The effect of interprofessional simulations on pharmacy and physician assistant students' learning of advanced cardiac life support concepts.

BACKGROUND: The Interprofessional Education Collaborative (IPEC) defined core competencies for IPE in 2011, and use of simulation in interprofessional education (IPE) continues to be developed in prelicensure health education programs. INTERPROFESSIONAL EDUCATION ACTIVITY: In this prospective, observational study, interprofessional student teams addressed reversible causes of cardiac arrest in weekly simulations during an Emergency Medicine course. Each simulation was followed by sequential team debriefs, first regarding the IPEC core competencies of interprofessional communication, teamwork, and roles and responsibilities, and second regarding the patient-related content of the case. DISCUSSION: Twenty-eight pharmacy students and 60 physician assistant students completed the course. A didactic knowledge exam was administered before, immediately after, and 150 days after the course. Both disciplines' exam scores significantly increased from baseline to the end of the course and from baseline to the 150-day follow-up. Students also completed the validated Interprofessional Perceptions Survey before and after the course. Both disciplines demonstrated significant increases in Team Value, Efficiency and Interprofessional Accommodation components. IMPLICATIONS: Participation in this simulation-based course resulted in 150-day retention of advanced cardiovascular life support knowledge and improved interprofessional perceptions in both pharmacy and physician assistant students.

Pharmacological Management of Hyperlipidemia in Older individuals.

OBJECTIVE: To provide an up-to-date review of current hyperlipidemia guidelines and discuss pharmacotherapeutic management of hyperlipidemia in older individuals. DATA SOURCES: A PubMed search of articles published through October 2020 was performed using a combination of the following words: older adults, hyperlipidemia, statin, ezetimibe, fibrate, fish oil, niacin, bile acid sequestrant, and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor. STUDY SELECTION/DATA EXTRACTION: Relevant original research, review articles, and guidelines were assessed for the management of hyperlipidemia in the older individuals. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS: Hyperlipidemia is a common chronic disease state in the elderly population, though there is limited evidence for clinical outcomes in older people when compared withwith the general adult population. Statins have the most evidence for primary and secondary prevention of cardiovascular disease in older people, though ezetimibe and PCSK9 inhibitors have a role as add-on or monotherapy in patients who do not tolerate statins. CONCLUSION: Optimal management of hyperlipidemia in older people is important in order to avoid further complications and improve outcomes. Pharmacists can help improve management in the elderly by incorporating up-to-date evidence from guidelines and providing medication education specifically for this population.

Aspirin Use for Primary Prevention of Cardiovascular Disease in Older Patients: A Review of Clinical Guidelines and Updated Evidence.

OBJECTIVE: To provide an up-to-date review of current guidelines, previous trials, and new trials regarding aspirin use in primary prevention of cardiovascular (CV) disease in the elderly population. DATA SOURCES: A PubMed search of articles published through April 2019 was performed using a combination of the following words: aspirin, bleeding, cardiovascular, elderly, hemorrhage, myocardial infarction, primary prevention, stroke. STUDY SELECTION/DATA EXTRACTION: Relevant randomized controlled trials, meta-analyses, and guidelines were assessed for the use of aspirin in primary prevention of CV disease in older patients. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS: The role of aspirin for primary prevention of CV disease in older adults is not well defined. As a result, the guideline recommendations for the use of aspirin in this setting are inconsistent. In 2018, the ARRIVE, ASCEND, and ASPREE studies were published. These studies tried to address some of the inconsistencies regarding the use of aspirin in primary prevention of CV disease. This article reviews the current recommendations along with previous and recent studies for aspirin use for primary prevention in older adults. CONCLUSION: The role of aspirin for primary prevention of CV disease in older adults should be individualized based on patient's risk factors, including risk of CV disease and likelihood of bleeding. Updated evidence provides more guidance regarding which patient populations will benefit from therapy.

Management of Heart Failure in the Older Adult: Treatment and Opportunities.

