underwent LVAD implantation and warfarin was started on postoperative day 1. He started to use LVAD@home to manage warfarin therapy after discharge (postoperative day 47). He sent his data to care providers daily. By using this system, the pharmacist observed his signs of reduced dietary intake 179 days after discharge, and after consulting the physician, told the patient to change the timing of the next measurement earlier than usual. On the next day, the prothrombin time-international normalized ratio increased from 2.0 to 3.0, and thus the dose was decreased by 0.5 mg. Four patients used this system to monitor warfarin therapy from October 2015 to March 2018. In these patients, the time in therapeutic range was 90.1 ± 1.3, which was higher than that observed in previous studies. Additionally, there were no thromboembolic events or bleeding events. Conclusions The cloud-based home management system can be applied to share real-time patient information of factors, including dietary intake that interact with warfarin. It can help to improve long-term anticoagulation outcomes in patients implanted with LVAD.
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Affiliation(s)
- Yoshiki Katada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Momoe Utsumi
- Department of Health Sciences, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Noriaki Kitada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yu-Ki Sato
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Katsuyuki Matsumura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Asami Sukeishi
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Satoshi Imai
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takayuki Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kenji Minakata
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideo Kanemitsu
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shinichi Nomoto
- Department of Human Health Science, Graduate School of Medicine, Kyoto University, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
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8
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Hollis IB, Doligalski CT, Jennings DJ. Pharmacotherapy for durable left ventricular assist devices. Pharmacotherapy 2021; 41:14-27. [PMID: 33278842 DOI: 10.1002/phar.2491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 12/12/2022]
Abstract
Left ventricular assist devices (LVADs) have revolutionized the care of patients with advanced heart failure, yet still require concomitant medications in order to achieve the best possible clinical outcomes. Since the outset of routine placement of durable, continuous-flow LVADs, much of the medication management of these patients to date has been based on International Society of Heart and Lung Transplantation (ISHLT) guidance, most recently published in 2013. Since 2013, numerous multidisciplinary pharmacotherapy publications have increased the LVAD community's understanding of best practices with respect to medications. We identified the major domains of LVAD medication management and conducted a comprehensive search of US National Library of Medicine MEDLINE® database using keywords chosen to identify medication-related publications of significance dated 2013 or later. Trials pertaining to the HeartMate II™ and the HeartMate™ 3 LVADs (Abbott, Chicago, IL) and the HeartWare™ HVAD™ System (Medtronic, Minneapolis, MN) were chosen for inclusion. Highest priority for inclusion was given to prospective, randomized, controlled studies. Absent these, controlled trials (retrospective or prospective observational) were given next-highest consideration, followed by retrospective uncontrolled studies, and finally case series. Reference lists of qualified publications were reviewed to find any other publications of interest that were not discovered on initial search. Case reports were generally excluded, except where the insight gained was deemed to be uniquely pertinent. This document serves to provide a comprehensive review of the current understanding of optimal medication management in patients with durable, continuous-flow LVADs.
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Affiliation(s)
- Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Christina T Doligalski
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Douglas J Jennings
- Department of Pharmacy Practice, Long Island University, New York-Presbyterian Hospital Columbia University Irving Medical Center, New York, New York, USA
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9
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Vogeler E, Dieterlen MT, Garbade J, Lehmann S, Jawad K, Borger MA, Meyer AL. Benefit of Self-Managed Anticoagulation in Patients with Left Ventricular Assist Device. Thorac Cardiovasc Surg 2020; 69:518-525. [PMID: 33260235 DOI: 10.1055/s-0040-1719153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The exact monitoring of the therapeutic-range international normalized ratio (INR) after left ventricular assist device (LVAD) implantation is an important aim to reduce the risk of thrombosis or bleeding complications. Service providers offer a telemedical anticoagulation service (CS). METHODS We compared LVAD patients using the CS (n = 15) to those who received regular medical care (RMC; n = 15) to investigate if telemedicine supervision increased the INR-specific time in the therapeutic range (TTR) during anticoagulation. All patients received self-management training for phenprocoumon medication according to their INR value. INR values were documented for 12 months. A survey (scale: 1 = not satisfied and 10 = very satisfied) was used to determine patient's satisfaction and psychological well-being. RESULTS A total of 1,798 INR measurements were analyzed. The TTRRosendaal was higher in patients undergoing RMC (78.1 ± 14.3%) compared with that in patients using the CS (58.3 ± 28.0%, p = 0.03). The patient's satisfaction with the coagulation setting at the beginning of the study (RMC: 6.7 ± 3.1, CS: 7.2 ± 3.0, p = 0.74) and psychological wellbeing (RMC: 6.5 ± 1.9, CS: 6.5 ± 2.7, p = 0.97) were comparable between both groups. CONCLUSION We found that INR self-management is superior regarding the efficiency of post-LVAD anticoagulation therapy when compared with telemedical (CS)-based INR management in a small study cohort. Intensive training by experienced staff was able to replace CS.
