Innovative 12 months ticagrelor virtual clinic – supporting appropriate extended dual anti-platelet therapy in post MI

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Khatib ◽  
S Awan ◽  
F Wilson ◽  
A Barrowcliff ◽  
S Wheatcroft ◽  
...  
Keyword(s):  
Risk Factors ◽  
Primary Care ◽  
High Risk ◽  
Funding Source ◽  
Close Monitoring ◽  
Index Point ◽  
High Risk Patients ◽  
Risk Of Bleeding ◽  
Risk Patients ◽  
Virtual Clinic

Abstract Background The ESC and NICE guidelines recommend extended dual antiplatelet therapy (DAPT) with Ticagrelor 60mg twice a day for 3 years after 12 months of a myocardial infarction (MI) among high risk patients with low risk of bleeding. As those patients in our health system are not routinely reviewed by a cardiologist, we introduced a 12 months Virtual Review clinic to support primary care in ensuring that appropriate patients are offered extended DAPT. Methods Working with primary care, a group for cardiologists and cardiology pharmacists established a clear guidance and pathway for identifying patients who are suitable for extended DAPT with Ticagrelor 60mg twice a day for 3 years inline with ESC guidelines. A virtual review clinic was established where primary care can refer potential candidates to be considered for extended DAPT. Patients needed to have had an MI approximately 12 months before the referral, have uptodate full blood counts and creatinine. Patients were reviewed virtually by a cardiology pharmacist against an agreed protocol. Patient risk factors and eligibility were identified and their risk of bleeding was assessed using the PRECISE-DAPT scoring. Complicated patients were discussed with a cardiologist and the final recommendation was sent to primary care electronically. Results 201 patients were reviewed in the virtual clinic; Mean age 69, 58% were males. 60% had NSTEMI, 37% STEMI, and the rest had either Unstable Angina or Type II MI. 28% had diabetes, 22% had prior MI, 60% had multivessel disease, and 22% were anaemic. 93% of patients had at least one high risk factor according to PEGASUS trial. 33% (n=67) of all patients reviewed were high risk of bleeding according to PRECISE-DAPT. Of these 78% (n=52) were not suitable to extended DAPT despite 71% (n=37) having risk factors. The virtual clinic recommended extended DAPT for 40% (n=81) of patients referred. In the case of 15 patients extended DAPT was recommended despite High risk of bleeding as deemed appropriate by the MDT with close monitoring. At discharge post index point, 18% (n=37) had recommendations to extend DAPT or not by the interventionist. 11% (n=4) of those recommendations were reversed at the 12 months review. 40% (n=80) of patients reviewed in clinic were inappropriately on Ticagrelor 90mg twice a day (with aspirin) beyond 12 months post MI. That is a total of 556 months of excess ticagrelor. 19 patients were HIGH risk of bleeding Discussion and conclusion The multidisciplinary innovative 12 months virtual review clinic improved appropriate initiation of extended DAPT in high risk patients and reduced risk of bleeding by stopping inappropriate antiplatelet dosing (90mg vs. 60mg). The clinic supported the low levels of recommendations made by the interventionist at index point and assured safety when actioning these recommendations. The virtual review clinic improved levels of extended DAPT prescribing and improved patient safety. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): This is a service development project funded by the Leeds NHS Community Commissioning Group

scholarly journals Uptake and detection rate of a stepwise cardiometabolic disease detection program in primary care—a cohort study

2019 ◽  
Vol 30 (3) ◽  
pp. 402-407
Author(s):  
Daphne M Stol ◽  
Monika Hollander ◽  
Ilse F Badenbroek ◽  
Mark M J Nielen ◽  
François G Schellevis ◽  
...  
Keyword(s):  
Risk Factors ◽  
Primary Care ◽  
Cohort Study ◽  
High Risk ◽  
Newly Diagnosed ◽  
Additional Risk ◽  
High Risk Patients ◽  
Detection Program ◽  
Risk Patients