OBJECTIVE: To provide a review of the available evidence regarding pharmacotherapy and areas of pharmacist intervention in transitions of care (TOC) for the geriatric population with heart failure (HF).
DATA SOURCES: A PubMed search of articles published from 1995 through July 2018 was performed using a combination of the following words: heart failure, geriatric, elderly, (TOC), multidisciplinary, pharmacist.
STUDY SELECTION/DATA EXTRACTION: Relevant original research, review articles, and guidelines were assessed for the management of elderly patients with HF. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results.
DATA SYNTHESIS: HF is a common cause of morbidity, mortality, and hospitalizations in the elderly population. While it is important that patients adhere to evidencebased medications for HF, there are additional precautions and monitoring recommendations for this population because of a higher risk of adverse effects. Elderly patients with HF also require additional care during the transition of care process because they are at high risk for readmission during this time because of a variety of factors, including medication changes, barriers to medication use, and lack of communication between health care providers. As part of a multidisciplinary team, pharmacists can help to identify and address issues.
CONCLUSION: Pharmacists can improve patient care outcomes in patients with HF by providing updated recommendations on pharmacotherapy and being involved in the TOC process.
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A Review of Clinical Guidelines and Pharmacotherapeutic Management of Hypertension in Older Adults.

OBJECTIVE: To provide an up-to-date review of current hypertension (HTN) guidelines and discuss pharmacotherapeutic management of HTN in the older adult population.
DATA SOURCES: A PubMed search of articles published through June 2018 was performed using a combination of the following words: elderly, older adults, geriatric, and HTN.
STUDY SELECTION/DATA EXTRACTION: Relevant original research, review articles, and guidelines were assessed for the management of HTN in older adults. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, complete results, and after a thorough discussion among the authors.
DATA SYNTHESIS: HTN is a common chronic disease state in older adults. Until recently, most guidelines recommended a higher threshold for blood pressure targets in this population, compared with the general adult population. In 2017, two new guidelines for the management of HTN were published, which provided conflicting recommendations for blood pressure goals in the older population. This article reviews current U. S. HTN guidelines published in 2014 to 2017 that most commonly influence patient care, and it specifically addresses the blood pressure targets and pharmacotherapeutic management of HTN in older adults.
CONCLUSION: Management of HTN in older adults is important to avoid further complications and improve outcomes in this population. Blood pressure targets and HTN management should be individualized in older adults based on comorbid conditions, life expectancy, and risk for adverse drug events.

Management of Venous Thromboembolism in the Elderly: A Review of the Non-Vitamin K Oral Anticoagulants.

Objective To provide an up-to-date review of the available evidence regarding pharmacotherapeutic management of venous thromboembolic events in the geriatric population. Data Sources A PubMed search of articles published through August 2017 was performed using a combination of the following words: apixaban, betrixaban, dabigatran, edoxaban, enoxaparin, geriatric, heparin, idaricizumab, rivaroxaban, and venous thromboembolism. Study Selection/data Extraction Relevant original research, review articles, and guidelines were assessed for the management of elderly patients with venous thromboembolism (VTE). References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. Data Synthesis VTE, which includes deep vein thrombosis and pulmonary embolism, is common in the geriatric population. Elderly patients are at high risk for VTE, but management is complicated by comorbidities and a higher risk of bleeding. Until recently, warfarin has been the mainstay of therapy. Newer oral anticoagulants, which include apixaban, dabigatran, edoxaban, and rivaroxaban are now available, but there is limited information on their safety and efficacy in the geriatric population. This article reviews the current literature regarding outcomes and summarizes pharmacotherapeutic management of VTE in the elderly population. Conclusion Appropriate management of pharmacotherapy for VTE can help improve outcomes in elderly patients, and pharmacists can provide guidance and education regarding evidence-based therapy.

A Clinical Review of Surgical vs Transcatheter Aortic Valve Replacement in Geriatric Patients.

OBJECTIVE: To provide an up-to-date review of the available evidence regarding management of elderly patients after transcatheter aortic valve replacement (TAVR). DATA SOURCES: A PubMed search of articles published (September 1969-December 2016) was done using a combination of the following words: aortic valve stenosis, geriatric, elderly, transcatheter aortic valve replacement, surgical aortic valve replacement, transcatheter aortic valve implantation (TAVI), and dual antiplatelet therapy. STUDY SELECTION/DATA EXTRACTION: Relevant original research, review articles, and guidelines were assessed for the management of elderly patients after TAVR. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS: Aortic valve stenosis is common in the geriatric population. While patients were historically treated with surgical aortic valve replacement (AVR), more patients are now undergoing TAVR. This article reviews the current literature regarding outcomes and pharmacotherapy between surgical and TAVR in the elderly population. CONCLUSION: Appropriate management of pharmacotherapy after surgical or TAVR can help improve outcomes in elderly patients, and pharmacists can provide guidance regarding evidence-based therapy.

