Stephen J. Voyce

A randomized, multicenter trial of weight-adjusted intravenous heparin dose titration and point-of-care coagulation monitoring in hospitalized patients with active thromboembolic disease

BACKGROUND Therapy with intravenous unfractionated heparin improves clinical outcome in patients with active thromboembolic disease, but achieving and maintaining a therapeutic level of anticoagulation remains a major challenge for clinicians. METHODS A total of 113 patients requiring heparin for at least 48 hours were randomly assigned at 7 medical centers to either weight-adjusted or non-weight-adjusted dose titration. They were separately assigned to either laboratory-based or point-of-care (bedside) coagulation monitoring. RESULTS Weight-adjusted heparin dosing yielded a higher mean activated partial thromboplastin time (aPTT) value 6 hours after treatment initiation than non-weight-adjusted dosing (99.9 vs 78.8 seconds; P =.002) and reduced the time required to exceed a minimum threshold (aPTT >45 seconds) of anticoagulation (10.5 vs 8.6 hours; P =.002). Point-of-care coagulation monitoring significantly reduced the time from blood sample acquisition to a heparin infusion adjustment (0.4 vs 1.6 hours; P <.0001) and to reach the therapeutic aPTT range (51 to 80 seconds) (16.1 vs 19.4 hours; P =.24) compared with laboratory monitoring. Although a majority of patients participating in the study surpassed the minimum threshold of anticoagulation within the first 12 hours and reached the target aPTT within 24 hours, maintaining the aPTT within the therapeutic range was relatively uncommon (on average 30% of the overall study period) and did not differ between treatment or monitoring strategies. CONCLUSIONS Weight-adjusted heparin dosing according to a standardized titration nomogram combined with point-of-care coagulation monitoring using the BMC Coaguchek Plus System represents an effective and widely generalizable strategy for managing patients with thromboembolic disease that fosters the rapid achievement of a desired range of anticoagulation. Additional work is needed, however, to improve on existing patient-specific strategies that can more effectively sustain a therapeutic state of anticoagulation.

Four-year trends of inappropriate proton pump inhibitor use after hospital discharge.

Background Several hospital-based studies have determined that physicians often inappropriately prescribe acid-suppressive medications for stress ulcer prevention in hospitalized patients and continue these drugs after discharge. We sought to determine the frequency of inappropriate proton pump inhibitor (PPI) use continued at discharge within our geographic region. Methods We undertook a retrospective review of the medical records and pharmacy prescription database of a large regional insurance carrier from January 2005 through December 2008 (total hospital admissions 96,669). The primary inclusion criterion was hospital-initiated PPI therapy and continuation on hospital discharge without an appropriate indication. Patients receiving a PPI at the time of admission were excluded from the analysis. Results The number of patients per year discharged on a PPI decreased during the study period: 876 (2005), 763 (2006), 562 (2007), and 485 (2008). Of the patients discharged on a PPI, the number (%) of patients receiving PPIs inappropriately were 695 (79%; 2005); 627 (82%; 2006), 441 (78%; 2007), and 397 (82%; 2008). The annual number of PPI prescriptions and PPI doses dispensed decreased from 2015 to 1263 and from 60,608 to 38,742, respectively, during the study period. The estimated 4-year cost of inappropriate PPI use was

Adaptive and maladaptive cardiovascular responses in human sepsis

595,809, although cost savings from the absolute reduction in inappropriate PPI use over time was

Pulmonary Artery Catheters: An Update

65,598. Conclusions We report a significant decrease of 39% in the number of inappropriate discharge prescriptions for PPIs during the study period; however, the percentage of inappropriate use of PPIs remains high. There is room for improvement in cost-effective use of PPIs.

