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Background: The initial management of acute aortic dissection centers around rapid control of blood pressure and heart rate, commonly requiring initiation of continuous intravenous (IV) antihypertensive agents and intensive care unit (ICU) admission. However, there is limited guidance for when and how to transition off IV infusions to enteral agents, potentially extending ICU length of stay (LOS) in stable patients who are otherwise ready for floor transfer. The objective of this study is to compare the impact of rapid vs. slow transition from IV to enteral vasoactive medications on ICU LOS. Methods: In this retrospective cohort study of 56 adult patients admitted with aortic dissection requiring IV vasoactive infusions for >6 hours, patients were grouped by time required to fully transition from IV to enteral vasoactive agents. Patients who transitioned in ≤72 hours were considered the "rapid" group, and the "slow" group required >72 hours to fully convert. The primary endpoint was ICU LOS. Results: For the primary endpoint, the median ICU LOS was 3.6 days for the "rapid" group, compared to 7.7 days in the "slow" group (P<0.001). The "slow" group required a significantly longer duration of IV vasoactive infusions (115.7 vs. 36.0 hours, P<0.001) and also trended towards longer median hospital LOS. The two cohorts had similar incidences of hypotension. Conclusions: In this study, rapid transition to enteral antihypertensives within 72 hours was associated with a shorter ICU LOS without an increase in hypotension.

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BACKGROUND/OBJECTIVE: Direct-acting oral anticoagulants (DOACs) are increasingly used to prevent or treat thromboembolism. We conducted a study to compare how well initial DOAC prescribing for adult inpatients adhered to dosing recommendations approved by the US Food and Drug Administration (FDA). DESIGN: Retrospective analysis. SETTING: Single academic medical center, July 1, 2014 to June 30, 2015. PATIENTS: 508 adult inpatients. MEASUREMENTS: DOAC prescriptions were evaluated to determine whether they met FDA-recommended dosing and administration according to patient age, weight, sex, race, kidney function, diagnoses, and concomitant medications. RESULTS: DOACs were prescribed in 635 admissions (247 apixaban, 97 dabigatran, 291 rivaroxaban). The indication was atrial fibrillation/flutter in 465 admissions (8% with bioprostheses or valve repair), chronic deep vein thrombosis (DVT) in 67, acute DVT in 32, chronic pulmonary embolism in 23, acute pulmonary embolism in 19, DVT prevention after hip or knee surgery in 19, and non-FDA-approved indications in 10. Sixteen percent of orders for venous thromboembolic disease were for patients with active malignancy. Dosages not concordant with recommendations were prescribed for apixaban in 18% of admissions, for rivaroxaban in 14%, and for dabigatran in 7% (𝑃 = 0.04). Lower than recommended dosing was more common than higher than recommended dosing (𝑃 < 0.05). Half the deviations were continuations of outpatient dosing. Atrial fibrillation/flutter and post-hip or -knee surgery dosing deviations were more common than venous thromboembolic disease deviations (𝑃 < 0.001) but were not related to prescriber specialty. CONCLUSIONS: DOAC prescribing recommendation deviations that can affect clinical efficacy were identified. Education and point-of-care decision support tools for improving dosing are needed, as are outcome data for patients who receive DOACs at lower than recommended dosing or for off-label indications.

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PURPOSE: Disease management programs have been associated with improved adherence to heart failure (HF) medications. However, there remain limited data on the benefit of a comprehensive multidisciplinary HF postdischarge management (PDM) clinic that promptly follows HF-related hospitalization on evidence-based HF medication adherence. OBJECTIVE: The aim of this study was to evaluate the effects of an HF-PDM clinic on adherence to evidence-based HF medication therapy. METHODS: In this retrospective cohort study, we identified patients discharged from the Veterans Affairs Greater Los Angeles Healthcare System between 2009 and 2012 with a primary diagnosis of HF. Data from patients who attended the HF-PDM clinic immediately following HF-related hospitalization between 2010 and 2012 were compared with those from historical controls, who did not attend the HF-PDM clinic, from 2009. The main outcome was adherence to evidence-based HF medications during the 90 days after discharge. Adherence was defined as the proportion of days covered at 90 days after discharge (PDC-90) of ≥0.80. The percentages of patients adherent to each medication were compared between the 2 groups using the χ2 test. A logistic regression model adjusted for potential confounding variables was constructed to evaluate the percentages of patients adherent to evidence-based HF medications. FINDINGS: A total of 277 patients (144 clinic, 133 control) were included in the study. Both univariate and multivariate analyses showed that the clinic was associated with improved medication adherence to angiotensin-converting enzyme inhibitors, a twice-daily ß-blocker, and aldosterone antagonists compared with controls. The most significant increases were in adherence to angiotensin-converting enzyme inhibitors, with mean PDC-90 values of 0.84 (control) versus 0.93 (clinic) (P = 0.008) and 90-day adherence rates of 69% (control) versus 87% (clinic) (P = 0.005). IMPLICATIONS: Care in the multidisciplinary HF-PDM clinic was associated with significant increases in 90-day adherence to evidence-based HF medications in patients who were recently discharged after an HF-related hospitalization.

