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Song Y, Li H, Zhang X, Wang L, Xu HY, Lu ZC, Wang XG, Liu B. Individualized anti-thrombotic therapy for acute myocardial infarction complicated with left ventricular thrombus: A case report. World J Clin Cases 2024; 12:835-841. [PMID: 38322693 PMCID: PMC10841139 DOI: 10.12998/wjcc.v12.i4.835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Presently, there is no established standard anti-blood clot therapy for patients facing acute myocardial infarction (AMI) complicated by left ventricular thrombus (LVT). While vitamin K antagonists are the preferred choice for oral blood thinning, determining the best course of blood-thinning medication remains challenging. It is unclear if non-vitamin K antagonist oral blood thinners have different effectiveness in treating LVT. This study significantly contributes to the medical community. CASE SUMMARY The blood-thinning treatment of a patient with AMI and LVT was analyzed. Triple blood-thinning therapy included daily enteric-coated aspirin tablets at 0.1 g, daily clopidogrel hydrogen sulfate at 75 mg, and dabigatran etexilate at 110 mg twice daily. After 15 d, the patient's LVT did not decrease but instead increased. Clinical pharmacists comprehensively analyzed the cases from the perspective of the patient's disease status and drug interaction. The drug regimen was reformulated for the patient, replacing dabigatran etexilate with warfarin, and was administered for six months. The clinical pharmacist provided the patient with professional and standardized pharmaceutical services. The patient's condition was discharged after meeting the international normalized ratio value (2-3) criteria. The patient fully complied with the follow-up, and the time in the therapeutic range was 78.57%, with no serious adverse effects during pharmaceutical monitoring. CONCLUSION Warfarin proves to be an effective drug for patients with AMI complicated by LVT, and its blood-thinning course lasts for six months.
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Affiliation(s)
- Yan Song
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Hua Li
- Department of Cardiology, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Xia Zhang
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Lei Wang
- Department of Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Hong-Yan Xu
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Zhi-Chao Lu
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Xiao-Gang Wang
- Department of Imaging, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Bo Liu
- Department of Pulmonary and Critical Care Medicine, Department of Clinical Microbiology, Zibo City Key Laboratory of Respiratory Infection and Clinical Microbiology, Zibo City Engineering Technology Research Center of Etiology Molecular Diagnosis, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
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Wong CK, Hai JJ, Lau YM, Zhou M, Lui HW, Lau KK, Chan KH, Mok TM, Liu Y, Feng Y, Tan N, Tam WC, Tam KC, Feng X, Zuo ML, Yin LX, Tan J, Zhang WJ, Jiang X, Huang X, Ye J, Liang Y, Jiang W, Lei Z, Huang D, Yue WS, Tan G, Yan BP, Evora MA, Chen JY, Siu CW. Protocol for Home-Based Solution for Remote Atrial Fibrillation Screening to Prevent Recurrence Stroke (HUA-TUO AF Trial): a randomised controlled trial. BMJ Open 2022; 12:e053466. [PMID: 35840293 PMCID: PMC9295642 DOI: 10.1136/bmjopen-2021-053466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Current international guidelines recommend ECG monitoring after an ischaemic stroke to detect atrial fibrillation (AF) in order to prevent stroke recurrence. However, optimal strategies to detect AF and the downstream management to prevent stroke recurrence remain to be established. The objective of the study was to explore the use of long-term home-based ECG monitoring for AF detection and stroke prevention in patients with a history of stroke. METHODS AND ANALYSIS This prospective, randomised, open-label trial with blinded endpoint adjudication aimed to evaluate the efficacy of long-term home-based ECG monitoring for AF detection and stroke prevention in a 24-month period. Patients aged >18 years with a history of ischaemic stroke will be stratified according to the time from the index ischaemic stroke: <1, 1-3 and >3 years and then randomised in 1:1 to (1) home-based AF screening and (2) control. The home-based AF screening system comprises (1) a handheld single-lead ECG recorder (Comfit Healthcare Devices, Hong Kong SAR, China) and (2) a patient-facing smartphone application specially designed for the study. Patients randomised to the home-based AF group will record a 30 s single-lead ECG using a specially designed handheld ECG device every morning or when symptomatic. All remotely obtained data will be automatically transmitted in real-time through the study smartphone application to a secured cloud hosting and analysed using an artificial intelligence-based diagnostic system. When a diagnosis of AF is made with the system, the patients will be called back for a formal cardiology consultation within 1 week. The primary endpoint is the time to first detection of AF at 24 months of follow-up. Secondary endpoints include recurrent stroke or transient ischaemic attack, initiation of long-term anticoagulation therapy, hospitalisation for heart failure, cardiovascular death and all-cause death. ETHICS AND DISSEMINATION The study protocol has been approved by the institutional review board of The University of Hong Kong, and Hong Kong West Cluster, Hospital Authority, Hong Kong SAR, China. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04523649.