Modified HAS-BLED Score and Risk of Major Bleeding in Patients Receiving Dabigatran and Rivaroxaban: A Retrospective, Case-Control Study.

OBJECTIVE: To determine if a modified HAS-BLED score (hypertension, abnormal renal/liver dysfunction, stroke, bleeding history, elderly, drugs) predicts risk for major bleeding in patients prescribed dabigatran or rivaroxaban. DESIGN: A retrospective, case-control study. SETTING: Two inpatient medical centers. PATIENTS: Patients prescribed dabigatran or rivaroxaban who experienced a major bleed from June 1, 2011, to August 31, 2013. INTERVENTIONS: Medication and demographic information were collected for patients who experienced a major bleeding episode. Each bleeding case was matched to four control patients based on drug, indication, month and year, and hospital. MAIN OUTCOME MEASURES: The primary outcome was the association between a modified HAS-BLED score and major bleeding in patients receiving dabigatran or rivaroxaban. The secondary objective was to determine which risk factors, whether individual components of HAS-BLED or alternative variables, were associated with major bleeding in patients receiving dabigatran or rivaroxaban. RESULTS: Thirty-eight major bleeds were identified, with 23 bleeds having occurred in patients receiving rivaroxaban, and 15 patients taking dabigatran. The most frequent type of bleed was gastrointestinal. Logistic regression yielded only protime (P < 0.001) and albumin (P < 0.042) as statistically significant risk factors for bleeding. CONCLUSIONS: A modified HAS-BLED score was not predictive of risk of major bleeding in this cohort of primarily elderly patients taking dabigatran or rivaroxaban.

Considerations for Systemic Anticoagulation in ESRD.

In the setting of end-stage kidney disease, the incidence and risk for thrombotic events are increased and use of anticoagulants is common. The incidence of bleeding, however, is also a frequent issue and creates additional challenges in the management of anticoagulation therapy. Patients with end-stage renal disease are typically excluded from large clinical trials exploring the use of anticoagulants, which limits our knowledge of optimal management approaches. Furthermore, varying degrees of renal failure in addition to conditions that alter the pharmacokinetics of various anticoagulants or pharmacodynamic response may warrant alternative approaches to dosing. This review will explore systemic chronic anticoagulation therapy in the setting of chronic kidney disease where hemodialysis is required. Agents discussed include vitamin K antagonists, low-molecular-weight heparins, fondaparinux, oral factor Xa antagonists, and direct thrombin inhibitors. Clinical challenges, approaches to dosing regimens, and tools for measuring responses and reversal will be explored.

Managing acute coronary syndromes in the elderly.

OBJECTIVE: To provide an up-to-date review of the available evidence regarding treatment of acute coronary syndromes (ACS) in elderly patients. DATA SOURCE: A PubMed search of articles published through January 2015 was done using a combination of the following words: acute coronary syndrome, pharmacy, elderly, geriatric, myocardial infarction, beta-blocker, statin, antiplatelet, antithrombin, angiotensin-converting enzyme inhibitor, and aspirin. STUDY SELECTION/DATA EXTRACTION: Relevant original research, review articles, and guidelines were assessed for the management of elderly patients with ACS. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS: Because of the high prevalence of ACS in elderly patients, appropriate treatment is necessary to reduce morbidity and mortality; however, these patients are often under-represented in trials. This article provides a review of the current literature on treatment of ACS in the elderly and provides guidance to pharmacists regarding optimal pharmacotherapy for these patients. CONCLUSION: Appropriate treatment of ACS can help improve outcomes in elderly patients, and the pharmacist can provide guidance regarding evidence-based therapy.

Updates in antiarrhythmic therapy for atrial fibrillation in geriatric patients.