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Affiliation(s)
- Elisa Vogeler
- Department for Cardiac Surgery, Leipzig Heart Center, HELIOS Clinic, Leipzig, Germany
| | | | - Jens Garbade
- Department for Cardiac Surgery, Leipzig Heart Center, HELIOS Clinic, Leipzig, Germany
| | - Sven Lehmann
- Department for Cardiac Surgery, Leipzig Heart Center, HELIOS Clinic, Leipzig, Germany
| | - Khalil Jawad
- Department for Cardiac Surgery, Leipzig Heart Center, HELIOS Clinic, Leipzig, Germany
| | - Michael A Borger
- Department for Cardiac Surgery, Leipzig Heart Center, HELIOS Clinic, Leipzig, Germany
| | - Anna L Meyer
- Department of Cardiac Surgery, University Hospital, Heidelberg, Germany
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10
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Point-of-Care Testing in Hypercoagulable Conditions Managed With Warfarin. POINT OF CARE 2020. [DOI: 10.1097/poc.0000000000000215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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11
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Nagy M, Tsermpini EE, Siamoglou S, Patrinos GP. Evaluating the current level of pharmacists' pharmacogenomics knowledge and its impact on pharmacogenomics implementation. Pharmacogenomics 2020; 21:1179-1189. [PMID: 33118449 DOI: 10.2217/pgs-2020-0076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The pharmacists' role is potentially vital in the growing field of personalized medicine, and well-defined guidelines and knowledge that support this role need to be established. To address the knowledge gap, over the past two decades, pharmacy schools have started providing pharmacogenomics-related courses, a field that overlaps with pharmacy and personalized medicine. Given the fact that pharmacists lead 50% of the Clinical Pharmacogenetics Implementation Consortium implementers' sites, their role can be particularly crucial to move forward the integration of precision medicine in clinical practice. Herein, we aim to identify the educational challenges for pharmacogenomics integration into clinical practice and their impact on pharmacists' knowledge and confidence, in addition to underscoring pharmacists' role in pharmacogenomics as a whole.
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Affiliation(s)
- Mohamed Nagy
- Department of Pharmaceutical Services, Personalised Medication Management Unit, Children's Cancer Hospital Egypt (57357), Cairo, Egypt
| | | | - Stavroula Siamoglou
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| | - George P Patrinos
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece.,Zayed Center of Health Sciences, United Arab Emirates University, Al-Ain, UAE.,Department of Pathology, College of Medicine & Health Sciences, United Arab Emirates University, Al-Ain, UAE
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12
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Management of anticoagulant therapy using a portable point-of-care international normalized ratio device and social networking service in a patient with a left ventricular assist device. J Cardiol Cases 2020; 22:156-158. [DOI: 10.1016/j.jccase.2020.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 05/03/2020] [Accepted: 05/26/2020] [Indexed: 11/17/2022] Open
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13
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Veenis JF, Brugts JJ. Remote monitoring for better management of LVAD patients: the potential benefits of CardioMEMS. Gen Thorac Cardiovasc Surg 2020; 68:209-218. [PMID: 31981137 DOI: 10.1007/s11748-020-01286-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/31/2019] [Indexed: 12/17/2022]
Abstract
Left ventricular assist devices (LVAD) are frequently used in the treatment of end-stage heart failure (HF), and due to the shortage of heart donors and destination programs, it is likely to keep on growing. Still, LVAD therapy is not without complications and morbidity and rehospitalization rates are high. New ways to improve LVAD care both from the side of the patient and the physician are warranted. Remote monitoring could be a tool to tailor treatment in these patients, as no feedback exists at all about patient functioning on top of the static pump parameters. We aim to provide an overview and evaluation of the novel remote monitoring strategies to optimize LVAD management and elaborate on the opportunities of remote hemodynamic monitoring with CardioMEMS, at home in these patients as the next step to improve care.
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Affiliation(s)
- Jesse F Veenis
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands.