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Affiliation(s)
- Chun Ka Wong
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Jo Jo Hai
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Yuk-Ming Lau
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Mi Zhou
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Hin-Wai Lui
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Kui Kai Lau
- Neurology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Koon-Ho Chan
- Neurology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Toi Meng Mok
- Department of Medicine, Centro Hospitalar Conde de São Januário, Macau, Macau, China
| | - Yong Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Yingqing Feng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Ning Tan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Weng-Chio Tam
- Department of Medicine, Centro Hospitalar Conde de São Januário, Macau, Macau, China
| | - Kun-Chong Tam
- Department of Cardiology, Kiang Wu Hospital, Macau, Macau, China
| | - Xiuhua Feng
- Department of Cardiology, Kiang Wu Hospital, Macau, Macau, China
| | - Ming-Liang Zuo
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
| | - Li-Xue Yin
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
| | - Jing Tan
- Department of Ultrasound in Medicine, Sichuan Provincial People's Hospital Affiliated Wenjiang Hospital, Chengdu, China
| | - Wen-Jun Zhang
- Department of Ultrasound in Medicine, Sichuan Provincial People's Hospital Affiliated Wenjiang Hospital, Chengdu, China
| | - Xiaofei Jiang
- Department of Cardiology, Zhuhai People's Hospital, Zhuhai, China
| | - Xiaoyu Huang
- Department of Cardiology, People's Hospital of Yangjiang, Yangjiang, Guangdong, China
| | - Jianfeng Ye
- Department of Cardiology, Dongguan TCM Hospital, Dongguan, China
| | - Yan Liang
- Department of Cardiology, Maoming People's Hospital, Guangdong, China
| | - Wei Jiang
- Department of Cardiology, Union Shenzhen Hospital, Huazhong University of Science and Technology, Shenzhen, China
| | - Zhen Lei
- Department of Cardiology, Union Shenzhen Hospital, Huazhong University of Science and Technology, Shenzhen, China
| | - Duo Huang
- Medical Imaging Key Laboratory, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Wen-Sheng Yue
- Medical Imaging Key Laboratory, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Guanming Tan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Bryan P Yan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Mario Alberto Evora
- Department of Medicine, Centro Hospitalar Conde de São Januário, Macau, Macau, China
| | - Ji-Yan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
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Zhou M, Chan EW, Hai JJ, Wong CK, Lau YM, Huang D, Lam CC, Tam CCF, Wong YTA, Yung SYA, Chan KWK, Feng Y, Tan N, Chen JY, Yung CY, Lee KL, Choi CW, Lam H, Ng A, Fan K, Jim MH, Yiu KH, Yan BP, Siu CW. Protocol, rationale and design of DAbigatran for Stroke PreVention In Atrial Fibrillation in MoDerate or Severe Mitral Stenosis (DAVID-MS): a randomised, open-label study. BMJ Open 2020; 10:e038194. [PMID: 32978200 PMCID: PMC7520829 DOI: 10.1136/bmjopen-2020-038194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Current international guidelines recommend non-vitamin K oral anticoagulants (NOACs) for stroke prevention among patients with non-valvular atrial fibrillation (AF) at significant ischaemic stroke risk given the superior safety and comparable efficacy of NOACs over warfarin. Nonetheless, the safety and effectiveness of NOACs have not been evaluated in patients with AF with underlying moderate or severe mitral stenosis (MS), hence the recommended stroke prevention strategy remains warfarin therapy. METHOD AND ANALYSIS MS remains disproportionately prevalent in Asian countries compared with the developed countries. This prospective, randomised, open-label trial with blinded endpoint adjudication aims to evaluate the safety and efficacy of dabigatran for stroke prevention in AF patients with moderate or severe MS. Patients with AF aged ≥18 years with moderate or severe MS not planned for valvular intervention in the coming 12 months will be randomised in a 1:1 ratio to receive dabigatran 110 mg or 150 mg two times per day or warfarin with international normalised ratio 2-3 in an open-label design. Patients with estimated creatinine clearance <30 mL/min, or with a concomitant indication for antiplatelet therapy will be excluded. The primary outcome is a composite of stroke and systemic embolism. Secondary outcomes are ischaemic stroke, systemic embolism, haemorrhagic stroke, intracranial haemorrhage, major bleeding and death. The estimated required sample size is approximately 686 participants. ETHICS AND DISSEMINATION The study protocol has been approved by the Institutional Review Board of the University of Hong Kong and Hong Kong West Cluster, Hospital Authority, Hong Kong for Fung Yiu King Hospital, Grantham Hospital, Queen Mary Hospital and Tung Wah Hospital in Hong Kong. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04045093); pre-results.
