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Background: Clinical guidelines recommend anticoagulation for patients with atrial fibrillation (AF) at high risk of stroke; however, studies report 40% of this population is not anticoagulated.
Objective: To evaluate a population health intervention to increase anticoagulation use in high-risk patients with AF.
Methods: We used machine learning algorithms to identify patients with AF from electronic health records at high risk of stroke (CHADS-VASc risk score ≥2), and no anticoagulant prescriptions within 12 months. A clinical pharmacist in the anticoagulation service reviewed charts for algorithm-identified patients to assess appropriateness of initiating an anticoagulant. The pharmacist then contacted primary care providers of potentially undertreated patients and offered assistance with anticoagulation management. We used a stepped-wedge design, evaluating the proportion of potentially undertreated patients with AF started on anticoagulant therapy within 28 days for clinics randomised to intervention versus usual care.
Results: Of 1727 algorithm-identified high-risk patients with AF in clinics at the time of randomisation to intervention, 432 (25%) lacked evidence of anticoagulant prescriptions in the prior year. After pharmacist review, only 17% (75 of 432) of algorithm-identified patients were considered potentially undertreated at the time their clinic was randomised to intervention. Over a third (155 of 432) were excluded because they had a single prior AF episode (transient or provoked by serious illness); 36 (8%) had documented refusal of anticoagulation, the remainder had other reasons for exclusion. The intervention did not increase new anticoagulant prescriptions (intervention: 4.1% vs usual care: 4.0%, p=0.86).
Conclusions: Algorithms to identify underuse of anticoagulation among patients with AF in healthcare databases may not capture clinical subtleties or patient preferences and may overestimate the extent of undertreatment. Changing clinician behaviour remains challenging.
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http://dx.doi.org/10.1136/bmjqs-2019-009367 | DOI Listing |
Intern Med J
December 2024
Internal Medicine Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
Background: Iron deficiency anaemia (IDA) related to occult gastrointestinal tract (GIT) blood loss is associated with high rates of GIT malignancies. Major society guidelines recommend bidirectional endoscopic evaluation for all men and post-menopausal women with newly diagnosed, unexplained IDA. However, in patients prescribed direct oral anticoagulants (DOACs), the endoscopic yield, specifically the rate of high-risk findings, including colorectal cancers (CRCs) and advanced adenomas (AAs), is unknown.
View Article and Find Full Text PDFCureus
November 2024
Internal Medicine, Creighton University School of Medicine, Phoenix, USA.
Acute pancreatitis, a sudden inflammatory condition, can lead to a hypercoagulable state resulting in complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). This case report discusses a unique presentation of a massive PE in a patient with acute pancreatitis despite being on appropriate prophylactic anticoagulation. A 27-year-old man presented with acute abdominal pain, nausea, and vomiting.
View Article and Find Full Text PDFRadiol Case Rep
February 2025
Department of Internal Medicine, An Najah National University Hospital, Nablus, Palestine.
Behçet's Disease (BD) is a multisystem inflammatory disorder that can lead to severe vascular complications, including Budd-Chiari Syndrome (BCS), a rare but life-threatening condition characterized by hepatic vein obstruction. The co-occurrence of BD and inherited thrombophilia, such as Factor V Leiden mutation, significantly increases the risk of thrombosis, complicating the clinical management of affected individuals. In this case, a 16-year-old female initially presented with nonspecific symptoms of generalized fatigue and bone pain, which later progressed to abdominal distension and significant hepatosplenomegaly.
View Article and Find Full Text PDFInt J Cardiol Heart Vasc
February 2025
Unit of Internal Medicine, Santa Chiara Regional Hospital, Azienda Provinciale per i Servizi Sanitari-APSS, Trento, Italy.
Background: Inferior vena cava agenesis (IVCA) is a rare vascular abnormality characterised by the absence of one or more segments of the inferior vena cava and represents an underestimated cause of deep vein thrombosis (DVT). Given the very low prevalence of this condition and the lack of clinical trials, there is no consensus about the optimal anticoagulation strategy in IVCA-associated DVT.
Objectives: To investigate efficacy and safety of direct oral anticoagulants (DOACs) in IVCA-associated DVT.
ESC Heart Fail
December 2024
Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio, USA.
Aims: The interstitial space is the major compartment in which the excess fluid is located, forming peripheral congestion in acute decompensated heart failure (ADHF). The lymphatic system is responsible for the constant drainage of the compartment. In ADHF, the inefficiency of this system causes extravascular fluid accumulation, underscoring the crucial role of lymphatic system failure in ADHF's pathophysiology.
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