OBJECTIVE: To provide a review of the current evidence for the use of antiarrhythmic therapy in the geriatric population. DATA SOURCES: A PubMed search of articles in the English language published from 1990 through August 2014 was performed using a combination of the following words: amiodarone, antiarrhythmic, atrial fibrillation, dofetilide, dronedarone, elderly, flecainide, geriatric, propafenone, sotalol. STUDY SELECTION/DATA EXTRACTION: Relevant original studies, review articles, and guidelines were assessed for use of antiarrhythmic therapy to manage atrial fibrillation (A fib) in the elderly. References from the above literature were also evaluated and included based on their relevance. DATA SYNTHESIS: The incidence of A fib increases as the population ages, which creates an increased need for clinicians to understand the place of antiarrhythmic therapy in management of A fib. This article provides a review of the current literature regarding this high-risk class of medications in the elderly population, with a focus on monitoring parameters and clinical considerations in the geriatric population. CONCLUSION: Elderly patients are more susceptible to the adverse effects of antiarrhythmic medications as a result of multiple factors, including decreased clearance and metabolism of medications as well as interactions caused by comorbid conditions and medications. Pharmacists can play a key role in a multidisciplinary team to monitor and educate patients on their antiarrhythmic therapy.

Use of ranolazine in the prevention and treatment of postoperative atrial fibrillation in patients undergoing cardiac surgery.

OBJECTIVE: To determine the evidence for use of ranolazine for treatment and prevention of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery. DATA SOURCES: A literature search of MEDLINE (1946 to January 2014) was conducted, using the search terms ranolazine, atrial fibrillation, and cardiac surgery. A search of reference citations was conducted to identify additional references. STUDY SELECTION AND DATA EXTRACTION: Clinical trials investigating the use of ranolazine for POAF were included in the review. DATA SYNTHESIS: Three clinical trials were reviewed; 2 trials, 1 retrospective and 1 prospective, compared ranolazine with amiodarone or usual care for prevention of POAF and demonstrated a significant decrease in the incidence of POAF without increasing the incidence of postoperative complications. A third prospective trial used ranolazine in combination with amiodarone for the treatment of POAF and demonstrated a significant reduction in the time required to convert patients from atrial fibrillation to normal sinus rhythm compared with amiodarone alone. CONCLUSIONS: In these current small trials, ranolazine appears to be a safe and efficacious therapeutic alternative for the treatment and prevention of POAF in patients undergoing cardiac surgery. However, larger randomized controlled trials are needed before ranolazine should be considered for the treatment or prevention of POAF. It is an attractive option compared with current treatments for this indication-primarily ß-blockers and amiodarone-because ranolazine has minimal effects on heart rate and blood pressure.

Safety of new oral anticoagulants with dual antiplatelet therapy in patients with acute coronary syndromes.

OBJECTIVE: To determine the safety of dabigatran, rivaroxaban, or apixaban with dual antiplatelet therapy in patients with acute coronary syndromes. DATA SOURCES: A literature search of MEDLINE (1946-January 2013) was conducted, using the search terms dabigatran, rivaroxaban, or apixaban in combination with dual antiplatelet therapy. A search of literature citations was conducted to identify additional references. STUDY SELECTION AND DATA EXTRACTION: Randomized controlled trials involving the use of one of the new anticoagulants with concomitant dual antiplatelet therapy were included in the review. DATA SYNTHESIS: Five randomized controlled trials were reviewed, including 1 trial of dabigatran, 2 trials of rivaroxaban, and 2 trials of apixaban. These studies were conducted in patients with a recent acute coronary syndrome, so most patients were receiving aspirin and clopidogrel as dual antiplatelet therapy in addition to a therapeutic dose of one of the anticoagulants. The 3 Phase 2 dose-ranging trials (1 each of dabigatran, rivaroxaban, and apixaban) found an increasing risk of major and clinically relevant nonmajor bleeding with increasing doses of the anticoagulants. The Phase 3 trial of apixaban was terminated early due to an excess of bleeding events, and the trial of rivaroxaban also found an increased risk of bleeding. CONCLUSIONS: The emerging use of dabigatran, rivaroxaban, and apixaban into clinical practice has introduced additional management options, but also safety concerns when combined with antiplatelet agents. Due to the increased risk of bleeding when combining an anticoagulant with 2 antiplatelet agents, clinicians should monitor and educate patients on avoiding potential complications. The need for continued triple regimens should be periodically reviewed.

Vitamin K dosing to reverse warfarin based on INR, route of administration, and home warfarin dose in the acute/critical care setting.