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Affiliation(s)
- Mi Zhou
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Jo Jo Hai
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chun Ka Wong
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yuk Ming Lau
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Duo Huang
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Cheung Chi Lam
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chor Cheung Frankie Tam
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yiu Tung Anthony Wong
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - See Yue Arthur Yung
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ki Wan Kelvin Chan
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yingqing Feng
- Cardiology Division, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Ning Tan
- Cardiology Division, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Ji-Yan Chen
- Cardiology Division, Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
- Cardiology Division, South China University of Technology, Guangzhou, Guangdong, China
| | - Chi Yui Yung
- Cardiology Division, Department of Medicine and Geriatrics, Ruttonjee and Tang Siu Kin Hospital, Hong Kong, Hong Kong SAR, China
| | - Kwok Lun Lee
- Cardiology Division, Department of Medicine and Geriatrics, Ruttonjee and Tang Siu Kin Hospital, Hong Kong, Hong Kong SAR, China
| | - Chun Wai Choi
- Cardiology Division, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong, Hong Kong SAR, China
| | - Ho Lam
- Cardiology Division, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong, Hong Kong SAR, China
| | - Andrew Ng
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, Hong Kong SAR, China
| | - Katherine Fan
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, Hong Kong SAR, China
| | - Man Hong Jim
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, Hong Kong SAR, China
| | - Kai Hang Yiu
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Bryan P Yan
- Cardiology Division, Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chung Wah Siu
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Shields LBE, Fowler P, Siemens DM, Lorenz DJ, Wilson KC, Hester ST, Honaker JT. Standardized warfarin monitoring decreases adverse drug reactions. BMC FAMILY PRACTICE 2019; 20:151. [PMID: 31699045 PMCID: PMC6836368 DOI: 10.1186/s12875-019-1041-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/21/2019] [Indexed: 12/31/2022]
Abstract
Background While warfarin is the most commonly prescribed medication to prevent thromboembolic disorders, the risk of adverse drug reactions (ADR) poses a serious concern. This prospective study evaluated how primary care providers (PCP) and cardiologists at our Institution managed patients treated with warfarin with the goal of decreasing the number of warfarin ADRs. Methods A multidisciplinary anticoagulation task force was established at our Institution in 2014 to standardize warfarin monitoring and management. Between 2013 and 2017, we analyzed patients who were prescribed warfarin by their PCP or cardiologist upon hospital discharge and in the ambulatory setting to determine the international normalized ratio (INR) within 5, 10, and 30 days after discharge, time in therapeutic range (TTR), number of severe warfarin ADRs, and total and average cost reduction of all severe warfarin ADRs to determine whether there was an organizational cost savings following the implementation of standardized warfarin care. Results The warfarin ADR rate significantly decreased over the 5-year period, from 3.8 to 0.98% (p < 0.0001). The proportion of warfarin prescriptions out of all anticoagulants significantly decreased, from 72.2 to 42.1% (p < 0.001). The proportion of individuals who received an INR at 5, 10, and 30 days after hospital discharge compared to the total number of patients prescribed warfarin significantly increased (p < 0.001). The total cost of severe warfarin ADRs decreased by 57.6% between 2013 and 2017. Conclusions This study serves as a model to reduce the number of severe warfarin ADRs by the following tactics: (1) educating PCPs and cardiologists about evidence-based guidelines for warfarin management, (2) increasing the use of our Institution’s electronic warfarin module, and (3) enhancing patient compliance with obtaining INR.
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Affiliation(s)
- Lisa B E Shields
- Norton Neuroscience Institute, Norton Healthcare, 210 East Gray Street, Suite 1102, Louisville, KY, 40202, USA.
| | - Paula Fowler
- Norton Medical Group, Norton Healthcare, 4801 Olympia Park Plaza, Suite 3000, Louisville, KY, 40241, USA
| | - Diane M Siemens
- Norton Medical Group, Norton Healthcare, 4801 Olympia Park Plaza, Suite 3000, Louisville, KY, 40241, USA
| | - Douglas J Lorenz
- Department of Bioinformatics & Biostatistics, University of Louisville, Louisville, KY, 40292, USA
| | - Kenneth C Wilson
- Norton Medical Group, Norton Healthcare, 4801 Olympia Park Plaza, Suite 3000, Louisville, KY, 40241, USA
| | - Steven T Hester
- Norton Medical Group, Norton Healthcare, 4801 Olympia Park Plaza, Suite 3000, Louisville, KY, 40241, USA
| | - Joshua T Honaker
- Norton Medical Group, Norton Healthcare, 4801 Olympia Park Plaza, Suite 3000, Louisville, KY, 40241, USA
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