Optimal Duration of Antiplatelet Therapy Following Acute Coronary Syndrome.

This newsletter provides an overview of the available data pertaining to the optimal duration of dual antiplatelet therapy following an acute coronary syndrome, with a focus on individualized treatment plans to optimize patient outcomes.

Improving transitions of care for patients with thromboembolic disease.

Patients with or at risk for thromboembolic disease have many transitional interactions within the healthcare system. Transitions of care--when patients move between or within sites of care, or transition from inpatient to outpatient status--create repeated and diverse opportunities for medication errors, rehospitalization, and other adverse events that may increase costs. Although effective antithrombotic therapies are available, these therapies are complex, underprescribed, and frequently suboptimally managed, a situation further exacerbated by poor patient adherence to therapy. Physician and patient education may help address knowledge gaps related to antithrombotic therapy to help ensure that patients receive appropriate therapy and adhere to the therapeutic regimen. Due to the complexities of antithrombotic therapy it is not surprising that when these patients experience transitions of care, the potential for errors and suboptimal outcomes becomes compounded. Efforts are under way to improve the process of transitional care, including the development of protocols for medication reconciliation, improved communication between clinicians at hand-off, the use of electronic medical records, and the introduction of a collaborative approach among different types of healthcare providers, including pharmacists, nurses, and care managers, so that transitional care is provided smoothly and safely.

Research to real-world application: experts weigh in on the underuse of anticoagulants.

Although numerous studies have shown that anticoagulants can reduce the risk of stroke and thromboembolic events in patients with nonvalvular atrial fibrillation, they are underprescribed in the clinical setting. While standardized risk scoring assessments are recommended in treatment guidelines to determine when anticoagulant use may be appropriate, they are not widely used in the real-world clinical setting. Many factors contribute to anticoagulant underuse, including patient characteristics and comorbidities. Reluctance to prescribe an anticoagulant may also stem from concerns about bleeding or other perceived risks. In addition, physicians may be discouraged from prescribing anticoagulant therapy, particularly warfarin, if follow-up care and monitoring is potentially unfeasible. Patient fears of treatment and lack of access to the healthcare system also contribute to underuse. Increased awareness and education, medical therapy management programs, better care coordination, and improvements in monitoring and follow-up programs may help to increase the use of anticoagulant therapies in appropriate patients.

Cardiac CT in the emergency department: convincing evidence, but cautious implementation.

In clinical practice, assessment of chest pain patients presenting to the emergency department is difficult and the work-up can be lengthy and costly. There is growing evidence supporting the use of coronary computed tomography angiography (CTA) in early assessment of patients presenting with acute chest pain to the emergency department. CTA appears to be a faster and more accurate way to diagnosis or rule out coronary stenosis, leading to reduced hospital admissions, decreased time in the ED and lower costs. The focus of this article is to review the current literature of the use of Coronary CTA and "triple rule out" protocols in the emergency department setting and to provide a chest pain algorithm, showing how Coronary CTA can be implemented effectively in clinical practice. Potential pitfalls and requirements for implementation will also be discussed.

Transitioning the patient with acute coronary syndrome from inpatient to primary care.

Patients with acute coronary syndrome (ACS) undergo several transitions in care throughout the hospital stay, from prehospitalization to the postdischarge period when patients return to primary care. Hospitalist core competencies promote safe transitions in care for patients with ACS, including hospital discharge. These competencies also highlight the central role of the hospitalist in facilitating the continuity of care and as a key link between the patient and the primary care provider (PCP). Core competencies address key decision points and processes that occur during hospitalization for ACS including the initial evaluation and risk stratification, medication reconciliation, and discharge planning. Discharge is a crucial transition and one where hospitalists can both facilitate the transition to primary care and improve adherence to quality measures established for ACS. Poor communication during discharge reportedly results in postdischarge adverse events, most often related to medications and lack of follow-up related to pending test results. Standards for a safe discharge such as Project RED (Re-Engineered Discharge), initiatives to improve outcomes after discharge like Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), and adaptive tools including the ACS Transitions Tool support timely and accurate communication of complex information between the hospitalist, the PCP, and the patient. While the role of hospitalists is evolving, it is clear that they have a central role in ensuring safe transitions in care for ACS.