Clinical experience with routine activated coagulation time monitoring during elective PTCA

48. Meyer TE, Sareli P, Marcus RH, Pocock W, Berk MR, 57. Davies J, Spry CJF, Sapsford R, Olsen EGJ, de Perez G, OakMcGregor M. Mechanism underlying Kussmaul’s sign in ley CM, Goodwin JF. Cardiovascular features of 11 patients chronic constrictive nericarditis. Am J Cardiol 1989;64:1069with eosinophilic endomyocardial disease. Q J Med 183;52:2372. 49. Navetta FI, Barber MJ, Gurbel PA, Moreadith RW, Bernstein R, Hlatky MA, Coleman RE, Bashore TM. Myocardial ischemiainconstrictivepericarditis.A~H~~~~J1988;116:1107-

Diagnosis, Management, and Complications of Nonpenetrating Cardiac Trauma: A Perspective for Practicing Clinicians

Pulmonary artery (PA) catheters are widely used in the care of the critically ill. Numerous catheter designs are available, and the list of indications for their use is con stantly expanding. Extensive physiological data are sup plied by catheters. Right atrial, right ventricular, PA, and PA wedge pressure waveforms, as well as cardiac output and several derived parameters (e.g., systemic vascular resistance, pulmonary vascular resistance) are easily measured. Clinical application of these data may aid in diagnosis and management of acutely ill patients. Physi cians using catheters need to be aware of the numerous complications associated with their use. Scrupulous at tention to insertion and maintenance techniques will minimize the incidence of many of these complications. The undefined risk/benefit ratio of PA catheterization has caused controversy among physicians. Prospective studies to define better the risks versus benefits of PA catheters are currently being planned. Physicians using PA catheters should recognize that the catheters have no direct therapeutic benefit and that PA catheterization should neither replace bedside clinical evaluation nor delay treatment of the patient.

Evaluation of Right-Heart Catheterization: Where Do We Go From Here?

Background: Intracoronary thrombosis is an im portant factor in the pathogenesis of acute complications during percutaneous coronary interventions. The activated coagulation time (ACT) is a simple, reproducible bedside test that has become standard as the means of monitoring the anticoagulant effect of heparin during these procedures. To determine if ACT-adjusted heparin dosing reduces the procedure-related complications of elective PTCA, 1200 patients who underwent nonemergent percutaneous transluminal coronary angioplasty (PTCA) between January 1, 1988 and February 26, 1992 were studied.Methods/Results: Two groups were identified based on the use of empirical heparin dosage (group 1, before July 1, 1990) vs. ACT-guided heparin administration strategies (group 2, after July 1, 1990). Group 2 patients were older, had worse left ventricular function, and were more likely to have experienced a prior myocardial infarction than patients in group 1. Patients in group 1 were more likely to have chronic stable angina and a positive exercise test, while group 2 patients were more likely to be undergoing PTCA for post-myocardial infarction (MI) angina. Angiographie characteristics were also consistent with a higher risk profile in group 2 than in group 1 (92.7% vs. 83.4%, p < 0.001). Postprocedural complications, including abrupt closure and late closure, were lower in group 2 patients. The incidence of abrupt vessel closure was decreased by approximately 50% (6.9% vs. 3.5%, p < 0.025), and delayed vessel closure was significantly reduced by over 60% (3.2% vs. 1.0%, p < 0.05). There were no differences in femoral artery complications between the two specified groups.Conclusions: ACTguided heparin therapy during percutaneous coronary interventions decreases acute and delayed vessel closure, even in the presence of clinical and angiographic characteristics that would predict a higher incidence of these events.

Angiographically documented thrombotic coronary artery occlusion secondary to mild nonpenetrating thoracic trauma

We provide a state-of-the-art review for practicing clincians concerning diagnosis and treatment of patients with non-penetrating cardiac trauma. Internists, cardiologists, and intensivists are becoming increasingly involved in the diagnosis and management of patients with nonpenetrating cardiac injuries. Electrocardiography and cardiac isoenzyme determinations are the least expensive and most common laboratory tests used to diagnose this condition. Despite widespread use, however, these tests have significant limitations in diagnostic sensitivity and specificy. Two-dimensional echocardiography is advocated by some to improve diagnostic accuracy and to identify patients at increased risk of cardiovascular complications. Patients identified as low risk may be suitable for limited monitoring and early hospital discharge. Transesophageal echocardiography is a useful diagnostic tool that offers many advantages over standard transthoracic imaging. Nuclear medicine techniques, including radionuclide-labeled antimyosin scanning, also represent exciting new developments in this area. Invasive techniques such as cardiac catheterization and pumonary artery catheterization should be reserved for patients with hemodynamic instability and overt mechanical complications. Appropriate selection of diagnostic tests can assist clinicians in rapid traging of patients with nonpenetrating cardiac trauma. Identification of patients at low risk for cardiovascular complications may lead to more appropriate use of hospital resources.