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14
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Bowman S, Weeks P, Chow E, Huang A, Nathan S, Radovancevic R, Kar B, Gregoric I. Implementation of pharmacist‐managed anticoagulation in patients with continuous flow left ventricular assist devices. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Stephanie Bowman
- Department of Pharmacy Memorial Hermann – Texas Medical Center Houston Texas
- Department of Pharmacy Nebraska Medicine Omaha Nebraska
| | - Phillip Weeks
- Department of Pharmacy Memorial Hermann – Texas Medical Center Houston Texas
| | - Elaine Chow
- Department of Pharmacy Memorial Hermann – Texas Medical Center Houston Texas
| | - Athena Huang
- Department of Pharmacy Memorial Hermann – Texas Medical Center Houston Texas
| | - Sriram Nathan
- Center for Advanced Heart Failure University of Texas Health Science Center‐Houston Houston Texas
| | - Rajko Radovancevic
- Center for Advanced Heart Failure University of Texas Health Science Center‐Houston Houston Texas
| | - Biswajit Kar
- Center for Advanced Heart Failure University of Texas Health Science Center‐Houston Houston Texas
| | - Igor Gregoric
- Center for Advanced Heart Failure University of Texas Health Science Center‐Houston Houston Texas
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15
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Urban M, Um J, Moulton M, Stoller D, Zolty R, Lowes B, Macdonald C, McCain N, Siddique A. Recurrent pump thrombosis is common after axial continuous-flow left ventricular assist device exchange. Int J Artif Organs 2019; 43:109-118. [PMID: 31530254 DOI: 10.1177/0391398819876293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In selected patients with left ventricular assist device-associated infection or malfunction, pump exchange may become necessary after conservative treatment options fail and heart transplantation is not readily available. We examined the survival and complication rate in patients (⩾19 years of age) who underwent HeartMate II to HeartMate II exchange at our institution from 1 January 2010 to 28 February 2018. Clinical outcomes were analyzed and compared for patients who underwent exchange for pump thrombosis (14 patients), breach of driveline integrity (5 patients), and device-associated infection (2 patients). There were no differences in 30-day mortality (p = 0.58), need for temporary renal replacement therapy (p = 0.58), right ventricular mechanical support (p = 0.11), and postoperative stroke (p = 0.80) among groups. Survival at 1 year was 90% ± 7% for the whole cohort and 85% ± 10% for those who underwent exchange for pump thrombosis. In patients exchanged for device thrombosis, freedom from re-thrombosis and survival free from pump re-thrombosis at 1 year were 49% ± 16% and 42% ± 15%, respectively. No association of demographic and clinical variables with the risk of recurrent pump thrombosis after the first exchange was identified. Survival after left ventricular assist device exchange compares well with published results after primary left ventricular assist device implantation. However, recurrence of thrombosis was common among patients who required a left ventricular assist device exchange due to pump thrombosis. In this sub-group, consideration should be given to alternative strategies to improve the outcomes.
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Affiliation(s)
- Marian Urban
- University of Nebraska Medical Center, Omaha, NE, USA
| | - John Um
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Ronald Zolty
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Brian Lowes
- University of Nebraska Medical Center, Omaha, NE, USA
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The Impact of Pharmacist-Based Services Across the Spectrum of Outpatient Heart Failure Therapy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:59. [DOI: 10.1007/s11936-019-0750-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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17
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Levesque AA, Lewin AR, Rimsans J, Sylvester KW, Coakley L, Melanson F, Mallidi H, Mehra M, Givertz MM, Connors JM. Development of Multidisciplinary Anticoagulation Management Guidelines for Patients Receiving Durable Mechanical Circulatory Support. Clin Appl Thromb Hemost 2019; 25:1076029619837362. [PMID: 30907120 PMCID: PMC6714942 DOI: 10.1177/1076029619837362] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Patients receiving durable mechanical circulatory support (MCS) require life-long
anticoagulation with a vitamin K antagonist (VKA). Due to alternations in hemostasis,
concomitant therapy with antiplatelet agents and critical illness, they are at increased
risk of thromboembolic and bleeding complications compared with the general population
managed on VKAs. To prevent thrombotic events, current guidelines recommend that patients
with MCS receive long-term anticoagulation with a VKA to maintain a target international
normalized ratio (INR) as specified by device manufacturers, but limited data exist
regarding specific routine management of anticoagulation therapy and its potential
complications. To optimize anticoagulation management and minimize risk in these patients,
we have centralized anticoagulation management in a collaborative approach between the
inpatient hemostatic and antithrombotic (HAT) stewardship service and between ambulatory
anticoagulation management service (AMS) and the advanced heart disease team. Patients are
followed by these three services beginning when the device is implanted and extending the
duration that patients have the device. The teams include multiple clinicians from cardiac
surgery, cardiology, hematology, pharmacy, nursing, case management, nutrition, and
psychiatry, therefore, in order to standardize practice among clinicians without
compromising patient centered decision making, we assembled an interdisciplinary team to
create multiple treatment guidelines. In addition to a centralized and collaborative
approach, our guidelines ensure seamless transitions of care between the inpatient and
outpatient settings. We believe our approach has demontrated a positive improvement in the
care of these challenging patients. In this article, we present our comprehensive
centralized anticoagulation management approach for patients with left ventricular assist
systems (LVAS).