Abstract Background Early detection and treatment of cardiometabolic diseases (CMD) in high-risk patients is a promising preventive strategy to anticipate the increasing burden of CMD. The Dutch guideline ‘the prevention consultation’ provides a framework for stepwise CMD risk assessment and detection in primary care. The aim of this study was to assess the outcome of this program in terms of newly diagnosed CMD. Methods A cohort study among 30 934 patients, aged 45–70 years without known CMD or CMD risk factors, who were invited for the CMD detection program within 37 general practices. Patients filled out a CMD risk score (step 1), were referred for additional risk profiling in case of high risk (step 2) and received lifestyle advice and (pharmacological) treatment if indicated (step 3). During 1-year follow-up newly diagnosed CMD, prescriptions and abnormal diagnostic tests were assessed. Results Twelve thousand seven hundred and thirty-eight patients filled out the risk score of which 865, 6665 and 5208 had a low, intermediate and high CMD risk, respectively. One thousand seven hundred and fifty-five high-risk patients consulted the general practitioner, in 346 of whom a new CMD was diagnosed. In an additional 422 patients a new prescription and/or abnormal diagnostic test were found. Conclusions Implementation of the CMD detection program resulted in a new CMD diagnosis in one-fifth of high-risk patients who attended the practice for completion of their risk profile. However, the potential yield of the program could be higher given the considerable number of additional risk factors—such as elevated glucose, blood pressure and cholesterol levels—found, requiring active follow-up and presumably treatment in the future.

Behavioral Emergencies and Crises

2010 ◽  
pp. 739-762
Author(s):  
Phillip M. Kleespies ◽  
Justin M. Hill
Keyword(s):  
Mental Health ◽  
Risk Factors ◽  
High Risk ◽  
Work Environment ◽  
Emotional Impact ◽  
High Risk Patients ◽  
Risk Patients ◽  
Life Threatening ◽  
Behavioral Emergencies ◽  
And Training

This chapter illustrates the mental health clinician’s relationship with behavioral emergencies. The chapter begins by distinguishing the terms behavioral emergency and behavioral crisis, and underlying themes among all behavioral emergencies are identified. Given that most clinicians will face a behavioral emergency in their careers, the importance of enhancing the process of educating and training practitioners for such situations far beyond the minimal training that currently exists is highlighted. The chapter continues by exploring various aspects of evaluating and managing high-risk patients (i.e., those who exhibit violent tendencies toward themselves or others, and those at risk for victimization). It includes a discussion of the benefits and limitations to estimating life-threatening risk factors and specific protective factors. The chapter concludes by discussing the emotional impact that working with high-risk patients has on clinicians, and an emphasis is placed on the importance of creating a supportive work environment.

Long-term outcomes of Japan-specific dosage of rivaroxaban in high-risk patients with non-valvular atrial fibrillation: analysis from the XAPASS

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T Ikeda ◽  
S Ogawa ◽  
T Kitazono ◽  
J Nakagawara ◽  
K Minematsu ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Major Bleeding ◽  
Factor Xa ◽  
Incidence Rates ◽  
Funding Source ◽  
High Risk Patients ◽  
Reduced Dose ◽  
Risk Patients

