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1.
Am J Cardiol ; 184: 80-89, 2022 12 01.
Article in English | MEDLINE | ID: mdl-36167736

ABSTRACT

This study aims to determine the incidence of all-cause hospitalization in patients with advanced heart failure (AHF) receiving ambulatory continuous, intravenous dobutamine versus milrinone for palliative intent. Despite medical optimization, patients with AHF develop refractory symptoms, resulting in frequent hospitalizations. Previous trials precede modern care standards. Data regarding inotrope choice in palliation are limited. This retrospective analysis included 222 patients with AHF and reduced left ventricular ejection fraction discharged on palliative dobutamine (n = 135) or milrinone (n = 87). The primary outcome was incidence of all-cause rehospitalization compared by treatment type. Demographics between groups were similar. In the milrinone arm, more patients were discharged on ß blockers (62% vs 22%; p <0.001); fewer patients were discharged to hospice (6% vs 30%). More patients in the milrinone arm than in the dobutamine arm were rehospitalized within 180 days (80% vs 59%; p = 0.002); when patients discharged to hospice were excluded, this difference was no longer significant (83% vs 74%; p = 0.14). Overall mortality was lower in the milrinone arm (63% vs 80%; p = 0.006); survival was longer (median: 228 vs 52 days; p <0.001). Patients receiving milrinone spent more days alive and out of the hospital at 90 days after discharge (70 vs 37 days; p <0.001). In conclusion, in patients with AHF receiving palliative inotropes, there was no difference in rehospitalization when excluding patients discharged to hospice. Milrinone use was associated with decreased mortality and longer survival. Agent selection must closely align with the patient's disease trajectory.


Subject(s)
Heart Failure , Milrinone , Humans , Milrinone/therapeutic use , Dobutamine/therapeutic use , Stroke Volume , Retrospective Studies , Cardiotonic Agents/therapeutic use , Ventricular Function, Left
2.
J Am Coll Clin Pharm ; 3(6): 1138-1146, 2020 Sep.
Article in English | MEDLINE | ID: mdl-32838223

ABSTRACT

The recent coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) challenges pharmacists worldwide. Alongside other specialized pharmacists, we re-evaluated daily processes and therapies used to treat COVID-19 patients within our institutions from a cardiovascular perspective and share what we have learned. To develop a collaborative approach for cardiology issues and concerns in the care of confirmed or suspected COVID-19 patients by drawing on the experiences of cardiology pharmacists across the country. On March 26, 2020, a conference call was convened composed of 24 cardiology residency-trained pharmacists (23 actively practicing in cardiology and 1 in critical care) from 16 institutions across the United States to discuss cardiology issues each have encountered with COVID-19 patients. Discussion centered around providing optimal pharmaceutical care while limiting staff exposure. The collaborative of pharmacists found for the ST-elevation myocardial infarction patient, many institutions were diverting COVID-19 rule-out patients to their Emergency Department (ED). Thrombolytics are an alternative to percutaneous coronary intervention (PCI) allowing for timely treatment of patients and decreased staff exposure. An emergency response grab and go kit includes initial drugs and airway equipment so the patient can be treated and the cart can be left outside the room. Cardiology pharmacists have developed policies and procedures to address monitoring of QT prolonging medications, the use of inhaled prostacyclins, and national drug shortages. Technology has allowed us to practice social distancing, while staying in close contact with our teams, patients, and colleagues and continuing to teach. Residents are engaged in unique decision-making processes with their preceptors and assist as pharmacist extenders. Cardiology pharmacists are in a unique position to work with other pharmacists and health care professionals to implement safe and effective practice changes during the COVID-19 pandemic. Ongoing monitoring and adjustments are necessary in rapidly changing times.

3.
Am J Health Syst Pharm ; 77(2): 123-127, 2020 Jan 08.
Article in English | MEDLINE | ID: mdl-31788685

ABSTRACT

PURPOSE: Aspirin has been the cornerstone of antiplatelet therapy in patients with acute coronary syndromes and is well accepted and recommended by several major healthcare organizations. A combination of aspirin and a P2Y12 inhibitor, commonly known as dual antiplatelet therapy, is recommended in patients with coronary stent implantation to reduce the risk of stent thrombosis and ischemic events. SUMMARY: We recently cared for an adult male who presented with an acute coronary syndrome who had a history of Reye syndrome during childhood. During this admission, he was rechallenged with low-dose aspirin for the first time since his diagnosis of Reye syndrome as a child after aspirin therapy. There have been various case reports in children and adults who have been rechallenged with aspirin within days to weeks after the initial diagnosis of Reye syndrome. These reports show mixed results in children and adults regarding the return of Reye syndrome upon aspirin rechallenge shortly after initial aspirin exposure. CONCLUSION: This, to our knowledge, appears to be the first report of a low-dose aspirin rechallenge 30 years later in life in an adult patient with a history of Reye syndrome while receiving aspirin therapy during childhood.