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Affiliation(s)
- Amy A Levesque
- 1 Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrea R Lewin
- 1 Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Jessica Rimsans
- 1 Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Katelyn W Sylvester
- 1 Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Lara Coakley
- 2 Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Frank Melanson
- 2 Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Hari Mallidi
- 3 Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mandeep Mehra
- 2 Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael M Givertz
- 2 Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jean M Connors
- 4 Department of Medicine, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
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18
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Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber G, Hannan MM, Kukucka M, de Jonge N, Loforte A, Lund LH, Mohacsi P, Morshuis M, Netuka I, Özbaran M, Pappalardo F, Scandroglio AM, Schweiger M, Tsui S, Zimpfer D, Gustafsson F. 2019 EACTS Expert Consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg 2019; 56:230-270. [PMID: 31100109 PMCID: PMC6640909 DOI: 10.1093/ejcts/ezz098] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.
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Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
| | - Christiaan Antonides
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Alain Combes
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de médecine intensive-réanimation, Institut de Cardiologie, APHP, Hôpital Pitié–Salpêtrière, Paris, France
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Margaret M Hannan
- Department of Medical Microbiology, University College of Dublin, Dublin, Ireland
| | - Marian Kukucka
- Department of Anaesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonio Loforte
- Department of Cardiothoracic, S. Orsola Hospital, Transplantation and Vascular Surgery, University of Bologna, Bologna, Italy
| | - Lars H Lund
- Department of Medicine Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Solna, Sweden
| | - Paul Mohacsi
- Department of Cardiovascular Surgery Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Mustafa Özbaran
- Department of Cardiovascular Surgery, Ege University, Izmir, Turkey
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Cardiac Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Vita Salute University, Milan, Italy
| | - Martin Schweiger
- Department of Congenital Pediatric Surgery, Zurich Children's Hospital, Zurich, Switzerland
| | - Steven Tsui
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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19
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Hamed S, Schmack B, Mueller F, Ehlermann P, Hittmann D, Ruhparwar A, Katus HA, Raake PW, Kreusser MM. Implementation of an intensified outpatient follow-up protocol improves outcomes in patients with ventricular assist devices. Clin Res Cardiol 2019; 108:1197-1207. [DOI: 10.1007/s00392-019-01451-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
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20
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Impact of time in therapeutic range after left ventricular assist device placement: a comparison between thrombus and thrombus-free periods. J Thromb Thrombolysis 2019; 47:361-368. [DOI: 10.1007/s11239-018-01800-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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21
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McDavid A, MacBrair K, Emani S, Yu L, Lee PHU, Whitson BA, Lampert BC, Agarwal R, Kilic A. Anticoagulation management following left ventricular assist device implantation is similar across all provider strategies. Interact Cardiovasc Thorac Surg 2018; 26:60-65. [PMID: 29049614 DOI: 10.1093/icvts/ivx255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/02/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Thromboembolic and bleeding events are potential complications following left ventricular assist device implantation. A tight control of the international normalized ratio (INR) is believed to be crucial in the reduction of postimplant complications. There is significant variability among institutions as to whether a device implanting centre should be managing the INR. In this study, we evaluated the effect of INR management strategies in maintaining a therapeutic INR. METHODS A retrospective review was utilized to identify patients implanted with either the HeartMate II or the HeartWare HVAD between January 2011 and February 2016. Patients were stratified into 4 groups based on the post-discharge INR management strategy: outside hospital system anticoagulation clinic, outside hospital primary care provider, implanting centre anticoagulation clinic or implanting centre ventricular assist device office. The INR data were collected and analysed for both the early (discharge, 7, 14, 21 and 30 days) and late (3, 6, 9 and 12 months) postoperative periods. RESULTS There were 163 patients identified during the study period who met the study inclusion criteria: 49 (30%) patients were managed by an outside hospital system anticoagulation clinic, 59 (36.2%) patients by an outside hospital physician/primary care provider, 22 (13.5%) patients by the implanting centre anticoagulation clinic and 33 (20.2%) patients by the implanting centre ventricular assist device office. There were no statistically significant differences found between management strategies across all time points. CONCLUSIONS There was no statistically significant difference found between the management strategies examined. Regardless of the chosen INR management strategy, patients have similar INR values and postoperative outcomes.
