Assessment of Anticoagulant Initiation in Patients With New-Onset Atrial Fibrillation During Emergency Department Visit-Point-by-Point Response.

Patients with atrial fibrillation (AF) have an increased risk of stroke and systemic thromboembolism. Diagnosis of AF is commonly encountered in the emergency department (ED). The purpose of this study was to assess the number of patients with new-onset AF appropriately initiated on oral anticoagulation (AC) during their ED encounter.

Optimization of DOAC management services in a centralized anticoagulation clinic.

Background: In 2017, the Brigham and Women's Hospital Anticoagulation Management Service (BWH AMS) expanded services to patients on direct oral anticoagulants (DOACs). We have since updated our DOAC management plan and adjusted the workflow of our clinic.

Objectives: This report describes how our DOAC management has evolved and describes key interventions made.

Atrial Fibrillation Patients on Warfarin and Their Transition to Direct Oral Anticoagulants.

Background: The standard of care for stroke prevention in nonvalvular atrial fibrillation (AF) is the use of direct oral anticoagulants (DOACs). However, many patients established on warfarin therapy have not been considered for a transition to a DOAC.

Objectives: Assess the AF patient population of Brigham and Women's Hospital (BWH) Anticoagulation Management Service (AMS) currently being treated with warfarin, transition eligible patients to a DOAC, and identify barriers to the transitional process.

Development of an Institutional Periprocedural Management Guideline for Oral Anticoagulants.

Patients on oral anticoagulation commonly undergo surgery or other invasive procedures. Periprocedural management of oral anticoagulants involves a careful balance of the thromboembolic risk and bleeding risk. To standardize clinical practice at our institution, we developed a guideline for periprocedural management for patients taking oral anticoagulants that incorporates published data and expert opinion.

Evaluation and optimization of prescribed concomitant antiplatelet and anticoagulation therapy centrally managed by an anticoagulation management service.

Patients on long-term anticoagulation combined with antiplatelet therapy have an increased risk of bleeding compared to patients on anticoagulation alone. The aim of this study was to evaluate the appropriateness of antiplatelet therapy in patients who are on long-term warfarin therapy and are managed by Brigham and Women's Hospital Anticoagulation Management Service (BWH AMS). This was a single-center, prospective chart review of patients managed by BWH AMS who were on long-term warfarin therapy plus full-dose aspirin (325 mg), an oral P2Y inhibitor (clopidogrel, prasugrel or ticagrelor) and/or acetylsalicylic acid/dipyridamole.

Development of Multidisciplinary Anticoagulation Management Guidelines for Patients Receiving Durable Mechanical Circulatory Support.

Patients receiving durable mechanical circulatory support (MCS) require life-long anticoagulation with a vitamin K antagonist (VKA). Due to alternations in hemostasis, concomitant therapy with antiplatelet agents and critical illness, they are at increased risk of thromboembolic and bleeding complications compared with the general population managed on VKAs. To prevent thrombotic events, current guidelines recommend that patients with MCS receive long-term anticoagulation with a VKA to maintain a target international normalized ratio (INR) as specified by device manufacturers, but limited data exist regarding specific routine management of anticoagulation therapy and its potential complications.

Expanding anticoagulation management services to include direct oral anticoagulants.

Despite the ease of use of direct oral anticoagulants (DOACs), these agents remain high risk medications and their clinical efficacy can be impacted by factors such as patient adherence, drug procurement barriers, bleeding leading to discontinuation, and prescribing that deviates from approved dosing regimens. Clinical monitoring of patients on DOACs should be performed by clinicians who specialize in anticoagulation and are familiar with the nuances of DOAC dosing, monitoring, and other components of anticoagulation management including peri-procedural management and care transitions. Although data for centralized warfarin management have consistently demonstrated improved clinical outcomes compared to traditional management by individual community providers, there are no published data addressing the impact of centralized management of DOACs on clinical outcomes or anticoagulation control.