Subject(s)
Acute Coronary Syndrome/drug therapy , Aspirin/therapeutic use , Platelet Aggregation Inhibitors/therapeutic use , Reye Syndrome/complications , Acute Coronary Syndrome/complications , Aspirin/administration & dosage , Humans , Male , Middle Aged , Platelet Aggregation Inhibitors/administration & dosage , Survivors
4.
Pharmacotherapy ; 35(12): 1117-23, 2015 Dec.
Article in English | MEDLINE | ID: mdl-26684552

ABSTRACT

STUDY OBJECTIVE: To compare the adverse effect profiles of adenosine and regadenoson in patients undergoing outpatient cardiac stress testing. DESIGN: Single-center retrospective cohort study. SETTING: Two outpatient clinics, both of which are part of a single tertiary academic medical health system; one clinic exclusively used adenosine for cardiac stress testing, and the other clinic exclusively used regadenoson. PATIENTS: A total of 489 patients who underwent an outpatient cardiac stress test between January 1, 2014, and December 31, 2014; of those patients, 254 received adenosine and 235 received regadenoson. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics were similar between groups, except for chronic kidney disease (p<0.001), congestive heart failure (p=0.041), and mean age (p=0.004). The primary outcome was the occurrence of adverse effects-arrhythmia, chest pain or tightness, dizziness, dyspnea, flushing, or headache, and use of the rescue agent aminophylline-in the adenosine and regadenoson groups. A significantly higher proportion of patients who were given regadenoson during cardiac stress testing experienced at least one adverse effect compared with patients who underwent an adenosine stress test (79.6% vs 31.5%, p<0.001). The patients given regadenoson experienced a significantly higher occurrence of arrhythmia (30.6% vs 16.1%, p<0.001), dyspnea (66.0% vs 17.7%, p<0.001), and headache (25.1% vs 3.1%, p<0.001), and they had a significantly higher rate of aminophylline rescue use (19.2% vs 0.8%, p<0.001). A secondary objective evaluated the financial impact of each agent, and adenosine exhibited a medication price that was more than $100/patient lower than regadenoson based on the average wholesale price. CONCLUSION: Among patients undergoing an outpatient pharmacologic stress test, the use of adenosine was associated with a lower occurrence of adverse effects and lower rate of a rescue agent use and may provide a potential medication cost savings opportunity compared with regadenoson.


Subject(s)
Adenosine/pharmacology , Exercise Test , Heart Rate/drug effects , Purines/pharmacology , Pyrazoles/pharmacology , Adenosine/administration & dosage , Adenosine/adverse effects , Cohort Studies , Female , Humans , Male , Middle Aged , Purines/administration & dosage , Purines/adverse effects , Pyrazoles/administration & dosage , Pyrazoles/adverse effects , Retrospective Studies
5.
J Am Pharm Assoc (2003) ; 54(6): 634-41, 2014.
Article in English | MEDLINE | ID: mdl-25379983

ABSTRACT

BACKGROUND: A key element missing in disease-management programs for heart failure (HF) is participation of the community pharmacist. The purpose of this study is to determine if a simple and efficient clinical tool will allow community pharmacists to identify patients at risk for worsening HF. DESIGN: The One Minute Clinic for Heart Failure (TOM-C HF) was developed as a simple six-item symptom screening tool to be used during routine patient/customer interactions. SETTING: Ten community pharmacies located in the upper Midwest. PATIENTS: Self-identified HF patients. RESULTS: 121 unique patients were evaluated over a 12-month period. The application of this clinical tool took between 1 and 5 minutes in over 80% of the interactions. Seventy-five patients (62%) had one or more signs or symptoms of worsening HF. The most common symptoms detected included edema (39%) and increased shortness of breath (17%). Self-reported weight gain of more than 5 pounds was seen in 19% of patients. CONCLUSION: The TOM-C HF tool was used to identify patients in a time-efficient manner in the community pharmacy setting who appear to be developing worsening HF. Inclusion of the community pharmacists as an early screen for HF decompensation may be an important link in disease-management programs to help reduce hospital readmission rates.