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Affiliation(s)
- Asia McDavid
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kelly MacBrair
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sitaramesh Emani
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lianbo Yu
- Department of Biomedical Informatics, Center for Biostatistics, Ohio State University, Columbus, OH, USA
| | - Peter H U Lee
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Brent C Lampert
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Riddhima Agarwal
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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22
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International Analysis of LVAD Point-of-Care Versus Plasma INR: A Multicenter Study. ASAIO J 2018; 64:e161-e165. [DOI: 10.1097/mat.0000000000000845] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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23
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Sage W, Gottiparthy A, Lincoln P, Tsui SSL, Pettit SJ. Improving anticoagulation of patients with an implantable left ventricular assist device. BMJ Open Qual 2018; 7:e000250. [PMID: 30306143 PMCID: PMC6173227 DOI: 10.1136/bmjoq-2017-000250] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 08/25/2018] [Accepted: 09/09/2018] [Indexed: 01/14/2023] Open
Abstract
Patients supported with implantable left ventricular assist devices (LVAD) have a significant risk of bleeding and thromboembolic complications. All patients require anticoagulation with warfarin, aiming for a target international normalised ratio (INR) of 2.5 and most patients also receive antiplatelet therapy. We found marked variation in the frequency of INR measurements and proportion of time outside the therapeutic INR range in our LVAD-supported patients. As part of a quality improvement initiative, home INR monitoring and a networked electronic database for recording INR results and treatment decisions were introduced. These changes were associated with increased frequency of INR measurement. We anticipate that changes introduced in this quality improvement project will reduce the likelihood of adverse events during long-term LVAD support.
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Affiliation(s)
- William Sage
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Amulya Gottiparthy
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Paul Lincoln
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Steven S L Tsui
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen J Pettit
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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24
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Hawes EM, Lambert E, Reid A, Tong G, Gwynne M. Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home. Am J Health Syst Pharm 2018; 75:901-910. [DOI: 10.2146/ajhp170174] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Emily M. Hawes
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
- UNC Eshelman School of Pharmacy, Chapel Hill, NC
| | - Erika Lambert
- UNC Medical Center, Chapel Hill, NC
- UNC Eshelman School of Pharmacy, Chapel Hill, NC
| | - Alfred Reid
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Gretchen Tong
- UNC Family Medicine Center, Chapel Hill, NC
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Mark Gwynne
- UNC Health Alliance, Chapel Hill, NC
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
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25
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Nicholson JD, Kaakeh Y. Pharmacotherapy considerations for long-term management of patients with left ventricular assist devices. Am J Health Syst Pharm 2018; 75:755-766. [PMID: 29802111 DOI: 10.2146/ajhp170317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Yaman Kaakeh
- Purdue University College of Pharmacy, West Lafayette, IN
- Indiana University School of Medicine, West Lafayette, IN
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26
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Hawes EM. Patient Education on Oral Anticoagulation. PHARMACY 2018; 6:E34. [PMID: 29677126 PMCID: PMC6025075 DOI: 10.3390/pharmacy6020034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 01/10/2023] Open
Abstract
Given the potential harm associated with anticoagulant use, patient education is often provided as a standard of care and emphasized across healthcare settings. Effective anticoagulation education involves face-to-face interaction with a trained professional who ensures that the patient understands the risks involved, the precautions that should be taken, and the need for regular monitoring. The teaching should be tailored to each patient, accompanied with written resources and utilize the teach-back method. It can be incorporated in a variety of pharmacy practice settings, including in ambulatory care clinics, hospitals, and community pharmacies.
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Affiliation(s)
- Emily M Hawes
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27514, USA.
- University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA.