Enoxaparin dosing in the elderly using adjusted body weight

Since its introduction in 1970 by Swan and associates [ 11, bedside balloon-tipped pulmonary artery (PA) catheterization has found widespread use in the management of critically ill patients. Although it is generally agreed that PA catheterization may enhance the understanding of cardiopulmonary pathophysiology, there is increasing concern that the technique is overused [2] and that the data generated by the catheter may not be optimally applied. Despite the lack of a large randomized trial demonstrating benefit of this procedure, use of PA catheters have continued to increase; estimated annual sales in the United States of nearly one million catheters each year have been reported [3]. Conditions in which PA catheterization may be useful are characterized by a clinically unclear or rapidly changing hemodynamic status. In hemodynamically unstable situations, clinical evaluation may be misleading [4]. PA catheters allow direct measurement of several major determinants of cardiac performance, thereby supplying potentially important data to aid clinical decision making. When using hemodynamic monitoring with the PA catheter, four central objectives should guide its use: (1) to assess left and/or right ventricular function, (2) to monitor changes in hemodynamic status, (3) to guide treatment with pharmacological and nonpharmacological agents, and ( 4 ) to provide prognostic information [5 ] . Physicians should have a complete understanding of the indications, equipment, insertion, and maintenance techniques prior to performing PA catheterization. Optimal use of the procedure also requires physicians expertise with interpretation of hemodynamic data. Insertion of a PA catheter should neither preclude a careful bedside evaluation nor delay institution of clinically indicated therapy. It must be stressed that the catheter is a diagnostic instrument and has no direct therapeutic benefits. The potential benefit of PA catheterization assumes that the physician using data supplied by the catheter will more accurately diagnose the underlying pathology and institute appropriate therapy. The unknown risk-to-benefit profile of PA catheters has led to controversy regarding the use of this procedure [2]. The lack of evidence demonstrating improved mortality among critically ill patients receiving PA catheters, as well as more recent information regarding optimal hemodynamic parameters for critically ill patients (61, has led to increased fervor in the calls for a randomized controlled trial of PA catheters [7]. In a 1987 report from our institution examining data from a multihospital, community-wide study of coronary disease [8], patients receiving PA catheterization in the setting of a complicated acute myocardial infarction were noted to have a higher mortality rate than patients with similar complications of myocardial infarction who did not undergo right-heart catheterization. The observed mortality differences persisted even after use of multivariate analyses to adjust for differences in infarct size and other short-term prognostic factors. Another study of PA catheterization in patients with acute myocardial infarction was recently reported by Zion and colleagues [9]. These investigators documented a higher in-hospital mortality in patients with acute myocardial infarction and congestive heart failure who received PA catheters; there was no mortality difference in patients with cardiogenic shock or persistent hypotension whether or not they underwent PA catheterization. Although these retrospective, nonrandomized studies have inherent limitations, their results emphasize the need for a prospective trial to more systematically define the efficacy of PA catheters in this patient population. The concept of what constitutes optimal hemodynamic parameters in critically ill patients is also controversial. Shoemaker and colleagues [6] have reported improved morbidity and mortality in high-risk surgical patients with PA catheters who were maintained with “supranormal” ‘hemodynamic parameters (e.g., cardiac index > 4.5 L/min/ m2). It is interesting to note that the mortality experience of patients with PA catheters who were maintained with ‘hormal” hemodynamic parameters was no different in comparison with that of control patients not receiving PA catheterization. Although “supranormal” hemodynamic parameters were beneficial in these post-operative and trauma patients, it is uncertain whether these results can be