Subject(s)
Community Pharmacy Services , Decision Support Techniques , Heart Failure/diagnosis , Pharmacists , Professional Role , Surveys and Questionnaires , Disease Progression , Dyspnea/etiology , Early Diagnosis , Edema/etiology , Feasibility Studies , Heart Failure/complications , Heart Failure/therapy , Humans , Midwestern United States , Pilot Projects , Predictive Value of Tests , Prognosis , Severity of Illness Index , Time Factors , Weight Gain
6.
Pharmacotherapy ; 34(8): 882-7, 2014 Aug.
Article in English | MEDLINE | ID: mdl-24990816

ABSTRACT

STUDY OBJECTIVE: To compare the effects of combination diuretic therapy with oral hydrochlorothiazide or intravenous chlorothiazide added to background intravenous loop diuretic therapy among patients hospitalized with heart failure. DESIGN: Single-center, retrospective review. SETTING: Cardiovascular hospital within a university-affiliated teaching institution. PATIENTS: Eighty-two patients hospitalized for heart failure between September 1, 2009, and August 31, 2011, who were receiving background intravenous furosemide therapy (total daily dose ≥ 160 mg); of those patients, 28 patients also received oral hydrochlorothiazide (median dose 25 mg [interquartile range 25-50 mg]), and 54 patients also received intravenous chlorothiazide (median dose 500 mg [interquartile range 250-750 mg]). MEASUREMENTS AND MAIN RESULTS: The primary outcome was change in 24-hour urine output. Urine output was recorded from the 24 hours before and after the first administration of either oral hydrochlorothiazide or intravenous chlorothiazide. Baseline characteristics, with the exception of female sex (p=0.01) and home loop diuretic dose (p=0.03), were similar between groups. Twenty-four-hour urine output before administration of the thiazide diuretic was not significantly different between groups. After treatment, 24-hour urine output increased in both groups; however, urine output increased to a lesser extent with oral hydrochlorothiazide (from mean ± SD 2104 ± 830 ml to 3038 ± 917 ml) than with intravenous chlorothiazide (from 2342 ± 978 ml to 4128 ± 1755 ml) (p=0.005). Hypokalemia occurred frequently in both groups: 71.4% and 83.3% in the oral hydrochlorothiazide and intravenous chlorothiazide groups, respectively (p=0.21). CONCLUSION: Among hospitalized patients with heart failure receiving intravenous loop diuretics, the addition of either oral hydrochlorothiazide or intravenous chlorothiazide augmented diuresis. Urine output increased to a greater extent with intravenous chlorothiazide compared with oral hydrochlorothiazide. However, given the positive response observed, ease of administration, and lower drug cost, oral hydrochlorothiazide should still be considered as an option for combination diuretic therapy in this patient population.


Subject(s)
Chlorothiazide/therapeutic use , Diuretics/therapeutic use , Furosemide/therapeutic use , Heart Failure/drug therapy , Hydrochlorothiazide/therapeutic use , Administration, Intravenous , Administration, Oral , Aged , Chlorothiazide/administration & dosage , Chlorothiazide/adverse effects , Diuretics/administration & dosage , Drug Therapy, Combination , Female , Furosemide/administration & dosage , Furosemide/adverse effects , Heart Failure/physiopathology , Humans , Hydrochlorothiazide/administration & dosage , Hydrochlorothiazide/adverse effects , Hypokalemia/chemically induced , Hypokalemia/epidemiology , Male , Middle Aged , Retrospective Studies , Sodium Potassium Chloride Symporter Inhibitors/administration & dosage , Sodium Potassium Chloride Symporter Inhibitors/adverse effects , Sodium Potassium Chloride Symporter Inhibitors/therapeutic use , Treatment Outcome
7.
Heart Surg Forum ; 16(2): E70-7, 2013 Apr.
Article in English | MEDLINE | ID: mdl-23625479

ABSTRACT

BACKGROUND: Guidelines recommend discontinuing clopidogrel for at least 5 days before elective coronary artery bypass graft surgery (CABG) to limit blood transfusions and for at least 24 hours before urgent CABG to reduce major bleeding complications. Studies have produced conflicting results regarding whether recent exposure to clopidogrel increases bleeding, the need for intraoperative and postoperative blood products, postoperative complications, and hospital length of stay. We evaluated the effect of clopidogrel exposure on major bleeding at our institution within 5 days of CABG. METHODS: We conducted a retrospective review of patients who underwent CABG at a tertiary academic medical center. The primary outcome was major bleeding, defined as transfusion of 4 units of packed red blood cells (PRBCs) and/or a need for reexploration. Secondary outcomes included non-life-threatening bleeding, defined as transfusion of 2 units but <4 units of PRBCs; postoperative complications; hospital length of stay; readmission within 30 days of the procedure; and hospital mortality. Major bleeding events were analyzed with a logistic regression model that adjusted for covariates of bleeding risk factors. RESULTS: Of the 715 patients we reviewed, 169 patients received clopidogrel within 5 days before CABG, and 546 patients did not. A significantly higher incidence of major bleeding was observed in the clopidogrel group compared with the group not exposed to clopidogrel (32% versus 17%, P = .002). After adjusting for covariates, patients exposed to clopidogrel had significantly higher odds of major bleeding (odds ratio, 2.1; 95% confidence interval, 1.3-3.4; P = .003). The groups were similar with respect to postoperative complications, except for infection. The clopidogrel-exposed group had a significantly higher rate of leg site infections (3% versus 0.2%, P = .003). CONCLUSIONS: Clopidogrel exposure within 5 days of CABG is associated with an increased risk of major bleeding.