Abstract Background XAPASS is a real-world, prospective, single-arm, observational study conducted as a post-marketing surveillance mandated by the health authority in Japan. Nowadays, direct oral anticoagulant therapy using factor Xa or thrombin inhibitor has been the standard of care for patients with non-valvular atrial fibrillation (NVAF) to prevent ischemic stroke. However, the clinical impact of reduced dosage (approved dose of 15 or 10 mg once daily in Japan is relatively reduced compared to global dosage) factor Xa inhibitor rivaroxaban in high-risk patients remains unclear. Purpose The present sub-analysis of XAPASS was carried out to assess long-term safety and effectiveness of reduced-dose rivaroxaban in high-risk NVAF patients for bleeding and thromboembolism. Methods All patients with NVAF who were newly started on rivaroxaban were eligible for surveillance. The principal safety outcome was a composite of major and non-major bleeding events, and the primary effectiveness outcome was a composite of ischaemic stroke, haemorrhagic stroke, non-central nervous system systemic embolism (non-CNS SE), and myocardial infarction (MI). In this present sub-analysis, high-risk patients were defined as those who had two of the following three risk factors: elderly (≥75 years old), low body weight (≤50 kg), and renal impairment (CrCl <50 mL/min). Results In total, 11,308 patients were enrolled between April 2012 and June 2014 from 1,419 hospitals, and overall data were analysed from 10,664 patients from whom data were collected. Among them, 3,694 patients matched the criteria for the high-risk patients defined in this sub-analysis, and 6,970 patients did not match the criteria (non-high-risk patients). The mean treatment duration was 791±673 days in the high-risk patients and 944±709 days in the non-high-risk patients. Mean patient age was 80.9±5.5 years and 69.0±9.0 years at baseline, respectively. Mean CHADS2 score was 2.8 and 1.8, and CHA2DS2-VASc score was 4.4 and 2.9, respectively. The rates of CHADS2 component comorbidities were lower in the non-high-risk patients except for diabetes mellitus. The incidence rates of any bleeding, major bleeding, and the primary effectiveness outcomes were 4.8, 1.6, and 2.1%/patient-year in the high-risk patients. The incidence rates of these clinical events in the non-high-risk patients were 3.3, 0.9, and 1.0%/patient-year, respectively. Conclusions Incidence rates of long-term bleeding and thromboembolism were higher in the high-risk patients than in the non-high-risk patients. However, the rates of these outcomes using the Japan-specific reduced dose were not so high. Furthermore, the balance between safety and effectiveness outcomes was within an acceptable range. The present study provides useful information for physicians to stratify high-risk patients using the reduced dose in daily clinical practice. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Bayer Yakuhin Ltd.

scholarly journals Prevention of Hypotension following Spinal Anaesthesia in Caesarean Section - then and now

2012 ◽  
Vol 8 (4) ◽  
pp. 415-419
Author(s):  
J K Mitra
Keyword(s):  
Risk Factors ◽  
Clinical Practice ◽  
High Risk ◽  
Caesarean Section ◽  
Spinal Anaesthesia ◽  
Limited Data ◽  
First Line ◽  
High Risk Patients ◽  
Risk Patients ◽  
Poor Efficacy

Hypotension during spinal anaesthesia for caesarean section remains a common scenario in our clinical practice. Certain risk factors play a role in altering the incidence of hypotension. Aortocaval compression counteraction does not help to prevent hypotension. Intravenous crystalloid prehydration has poor efficacy; thus, the focus has changed toward co-hydration and use of colloids. Phenylephrine is established as a first- line vasopressor, although there are limited data from high-risk patients. Ephedrine crosses the placenta more than phenylephrine and cause possible alterations in the foetal physiology.http://dx.doi.org/10.3126/kumj.v8i4.6242 Kathmandu Univ Med J 2010;8(4):415-19   

Improving harm reduction with a naloxone intervention in primary care to prescribe and educate a support person

2021 ◽  
Vol 17 (2) ◽  
pp. 109-113
Author(s):  
Julienne K. Kirk, PharmD, CDE, BCPS ◽  
Matthew Q. Tran, PharmD ◽  
Samantha Pelc, PharmD ◽  
Katherine G. Moore, PharmD, BCPS, BCACP
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Family Medicine ◽  
Quality Improvement Intervention ◽  
Opioid Overdose ◽  
Naloxone Administration ◽  
Support Person ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