BACKGROUND: Vitamin K is commonly used for reversal of anticoagulation of warfarin. However, the optimal dose and route of vitamin K that does not increase the duration of bridging therapy is unknown. OBJECTIVE: To determine factors influencing the extent and rate of INR reversal with vitamin K in the acute/critical care setting. METHODS: This was a chart review of 400 patients who received vitamin K for reversal of warfarin effects between February 2008 and November 2010. Data collected included international normalized ratios (INRs) 12 hours, 24 hours, and 48 hours prior to vitamin K administration; intravenous or oral vitamin K dose; and whether or not fresh frozen plasma (FFP) was administered. RESULTS: Intravenous vitamin K reduced INR more rapidly than oral vitamin K (5.09, 1.91, 1.54, and 1.41 vs 5.67, 2.90, 2.14, and 1.58) at baseline, 12, 24, and 48 hours, respectively. The dose of vitamin K (p < 0.001), route of administration (p < 0.001), and baseline INR (p < 0.001) influenced subsequent INR values. The INR reduction was similar for intravenous vitamin K doses 2 mg or greater. Home warfarin dose did not affect INR responses to intravenous (p = 0.27) or oral vitamin K (p = 0.98). FFP did not influence INR values at 48 hours. Although longer anticoagulation bridge therapy seemed to be associated with higher vitamin K doses, the incidence (p = 0.63) and duration (p = 0.61) were not significant. CONCLUSIONS: Vitamin K dose, route, and initial INR influence subsequent INR values. INR reduction is similar for intravenous vitamin K doses of 2 mg or greater. Preadministration of FFP does not alter INR values at 48 hours or more after vitamin K administration.

Comparison of bivalirudin dosing strategies using total, adjusted, and ideal body weights in obese patients with heparin-induced thrombocytopenia.

STUDY OBJECTIVES: To compare dosing strategies using total body weight (actual measured body weight), adjusted body weight, and ideal body weight when starting bivalirudin for the treatment for heparin-induced thrombocytopenia (HIT) in obese patients, and to compare differences in dosing requirements and clinical outcomes between obese and nonobese patients. DESIGN: Retrospective medical record review. SETTING: Academic tertiary care medical center. PATIENTS: One hundred thirty-five medical and surgical patients who were treated with bivalirudin for HIT between June 1, 2004, and October 1, 2009. MEASUREMENTS AND MAIN RESULTS: The 135 patients were separated into two groups based on body mass index (BMI): 46 patients had a BMI greater than 30 kg/m(2) and were classified in the obese group; the nonobese group consisted of 89 patients with a BMI less than 30 kg/m(2) . The mean BMI in the obese group was 37.7 kg/m(2) (range: 30.1-56.2 kg/m(2) ). Weight-standardized doses that achieved activated partial thromboplastin time (aPTT) goal were compared in the obese group. The mean ± SD doses that achieved aPTT goal with total (actual), adjusted, and ideal body weights in this group were 0.1 ± 0.07, 0.11 ± 0.08, and 0.14 ± 0.09 mg/kg/hour, respectively. Of the three weight-based dosing approaches, total body weight followed by adjusted body weight provided the closest correlation to rates observed at the target aPTT goal. The secondary analysis compared initial doses of bivalirudin, doses required to reach goal aPTT, time to achieve goal aPTT, and clinical outcomes (number of patients not achieving goal, new thrombosis, major bleeding, and 30-day all-cause mortality) between the obese and nonobese groups. A significant difference in initial dose was noted between groups; however, no significant differences in dose required to achieve goal aPTT, time to achieve goal aPTT, and clinical outcomes were noted between the obese and nonobese groups. CONCLUSION: This study provides evidence that the dosing strategy for bivalirudin based on total body weight is the most accurate predictor of achieving aPTT goal in obese patients with HIT. The study also suggests that there are no clinical differences that warrant different dosing strategies between obese and nonobese patients. Further prospective studies are needed to confirm these findings.

Bivalirudin dosing adjustments for reduced renal function with or without hemodialysis in the management of heparin-induced thrombocytopenia.