Subject(s)
Coronary Artery Bypass/mortality , Drug-Related Side Effects and Adverse Reactions/mortality , Hospital Mortality , Postoperative Hemorrhage/mortality , Ticlopidine/analogs & derivatives , Causality , Clopidogrel , Comorbidity , Female , Humans , Male , Middle Aged , Ohio/epidemiology , Platelet Aggregation Inhibitors/therapeutic use , Prevalence , Retrospective Studies , Risk Assessment , Survival Analysis , Survival Rate , Ticlopidine/therapeutic use , Treatment Outcome
8.
Pharmacotherapy ; 27(4 Pt 2): 29S-32S, 2007 Apr.
Article in English | MEDLINE | ID: mdl-17381372

ABSTRACT

Clinical pharmacists in all settings see a large number of patients with heart failure, many of whom are Medicare recipients. Clinical studies have identified appropriate drug therapy for patients with heart failure, and several professional organizations have compiled excellent guidelines. Regardless, many patients are not benefiting from treatment with drugs proven to help reduce morbidity and mortality. Following the evidence-based or consensus guidelines can reduce morbidity, mortality, and costs associated with heart failure.


Subject(s)
Drug Therapy/methods , Heart Failure/prevention & control , Managed Care Programs/standards , Drug Therapy/economics , Drug Therapy/trends , Evidence-Based Medicine/standards , Guideline Adherence , Heart Failure/drug therapy , Humans , Managed Care Programs/organization & administration , Pharmacists , Practice Guidelines as Topic/standards , Professional Role
9.
Pharmacotherapy ; 24(8): 1095-8, 2004 Aug.
Article in English | MEDLINE | ID: mdl-15338858

ABSTRACT

Depression is a common comorbidity in patients with heart failure or implantable cardioverter-defibrillators (ICDs). A 35-year-old woman with depression, nonischemic cardiomyopathy, and a history of cardiac arrest had an ICD implanted. During initial testing, the device failed to internally defibrillate the patient. Venlafaxine, an antidepressant with cardiac sodium channel blocking activity, was identified as a potential contributor to her elevated defibrillation threshold. After the venlafaxine was discontinued, the ICD was able to successfully internally defibrillate the patient. Clinicians should be aware of this potential adverse drug-device interaction. Further studies are needed to determine the clinical significance of venlafaxine therapy in patients with ICDs.


Subject(s)
Antidepressive Agents, Second-Generation/adverse effects , Cyclohexanols/adverse effects , Defibrillators, Implantable , Depressive Disorder, Major/drug therapy , Equipment Failure , Heart Arrest/therapy , Adult , Depressive Disorder, Major/complications , Female , Heart Arrest/complications , Humans , Venlafaxine Hydrochloride
10.
Pharmacotherapy ; 23(6): 754-71, 2003 Jun.
Article in English | MEDLINE | ID: mdl-12820818

ABSTRACT

Patients with cardiac disease, specifically ischemic heart disease and heart failure, have a higher frequency of major depressive disorder than patients without cardiac disease. The pathophysiologic reason for this is not completely understood. Previous depression, other debilitating illnesses, and type A personality are risk factors for the development of depression in cardiac patients. Depression has been shown to lower the threshold for ventricular arrhythmias. Therefore, treatment of depression potentially may prolong life in these patients. Antidepressant options that have been evaluated include several of the tricyclic antidepressants, trazodone, bupropion, and several of the selective serotonin reuptake inhibitors. Individual antidepressant drugs vary in their pharmacologic activity and side-effect profiles. Although clinical data are limited, it is important to individualize therapy in order to minimize cardiac adverse effects. Clinicians are encouraged to evaluate patients with cardiac disease for major depressive disorder and to consider antidepressant drug therapy for these patients when appropriate.


Subject(s)
Antidepressive Agents/adverse effects , Depressive Disorder/drug therapy , Heart Diseases/complications , Antidepressive Agents/therapeutic use , Antidepressive Agents, Second-Generation/adverse effects , Antidepressive Agents, Second-Generation/therapeutic use , Antidepressive Agents, Tricyclic/adverse effects , Antidepressive Agents, Tricyclic/therapeutic use , Clinical Trials as Topic , Depressive Disorder/complications , Humans , Treatment Outcome
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