Objective: To determine whether a pharmacist-led intervention would increase the number of naloxone prescriptions and naloxone administration education in a primary care family medicine setting.Design: Prospective quality improvement intervention in an academic family medicine clinic.Methods: We surveyed providers about naloxone knowledge, prescribing habits, and prescribing barriers. We identified patients on chronic opioid therapy, through electronic health records for the year 2019. Overdose risk categories based upon morphine milligram equivalent doses and concomitant benzodiazepine use were used to determine patients who met criteria for naloxone. Pharmacists phoned qualified patients to discuss overdose risk and naloxone benefits. Patients who accepted naloxone prescriptions used their local pharmacy through a department-approved standing order set.Results: From the survey results, there were 47 of 54 provider responses, and the majority noted that they do not routinely prescribe naloxone in high-risk patients. The predominant barriers were lack of time during visit and naloxone administration education. The population of patients from chart review included 93 high-risk patients with a mean age of 58 years. During the time of intervention, 71 patients remained eligible for naloxone coprescribing. Of the patients contacted, 29 (40 percent) accepted the intervention prescription, and subsequently, 22 picked up their prescription from the pharmacy. Sixteen received counseling with a support person. Twelve patients had naloxone already at home, and two received counseling with a support person.Conclusion: The naloxone prescribing intervention is achievable. The results of this intervention support identifying patients at increased risk of opioid overdose and offer education of a support person for naloxone in a large academic family medicine clinic.

Using mHealth tools to improve access, coverage and treatment of uninsured people with high cardiovascular disease risk in Argentina: a study protocol for a pragmatic cluster randomised trial

2018 ◽  
Vol 4 (3) ◽  
pp. 135-141 ◽  
Author(s):  
Shafika Abrahams-Gessel ◽  
Andrea Beratarrechea ◽  
Vilma Irazola ◽  
Laura Gutierrez ◽  
Daniela Moyano ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Primary Care ◽  
High Risk ◽  
Randomised Trial ◽  
Text Messages ◽  
Cluster Randomised Trial ◽  
Cvd Risk ◽  
High Risk Patients ◽  
Cluster Randomised ◽  
Risk Patients

IntroductionCardiovascular disease (CVD) accounts for approximately one-third of Argentina’s deaths. Despite government provision of free primary care health services to the uninsured population, with a focus on non-communicable diseases, screening and management of those with high CVD risk at primary care clinics (PCCs) remain low.Methods and analysisThis pragmatic cluster randomised trial will take place in two provinces of Argentina and will recruit 740 participants. Eight PCCs will be randomised to either the intervention or current practice arm. Community health workers (CHWs) in the intervention arm will be trained to use a set of integrated mHealth tools (a validated risk screening tool mobile application; electronic scheduling system using wireless access to PCCs; and educational text messages) to screen for CVD and to schedule appointments with primary care providers for persons with high CVD risk (≥10%). The primary aims of this study are to determine if the use of mHealth tools will (1) increase attendance of first appointments scheduled by CHWs for persons determined to have high risk for CVD during screening and, (2) lead to an increase in follow-up visits at PCCs by high risk patients. Secondary outcomes include assessing the proportion of high-risk patients receiving appropriate medications and a cost-effective analysis of the intervention.Ethics and disseminationThis study has been approved by the Institutional Review Boards at Partners/Brigham and Women’s Hospital (USA) and the Hospital Italiano de Buenos Aires (Argentina). The open-source software for the mHealth tools will be made publicly available at the end of the study.Trial registration numberNCT02913339.