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BACKGROUND: Specialized chronic heart failure (HF) clinics have demonstrated significant reductions in readmissions. Limited evidence is available regarding HF clinics in the immediate post-discharge period. OBJECTIVE: To evaluate the effect of a multidisciplinary HF clinic on 90-day readmission rates and all-cause mortality in those recently discharged from a HF hospitalization. METHODS: In this retrospective cohort study, patients discharged with a primary HF diagnosis who attended the HF postdischarge clinic in 2010-2012 were compared with controls from 2009. During 6 clinic visits, patients were seen by a physician assistant, clinical pharmacist specialist, and case manager, with care overseen by a cardiologist. The program focused on optimizing therapy, identifying HF etiology/precipitating factors, medication titration, education, and medication adherence. The primary outcome was 90-day HF readmission. A multivariate Cox proportional hazards model was used to compare outcomes. RESULTS: Among the 277 patients (144 clinic, 133 control) in the study, 7.6% of patients in the clinic and 23.3% of patients in the control group were readmitted for HF within 90 days (aHR (adjusted hazard ratio) = 0.17; 95% CI = 0.07-0.41; P < 0.001; ARR (absolute risk reduction) = 15.7%; NNT (number needed to treat) = 7). Clinic patients had lower 90-day time-to-first HF readmission or all-cause mortality (9.0% vs 28.6%; aHR = 0.28; 95% CI = 0.06-0.31; P < 0.001; ARR = 19.6%; NNT = 6). CONCLUSIONS: The multidisciplinary HF posthospitalization outpatient program was associated with a significant reduction in 90-day HF readmissions in patients who were recently discharged from a HF hospitalization.

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OBJECTIVE: To evaluate the evidence for the use of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel following coronary artery bypass graft (CABG) surgery. DATA SOURCES: Literature was accessed through PubMed (1950-November 2011), EMBASE (1976-November 2011), and the Cochrane databases using the terms clopidogrel and coronary artery bypass graft. Citations from available articles were used for additional references and ClinicalTrials.gov was accessed for abstracts of ongoing studies. STUDY SELECTION AND DATA EXTRACTION: Peer-reviewed studies that evaluated DAPT use after CABG surgery in adult humans were assessed for inclusion. DATA SYNTHESIS: Four randomized clinical trials evaluating surrogate end points and 9 studies (3 subgroup analyses, 6 observational) evaluating clinical outcomes were reviewed. Three clinical trials assessing surrogate end points failed to demonstrate an improvement in graft patency with DAPT use, while 1 clinical trial found an increase in graft patency. As for clinical outcomes, 1 subgroup analysis demonstrated that the benefit of DAPT post-CABG after a non-ST-elevation acute coronary syndrome diminished following surgery, while an observational study demonstrated a trend toward decreased mortality. In post-CABG patients who did not experience acute coronary syndrome, 2 subgroup analyses proved inconclusive and an observational study found DAPT use to be associated with reducing in-hospital mortality, while another observational study was not associated with reduced long-term mortality. Three observational studies in off-pump CABG patients showed that DAPT use was feasible. CONCLUSIONS: Evidence for DAPT use following CABG is limited to subgroup analyses, observational studies, and trials with surrogate end points. The majority of clinical trials have failed to demonstrate an improvement in graft patency with DAPT. Current evidence does not support the use of DAPT to improve graft patency, and more evidence from randomized controlled trials assessing clinical outcomes is necessary to make definitive recommendations.

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