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27
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Martinez BK, Yik B, Tran R, Ilham S, Coleman CI, Jennings DL, Baker WL. Meta-Analysis of Time in Therapeutic Range in Continuous-Flow Left Ventricular Assist Device Patients Receiving Warfarin. Artif Organs 2018; 42:700-704. [DOI: 10.1111/aor.13116] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 12/01/2022]
Affiliation(s)
| | - Brenda Yik
- University of Connecticut School of Pharmacy, Department of Pharmacy Practice; Storrs CT USA
| | - Raymond Tran
- University of Connecticut School of Pharmacy, Department of Pharmacy Practice; Storrs CT USA
| | - Sabrina Ilham
- University of Connecticut School of Pharmacy, Department of Pharmacy Practice; Storrs CT USA
| | - Craig I. Coleman
- Hartford Hospital, Department of Pharmacy; Hartford CT USA
- University of Connecticut School of Pharmacy, Department of Pharmacy Practice; Storrs CT USA
| | - Douglas L. Jennings
- New York-Presbyterian Hospital, Department of Pharmacy, Columbia University Medical Center; New York NY USA
| | - William L. Baker
- Hartford Hospital, Department of Pharmacy; Hartford CT USA
- University of Connecticut School of Pharmacy, Department of Pharmacy Practice; Storrs CT USA
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28
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29
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Halder LC, Richardson LB, Garberich RF, Zimbwa P, Bennett MK. Time in Therapeutic Range for Left Ventricular Assist Device Patients Anticoagulated With Warfarin: A Correlation to Clinical Outcomes. ASAIO J 2017; 63:37-40. [DOI: 10.1097/mat.0000000000000449] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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30
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Zhou S, Sheng XY, Xiang Q, Wang ZN, Zhou Y, Cui YM. Comparing the effectiveness of pharmacist‐managed warfarin anticoagulation with other models: a systematic review and meta‐analysis. J Clin Pharm Ther 2016; 41:602-611. [PMID: 27677651 DOI: 10.1111/jcpt.12438] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 07/29/2016] [Indexed: 12/01/2022]
Affiliation(s)
- S. Zhou
- Department of Pharmacy Peking University First Hospital Beijing China
| | - X. Y. Sheng
- Department of Pharmacy Peking University First Hospital Beijing China
| | - Q. Xiang
- Department of Pharmacy Peking University First Hospital Beijing China
| | - Z. N. Wang
- Department of Pharmacy Peking University First Hospital Beijing China
| | - Y. Zhou
- Department of Pharmacy Peking University First Hospital Beijing China
| | - Y. M. Cui
- Department of Pharmacy Peking University First Hospital Beijing China
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31
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A multidisciplinary team-based process improves outpatient anticoagulation quality with continuous-flow left-ventricular assist devices. Int J Cardiol 2016; 218:118-119. [DOI: 10.1016/j.ijcard.2016.05.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 11/18/2022]
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32
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Correlation Between Home INR and Core Laboratory INR in Patients Supported with Continuous-Flow Left Ventricular Assist Devices. ASAIO J 2016; 61:386-90. [PMID: 25905496 DOI: 10.1097/mat.0000000000000229] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
It has been well established that patient self-testing (PST) of international normalized ratio (INR) using home monitoring devices increases the average therapeutic time and patient satisfaction. Long-term anticoagulation therapy with warfarin is used in patients with continuous-flow left ventricular assist device (CF-LVAD) to minimize the occurrence of thromboembolic events; however, PST devices have never been tested in patients with CF-LVADs. The purpose of this study was to determine the reliability of the PST device Alere INRatio 2 in patients supported with CF-LVADs. A correlation study was performed in 50 patients with CF-LVAD who were on stable warfarin therapy for a minimum of 3 weeks. Simultaneous INR values were determined from capillary whole blood samples using the Alere PST device and venous blood samples processed in the core laboratory at Columbia University Medical Center. There was a moderate correlation between the venous and the capillary INR values with a correlation coefficient of 0.83. The median difference between the methods was 0.39, with 44 of 50 patients recording higher INRs with Alere. Results remained unchanged after adjusting for use of amiodarone, abnormal hematocrit and liver enzymes, creatinine, and thyroid-stimulating hormone. Point of care testing with Alere correlates moderately well but consistently overestimates INR when compared with conventional laboratory testing in patients with CF-LVAD.
