Comparison of Postoperative Bleeding in Total Hip and Knee Arthroplasty Patients Receiving Rivaroxaban, Enoxaparin, or Aspirin for Thromboprophylaxis.

BACKGROUND: Guidelines recommend the use of multiple pharmacologic agents and/or mechanical compressive devices for prevention of venous thromboembolism, but preference for any specific agent is no longer given in regard to safety or efficacy. OBJECTIVE: To compare postoperative bleeding rates in patients receiving enoxaparin, rivaroxaban, or aspirin for thromboprophylaxis after undergoing elective total hip arthroplasty or total knee arthroplasty. METHODS: This retrospective cohort analysis evaluated patients who received thromboprophylaxis with either enoxaparin, rivaroxaban, or aspirin. All data were collected from the electronic medical record. The primary outcome was any postoperative bleeding. RESULTS: A total of 1244 patients were included with 366 in the aspirin, 438 in the enoxaparin, and 440 in the rivaroxaban arms. Those who received aspirin or enoxaparin were less likely to experience any bleeding compared to those patients who received rivaroxaban ( P < .05). There was also a lower rate of major bleeding in these groups, but the differences were not significant. CONCLUSIONS: Aspirin and enoxaparin conferred similar bleeding risks, and both exhibited less bleeding than patients who received rivaroxaban.

Evaluation of the Hemodynamic Effects of Intravenous Amiodarone Formulations During the Maintenance Phase Infusion.

BACKGROUND: Two of the excipients in intravenous formulations of amiodarone, polysorbate 80 and benzyl alcohol, have been shown to cause hypotension. A newer formulation of amiodarone, which contains cyclodextrin, is devoid of these excipients. OBJECTIVE: To evaluate the change in mean arterial pressure when utilizing 2 intravenous amiodarone formulations. METHODS: This was a retrospective cohort analysis conducted at an academic medical center. Patients received intravenous amiodarone containing either polysorbate 80/benzyl alcohol (control) or cyclodextrin (cyclodextrin). Patients received these formulations based on a standard institutional protocol of 1 mg/min for 6 hours, followed by 0.5 mg/min for at least 18 hours or until discontinued by the provider. All data were collected from the medical record and included changes in blood pressures, time to lowest systolic blood pressure, concurrent antihypertensive use, and number of patients requiring treatment for hypotension. RESULTS: A total of 160 patients (120 control, 40 cyclodextrin) were included. There was a statistically significant difference in mean arterial pressure between the groups receiving the control formulation of amiodarone compared with the cyclodextrin formulation across the 24-hour maintenance phase infusion (P < 0.001). There was a significant difference between formulations with regard to the change in mean arterial pressure during the 0- to 6-hour and 12- to 18-hour time blocks. There was a statistically significant difference in the number of patients receiving fluid boluses for treatment of hypotension (P = 0.001). CONCLUSIONS: The excipients in the formulation of intravenous amiodarone may have a significant role in the hypotensive effects seen throughout the duration the maintenance phase infusion.

Use of erythropoiesis-stimulating agents in the treatment of anemia in patients with systolic heart failure.

OBJECTIVE: To determine the efficacy and safety of erythropoiesis-stimulating agents (ESAs) for the treatment of anemia in patients with systolic heart failure. DATA SOURCES: A search of MEDLINE (1946-January 2014) and EMBASE (1947-January 2014) was conducted using the search terms erythropoietin and systolic heart failure. In addition, bibliographies of relevant articles were reviewed for additional citations. STUDY SELECTION AND DATA EXTRACTION: All English language randomized controlled trials evaluating clinical outcomes or adverse events when using ESAs in the setting of systolic heart failure were included. DATA SYNTHESIS: A total of 9 studies were reviewed. All studies examining hematological parameters found a statistically significant increase in hemoglobin levels with active treatment versus placebo. Of the 7 trials evaluating exercise tolerance or capacity, only 4 demonstrated statistically significant improvement in these measures in patients receiving ESAs, whereas the remainder showed no clinical benefit. Four studies examined quality-of-life measures. Although numerical improvements were observed in most trials, statistical significance was reached in only 2 trials. A nonsignificant trend for decreased mortality in patients treated with darbepoetin with a similar adverse event profile compared to placebo was shown in one study; however, the largest trial to date showed no benefit in all-cause mortality or heart failure-related hospitalizations with the use of ESAs. Additionally, a statistically significant increase in the number of cerebrovascular events and thrombotic events was found. CONCLUSION: There is inconclusive evidence to suggest that the use of ESAs in treating anemia in patients with heart failure is beneficial. Although ESAs demonstrated a clear ability for increasing hemoglobin levels, the data regarding clinical outcomes such as exercise parameters, quality of life, and hospitalizations are conflicting. In addition, a mortality benefit has not been shown; therefore, the potential for improved symptomatology must be weighed against the potential for adverse events.

Safety of Levalbuterol Compared to Albuterol in Patients With a Tachyarrhythmia.

Objective: To determine the safety of levalbuterol versus albuterol in patients with a tachyarrhythmia. Data Sources: A PubMed search was conducted using the MeSH search terms levalbuterol, albuterol, and tachyarrhythmia. Bibliographies of relevant articles were reviewed for additional citations. Study Selection and Data Extraction: Search results were limited to humans and randomized controlled trials. Those studies that excluded patients with predetermined tachyarrhythmias were excluded from this review. Trials that failed to compare levalbuterol and albuterol outcomes were excluded. Data Synthesis: Beta-2 receptor agonists are the mainstay of treatment in patients with respiratory disease, such as asthma or chronic obstructive pulmonary disease. Racemic albuterol has been linked to poor outcomes due to the fact that it contains both the S-isomer and the R-isomer. Levalbuterol, the "pure" R-isomer, has been thought to decrease cardiac side effects since it only contains the therapeutic component of the racemic mixture. Patients with tachyarrhythmias are at an increased probability to experience harmful, if not fatal, cardiac side effects from these drugs. Limitations of current studies include a lack of data in patient populations with baseline tachyarrhythmias. Conclusions: Tachyarrhythmias put a patient at increased risk of poor outcomes, including death. Evidence for using either racemic albuterol or levalbuterol for respiratory disease management in these patients is lacking and insufficient. Randomized controlled trials show that in intensive care unit patient populations there is no clear advantage to using levalbuterol over albuterol; however, this did not hold true in pediatric populations. No clinical trials exist that look at a direct comparison of these 2 agents in patients with underlying tachyarrhythmias. Further research into the most efficacious and safe ß-2 receptor agonists in this specialized patient population should be conducted to help reduce potential harmful outcomes.