Guidelines for the Management of Pediatric and Adult Tumor Lysis Syndrome: An Evidence-Based Review

2008 ◽  
Vol 26 (16) ◽  
pp. 2767-2778 ◽  
Author(s):  
Bertrand Coiffier ◽  
Arnold Altman ◽  
Ching-Hon Pui ◽  
Anas Younes ◽  
Mitchell S. Cairo
Keyword(s):  
At Risk ◽  
High Risk ◽  
Tumor Lysis Syndrome ◽  
The United States ◽  
Standards Of Care ◽  
Close Monitoring ◽  
Tumor Lysis ◽  
High Risk Patients ◽  
Patients At Risk ◽  
Risk Patients

PurposeTumor lysis syndrome (TLS) has recently been subclassified into either laboratory TLS or clinical TLS, and a grading system has been established. Standardized guidelines, however, are needed to aid in the stratification of patients according to risk and to establish prophylaxis and treatment recommendations for patients at risk or with established TLS.MethodsA panel of experts in pediatric and adult hematologic malignancies and TLS was assembled to develop recommendations and guidelines for TLS based on clinical evidence and standards of care. A review of relevant literature was also used.ResultsNew guidelines are presented regarding the prevention and management of patients at risk of developing TLS. The best management of TLS is prevention. Prevention strategies include hydration and prophylactic rasburicase in high-risk patients, hydration plus allopurinol or rasburicase for intermediate-risk patients, and close monitoring for low-risk patients. Primary management of established TLS involves similar recommendations, with the addition of aggressive hydration and diuresis, plus allopurinol or rasburicase for hyperuricemia. Alkalinization is not recommended. Although guidelines for rasburicase use in adults are provided, this agent is currently only approved for use in pediatric patients in the United States.ConclusionThe potential severity of complications resulting from TLS requires measures for prevention in high-risk patients and prompts treatment in the event that symptoms arise. Recognition of risk factors, monitoring of at-risk patients, and appropriate interventions are the key to preventing or managing TLS. These guidelines should assist in the prevention of TLS and improve the management of patients with established TLS.

Risk Factors for Post-ERCP Pancreatitis in High-Risk Patients Receiving Post-procedure Rectal Indomethacin

2018 ◽  
Vol 22 (11) ◽  
pp. 1903-1910
Author(s):  
Xiaoyu Kang ◽  
Liyue Zheng ◽  
Wei Zeng ◽  
Shengye Yang ◽  
Hao Sun ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
High Risk Patients ◽  
Post Procedure ◽  
Risk Patients ◽  
Rectal Indomethacin

Abstract P275: Demographic and Clinical Profile of Patients with Risk Factors for Coronary Heart Disease (CHD) Defined by National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III Guidelines

Circulation ◽  
2014 ◽  
Vol 129 (suppl_1) ◽  
Author(s):  
David M Kern ◽  
Sanjeev Balu ◽  
Ozgur Tunceli ◽  
Swetha Raparla ◽  
Deborah Anzalone
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Risk Groups ◽  
Lipid Lowering ◽  
High Risk Patients ◽  
Low Hdl ◽  
Risk Patients ◽  
Artery Disease ◽  
Very High ◽  
Statin Use