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33
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HeartMate II Left Ventricular Assist Device Geometry on Chest Radiograph Does Not Correlate with Risk of Pump Thrombosis. ASAIO J 2016; 62:128-32. [DOI: 10.1097/mat.0000000000000326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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34
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Management of anticoagulation and antiplatelet therapy in patients with left ventricular assist devices. J Thromb Thrombolysis 2015; 39:337-44. [PMID: 25549823 DOI: 10.1007/s11239-014-1162-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Left ventricular assist devices (LVADs) have increased the survival of patients with advanced heart failure fourfold. Despite these advances, significant bleeding and thrombotic complications occur. Hemorrhage requiring surgery has been reported in up to 30% of adults and 50% of children after LVAD placement. LVAD thrombosis and embolic stroke lead to significant long-term morbidity. Adults are treated with antithrombotic therapy to prevent thrombotic complications, but the amount and intensity of treatment differs between institutions. The goal international normalized ratio for warfarin therapy varies from 1.5 to 3.0. Some physicians manage adult LVAD patients without antiplatelet medication, whereas other adults are treated with aspirin as a single agent or combined with dipyridamole. In contrast, physicians typically manage children with LVADs using the Edmonton Anticoagulation and Platelet Inhibition Protocol, a detailed algorithm for anticoagulation and antiplatelet treatment modified based on thromboelastography results. LVAD implantation causes consumption of coagulation proteins, activation of fibrinolysis, and loss of high molecular weight von Willebrand protein multimers. How these changes in the coagulation system influence the risk of hemorrhage and initiation of thrombosis is unknown. Prospective, controlled studies are needed to determine the antithrombotic regimen that most effectively balances bleeding and thrombosis in LVAD patients.
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35
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Sen I, Stephen E, Agarwal S, Rebekah G, Nair SC. Analytical performance of a point-of-care device in monitoring patients on oral anticoagulation with vitamin K antagonists. Phlebology 2015; 31:660-7. [PMID: 26415605 DOI: 10.1177/0268355515608569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND [Please check the following sentence for clarity: "Point-of-care devices measuring international normalized ratio have clinical appeal, reports of 'off-label' in-hospital/primary care use report improved time to intervention/dose adjustment."]Point-of-care devices measuring international normalized ratio have clinical appeal, reports of 'off-label' in-hospital/primary care use report improved time to intervention/dose adjustment. We evaluated the accuracy and precision of a device for such multiple patient use compared to a reference laboratory. METHODS The point-of-care international normalized ratio result of patients on oral anticoagulation at the Vascular Surgery clinic was compared to the reference to check for statistical and clinical correlation. This was a prospective case-control study design with sample size calculated for sensitivity of 87.5%, precision 5% and desired confidence level 95%. RESULTS There were 168 patients tested; 55% were male, the mean age was 45.4. Sixty per cent were in the target international normalized ratio range. Tests were done for statistical and clinical correlation. The international normalized ratio range using the point-of-care device was 0.8-7.5 (reference lab 0.8-10), mean international normalized ratio was 2.22 ± 1.6 (point-of-care device) compared to 2.46 ± 1.3 (reference lab). The mean absolute difference was 0.79 ± 0.92 and the mean relative difference was 8.1% ± 1.03. Data was analysed using a Bland-Altman plot yielding a mean of 0.738 (standard deviation 0.92). Concordance between the tests was 75% with r2 = 0.52 on linear regression. Using an error grid plot, excellent clinical correlation was seen in 63.8%. In 5.4% major corrective action was needed but potentially missed if relying on the point-of-care device. CONCLUSION The accuracy and precision of this point-of-care device is moderate. It may have potential utility only where access to a reference lab is difficult.