BACKGROUND: While not approved by the Food and Drug Administration for treatment of heparin-induced thrombocytopenia (HIT), except in patients undergoing percutaneous interventions, the direct thrombin inhibitor bivalirudin is a treatment option that is gaining use. An initial dose of bivalirudin 0.15-0.2 mg/kg/h, adjusted to an activated partial thromboplastin time (aPTT) of 1.5-2.5 times the baseline value, has been suggested. Initial dosing in patients with renal dysfunction, including those on hemodialysis, is unclear. OBJECTIVE: To evaluate initial bivalirudin dosing requirements in patients with and without renal dysfunction, including patients on different forms of dialysis. METHODS: A retrospective analysis of 135 patients treated with bivalirudin for HIT between June 2004 and October 2009 was conducted at a tertiary care medical center. The patients were divided into groups, based on renal function. Patients receiving dialysis were divided into 3 subgroups based on the mode of hemodialysis: intermittent hemodialysis (IHD, n = 24), sustained low-efficiency daily diafiltration (SLEDD, n = 12), or continuous renal replacement therapy (CRRT, n = 5). Patients not receiving dialysis were separated into 3 subgroups based on calculated creatinine clearance (CrCl): CrCl >60 mL/min (n = 52), CrCl 30-60 mL/min (n = 26), and CrCl <30 mL/min (n = 16). RESULTS: Compared with patients with normal renal function (CrCl >60 mL/min), patients with differing degrees of renal dysfunction (CrCl 30-60 and <30 mL/min) required lower doses of bivalirudin to achieve aPTT goal (0.13 vs 0.08 vs 0.05 mg/kg/h, respectively; p < 0.001). Patients on dialysis (IHD, SLEDD, CRRT) also required dose reductions (0.07, 0.09, and 0.07 mg/kg/h) compared with patients with normal renal function, but higher dosing requirements than patients not receiving dialysis with CrCl <30 mL/min. CONCLUSIONS: Patients with renal dysfunction require a reduced dose of bivalirudin to reach a therapeutic aPTT goal. Slightly higher doses may be observed in patients receiving hemodialysis.

Bivalirudin for anticoagulation during hypothermic cardiopulmonary bypass and recombinant factor VIIa for iatrogenic coagulopathy.

OBJECTIVE: To describe management of anticoagulation with a decreased dose requirement of bivalirudin during cardiopulmonary bypass using deep hypothermic circulatory arrest (DHCA) and the reversal of the ensuing coagulopathy with recombinant factor VIIa (rFVIIa). CASE SUMMARY: A 48-year-old male developed chest pain, hypertension, and an aortic aneurysm requiring urgent surgical repair. At the time of surgery, the patient reported an allergy to heparin, so bivalirudin was used for anticoagulation (1 mg/kg loading dose, followed by intermittent infusions of 1.25-2.5 mg/kg/h over the 5 hours of cardiopulmonary bypass). When the cooling process was initiated, bivalirudin was stopped in anticipation of loss of the clotting cascade function and potential slowing of drug elimination. Bivalirudin was restarted for 45 minutes during the rewarming period because of concern for potential clot formation in the bypass circuit with recovery of hemostasis; it was again stopped due to the patient's activated clotting time (ACT) of 504 seconds. Despite this measure, diffuse and severe coagulopathy was observed upon rewarming, with ACTs longer than 999 seconds. Although multiple blood products were administered, visualization of a clot in the surgical field was not notable. A total dose of rFVIIa 20 µg/kg was administered, resulting in visual clot formation within 4 minutes. On postsurgical day 6, bilateral asymptomatic distal deep vein thromboses were noted on imaging; on postsurgical day 8, fondaparinux 2.5 mg subcutaneously was administered daily to prevent clot extension. The patient was discharged on postoperative day 23 with no acute issues and no further anticoagulants. DISCUSSION: Alternative anticoagulation agents such as bivalirudin are used in patients who have an allergy or contraindication to heparin. We propose that prolonged coagulopathy after the induction of hypothermia is due to decreased clotting cascade function as well as slowing of protease activity resulting in decreased bivalirudin elimination. We observed a positive response to low-dose rFVIIa, which could be due to activation of the extrinsic pathway and/or a thrombin burst, resulting in hemostasis. Currently, there is limited evidence supporting reversal of direct thrombin inhibitors with rFVIIa. CONCLUSIONS: In the setting of DHCA, bivalirudin should be used cautiously, with frequent monitoring of the ACTs and potential cessation of the infusion in anticipation of prolonged drug effect with subsequent potential coagulopathy. If coagulopathy ensues, use of low-dose rFVIIa may be an option to initiate hemostasis. When using rFVIIa, it is important to consider the risk of thrombosis and monitor patients accordingly.