Introduction: This study aimed to compare the demographic and clinical characteristics of patients with different risk factors for CHD as defined by NCEP ATP III guidelines. Methods: Dyslipidemia patients (≥1 medical claim for dyslipidemia, ≥1 pharmacy claim for a statin, or ≥1 LDL-C value ≥100 mg/dL [index date]) aged ≥18 y were identified from the HealthCore Integrated Research Environment from 1/1/2007-7/31/2012. Patients were classified as low risk (0 or 1 risk factor): hypertension, age ≥45 y [men] or ≥55 y [women], or low HDL-C), moderate/moderately high risk (≥2 risk factors), high risk (having CHD or CHD risk equivalent), or very high risk (having ACS or other established cardiovascular disease plus diabetes or metabolic syndrome). Demographics, comorbidities, medication use and lipid levels during the 12 months prior, and statin use during the 6 months post-index date were compared across risk groups (very high vs each other risk group). Results: There were 1,524,351 low-risk (mean age: 47 y; 45% men), 242,357 moderate-risk (mean age: 58 y; 59% men), 188,222 high-risk (mean age: 57 y; 52% men), and 57,469 very-high-risk (mean age: 63 y; 61% men) patients identified. Mean Deyo-Charlson comorbidity score differed greatly across risk strata: 0.20, 0.33, 1.26, and 2.22 from low to very high risk (p<.0001 for each). Compared with high-risk patients, very-high-risk patients had a higher rate of ischemic stroke: 5.4% vs 4.1%; peripheral artery disease: 17.1% vs 11.6%; coronary artery disease: 8.5% vs 8.2%; and abdominal aortic aneurysm: 2.3% vs 2.0% (p<.05 for each). Less than 1% of the total population had a prior prescription for each non-statin lipid-lowering medication (bile acid sequestrants, fibrates, ezetimibe, niacin, and omega-3). Very-high-risk patients had lower total cholesterol (very-high-risk mean: 194 mg/dL vs 207, 205, and 198 mg/dL for low-, moderate-/moderately-high-, and high-risk patients, respectively) and LDL-C (very-high-risk mean: 110 mg/dL vs 126, 126, and 116 mg/dL for the other risk groups; p<.0001 for each); higher triglycerides (TG) (very-high-risk mean: 206 mg/dL vs 123, 177, and 167 mg/dL for the other groups; p<.0001 for each); and lower HDL-C (very-high-risk mean: 45 mg/dL vs 57 [p<.0001], 45 [p=.006], and 51 mg/dL [p<.0001]). Statin use was low overall (15%), but higher in the very-high-risk group (45%) vs the high- (29%), moderate-/moderately-high- (18%), and low- (12%) risk groups (p<.0001 for each). Conclusions: Despite a large proportion of patients having high lipid levels, statin use after a dyslipidemia diagnosis was low: ≥80% of all patients (and more than half at very high risk) failed to receive a statin, indicating a potentially large population of patients who could benefit from statin treatment. Prior use of non-statin lipid-lowering medications was also low considering the high TG and low HDL-C levels among high-risk patients.

Abstract 78: Risk Factors Associated with Failure of Aggressive Medical Therapy in the SAMMPRIS Trial

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Michael F Waters ◽  
Brian L Hoh ◽  
Michael J Lynn ◽  
Tanya N Turan ◽  
Colin P Derdeyn ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Medical Therapy ◽  
Primary Endpoint ◽  
Univariate Analysis ◽  
Baseline Risk ◽  
Medical Group ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

Background: The SAMMPRIS trial showed that aggressive medical therapy was more effective than stenting for preventing stroke in high-risk patients with symptomatic intracranial stenosis. However, 15% of patients in the medical group still had a primary endpoint (any stroke or death within 30 days of enrollment or stroke in the territory beyond 30 days) during a median follow-up of 32.7 months. We sought to determine baseline risk factors that were associated with a primary endpoint in the medical arm of SAMMPRIS. Methods: Data on 227 patients randomized to the medical group in SAMMPRIS were analyzed. Baseline demographic features, vascular risk factors, qualifying event, brain imaging and angiographic features were analyzed. The hazard ratio and p-value from a Cox proportional hazard regression model relating time until a primary endpoint to each factor were calculated. Results: Female gender, diabetes, stroke as the qualifying event (especially non-penetrator stroke), old infarct in the territory of the stenotic artery, and > 80% stenosis were associated (p < 0.10) with a higher risk of the primary endpoint on univariate analysis (see accompanying table) (multivariate analysis will be available by the time of ISC). Variables not associated with a higher risk of a primary endpoint in the medical arm included: age, race, antithrombotic therapy at the time of a qualifying event, time from qualifying event to enrollment (< 7 days vs. > 7 days), and location of stenosis. Conclusions: Several features were associated with an increased risk of the primary endpoint in the medical group in SAMMPRIS. On univariate analysis, the most important risk factors were an old infarct in the territory of the stenotic artery and stroke (especially non-penetrator stroke) as the qualifying event. These features will be useful for identifying particularly high-risk patients who should be targeted for future clinical trials testing alternative therapies to aggressive medical management.

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