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Affiliation(s)
- Indrani Sen
- Department of Vascular Surgery, Christian Medical College, Vellore, India
| | - Edwin Stephen
- Department of Vascular Surgery, Christian Medical College, Vellore, India
| | - Sunil Agarwal
- Department of Vascular Surgery, Christian Medical College, Vellore, India
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College, Vellore, India
| | - Sukesh Chandran Nair
- Transfusion Medicine and Immunohaematoloy, Christian Medical College, Vellore, India
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Baumann Kreuziger LM, Kim B, Wieselthaler GM. Antithrombotic therapy for left ventricular assist devices in adults: a systematic review. J Thromb Haemost 2015; 13:946-55. [PMID: 25845489 DOI: 10.1111/jth.12948] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) have dramatically increased the survival of adults with end-stage systolic heart failure. However, rates of bleeding and thromboembolism remain high. OBJECTIVES We completed a systematic review to evaluate outcomes of adults with LVADs treated with various anticoagulant and antiplatelet strategies. METHODS Databases were searched using the terms 'assist device', 'thrombosis', and 'anticoagulant' or 'platelet aggregation inhibitor' with appropriate synonyms, device names and manufacturers. RESULTS AND CONCLUSIONS Of 977 manuscripts, 24 articles met the inclusion criteria of adults with implanted LVADs where clinical outcomes were defined based on anticoagulant and/or antiplatelet regimen. Most studies reported treatment with unfractionated heparin post-operatively which was transitioned to a vitamin K antagonist (VKA). Goal INR varied between 1.5-3.5. Antiplatelet regimens ranged from no treatment to dual therapy. Definition of major bleeding differed between trials and incidence varied between 0% and 58%. The available evidence could not demonstrate a clear benefit of aspirin compared with VKA therapy alone [stroke RR 1.02 (95% CI 0.49-2.1)]. There was a suggestion that treatment with aspirin and dipyridamole decreased the risk of thromboembolism compared to aspirin [RR 0.50 (0.36-0.68)], but the comparison is limited by differences in demographics, devices, and INR goals among studies. Additionally, most studies did not blind investigators to outcomes thus contributing to an increased risk for bias. Clinical equipoise exists as to the most appropriate antithrombotic therapy in LVAD patients. Randomization between regimens within a prospective trial is needed to define the treatment regimen that minimizes both bleeding and thrombotic complications.
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Affiliation(s)
- L M Baumann Kreuziger
- Department of Medicine/Hematology and Oncology, Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Kim
- University of California San Francisco, San Francisco, CA, USA
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Owusu-Obeng A, Weitzel KW, Hatton RC, Staley BJ, Ashton J, Cooper-Dehoff RM, Johnson JA. Emerging roles for pharmacists in clinical implementation of pharmacogenomics. Pharmacotherapy 2014; 34:1102-12. [PMID: 25220280 PMCID: PMC4188772 DOI: 10.1002/phar.1481] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pharmacists are uniquely qualified to play essential roles in the clinical implementation of pharmacogenomics. However, specific responsibilities and resources needed for these roles have not been defined. We describe roles for pharmacists that emerged in the clinical implementation of genotype-guided clopidogrel therapy in the University of Florida Health Personalized Medicine Program, summarize preliminary program results, and discuss education, training, and resources needed to support such programs. Planning for University of Florida Health Personalized Medicine Program began in summer 2011 under leadership of a pharmacist, with clinical launch in June 2012 of a clopidogrel-CYP2C19 pilot project aimed at tailoring antiplatelet therapies for patients undergoing percutaneous coronary intervention and stent placement. More than 1000 patients were genotyped in the pilot project in year 1. Essential pharmacist roles and responsibilities that developed and/or emerged required expertise in pharmacy informatics (development of clinical decision support in the electronic medical record), medication safety, medication-use policies and processes, development of group and individual educational strategies, literature analysis, drug information, database management, patient care in targeted areas, logistical issues in genetic testing and follow-up, research and ethical issues, and clinical precepting. In the first 2 years of the program (1 year planning and 1 year postimplementation), a total of 14 different pharmacists were directly and indirectly involved, with effort levels ranging from a few hours per month, to 25-30% effort for the director and associate director, to nearly full-time for residents. Clinical pharmacists are well positioned to implement clinical pharmacogenomics programs, with expertise in pharmacokinetics, pharmacogenomics, informatics, and patient care. Education, training, and practice-based resources are needed to support these roles and to facilitate the development of financially sustainable pharmacist-led clinical pharmacogenomics practice models.
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Affiliation(s)
- Aniwaa Owusu-Obeng
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Pharmacy Department, The Mount Sinai Hospital, New York, New York
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kristin W. Weitzel
- UF Health Personalized Medicine Program, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida
- Clinical & Translational Science Institute, University of Florida, Gainesville, Florida
| | - Randy C. Hatton
- Pharmacy Department, UF Health Shands Hospital, Gainesville, Florida
| | | | - Jennifer Ashton
- Pharmacy Department, UF Health Shands Hospital, Gainesville, Florida
| | - Rhonda M. Cooper-Dehoff
- UF Health Personalized Medicine Program, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Julie A. Johnson
- UF Health Personalized Medicine Program, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida
- Clinical & Translational Science Institute, University of Florida, Gainesville, Florida
- Department of Medicine, University of Florida, Gainesville, Florida
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