Journal Watch: Recent studies of note

Recent studies about stratifying bleeding risk in NSTEMI patients, computerized drug reconciliation tools, and other topics.

New scoring tool helps stratify bleeding risk in NSTEMI patients

A new scoring tool helps determine the risk for in-hospital major bleeding among patients with non-ST-segment elevation myocardial infarction (NSTEMI), according to a study in the April 14 Circulation.

Researchers used data from over 89,000 patients in the CRUSADE study to develop and validate a model to stratify NSTEMI patients according to their bleeding risk. They found that admission values of hematocrit less than 36%, estimated creatinine clearance, heart rate, systolic blood pressure, signs of congestive heart failure, female sex, previous vascular disease, and diabetes mellitus were all independent predictors of major bleeding in this population. Major bleeding, which was previously shown to be associated with a five-fold increase in 30-day mortality, was defined as intracranial or retroperitoneal hemorrhage, an acute drop in hematocrit of at least 12%, any red cell transfusion when baseline hematocrit was at least 28%, or any red cell transfusion when the baseline hematocrit was less than 28% with a witnessed bleed.

The researchers assigned weighted integers to each predictor according to its coefficient in the regression model to develop the CRUSADE bleeding score. As the score increased, so did the major bleeding rates: 3.1% for those at very low risk (a score of 20 or less), 5.5% for those at low risk (a score of 21 to 30), 8.6% for those at moderate risk (a score of 31 to 40), 11.9% for those at high risk (a score of 41 to 50), and 19.5% for those at very high risk (a score over 50) (P < 0.001 for trend). Although they excluded patients who died within 48 hours of hospitalization or who were taking warfarin before admission, and they did not include data on previous bleeding or bleeding diathesis, the authors concluded that their study offers an effective tool to help clinicians assess and treat patients with NSTEMI. A bleeding score calculator is available online.

Computerized drug reconciliation tool helps reduce adverse events

Using a computerized medication reconciliation tool at discharge led to fewer adverse drug events at two hospitals, a study has reported.

Researchers enrolled 322 patients admitted to two academic hospitals and randomly assigned 14 medical teams to test a computerized medication reconciliation tool and process redesign involving physicians, nurses and pharmacists. Among 160 control patients, there were 230 potential adverse drug events (PADEs) (1.44 per patient) compared with 170 PADEs (1.05 per patient) in the 162-patient intervention group, a 28% relative reduction. However, a significant benefit was only found at one of the two hospitals. The results appeared in the April 27 Archives of Internal Medicine.

The authors said the intervention's success was due to effective process redesign combined with information technology. The process encouraged interdisciplinary communication and cross-checks, they explained, while the IT application facilitated accurate medication histories and displayed the preadmission medication list with the current inpatient medications during the discharge ordering process. However, the authors acknowledged that their system was “far from perfect” given the number of PADEs in the intervention group.

The intervention was more successful in patients at high risk for medication discrepancies, they added, and worked to reduce PADEs at discharge but not at admission. They attributed the latter in part to PADEs being more common at discharge and a tendency for errors of reconciliation to occur at discharge.

The authors speculated that the different outcomes between the two hospitals may have been due to a better, phased rollout process at one hospital, which also had greater involvement of nurses in confirming accuracy of medication lists at admission. In addition, reducing reconciliation errors at one hospital was aided by a better computer system that made it easier to see inpatient and preadmission medications simultaneously and order medications from either list at discharge.

Alerts help prevent symptomatic venous thromboembolism

Physicians who received alerts from staff members about hospitalized patients at high risk for symptomatic venous thromboembolism (VTE) were more likely to initiate prophylaxis, although the system was less effective than electronic alerts, a study has found.

In the study, published online April 13 in Circulation, researchers randomized 2,493 patients at 25 sites to an intervention group, in which attending physicians received alerts from staff members, or a control group in which physicians received no alerts. The patients, 82% of whom were on medical services, were enrolled based on a validated point score system to detect those at high risk for symptomatic VTE who were not receiving prophylaxis.

Patients in the intervention group were more than twice as likely to receive VTE prophylaxis as control group patients (46.0% vs. 20.6%; P< 0.0001) and the symptomatic VTE rate was lower, although not statistically significant, in the intervention group (2.7% vs. 3.4%; hazard ratio, 0.79; 95% CI, 0.50 to 1.25). The rate of major bleeding after 30 days did not differ significantly between groups. Despite guidelines supporting the use of VTE prophylaxis in high-risk patients, this study suggests that it is still underused, researchers noted, as patients in the intervention group received VTE prophylaxis less than half of the time (compared with less than one-quarter of the time in the control group).

Researchers also noted that their previous study of electronic alerts resulted in a 41% reduction in symptomatic VTE, compared with a 21% reduction in the current study, suggesting that computer-based systems work better than human reminders. This is despite the fact that prophylaxis was ordered more often with staff alerts than electronic alerts (46% vs. 33%). Researchers theorized that electronic alerts may be more effective because they are harder to ignore and have the advantage of providing direct access to decision support tools, such as evidence-based guidelines.

“Add-on” therapy may be useful in patients with advanced decompensated heart failure

Isosorbide dinitrate and hydralazine may improve hemodynamic profiles and outcomes in patients with low-output advanced decompensated heart failure when added to traditional agents such as angiotensin-converting enzyme (ACE) inhibitors, a study has found.

Researchers performed a retrospective study of consecutive chronic systolic heart failure patients (NYHA class III to IV) at the Cleveland Clinic who received intensive medical therapy for advanced decompensated heart failure and were subsequently discharged between Jan. 1, 2003 and Dec. 31, 2006. The goal of the study was to determine whether adding isosorbide dinitrate and hydralazine to ACE inhibitors and angiotensin receptor blockers (ARBs) at discharge improved hemodynamic profiles and outcomes. The results appeared in the April 15 American Journal of Cardiology.

Ninety-seven patients in the control group (ACE inhibitors and ARBs only) and 142 patients in the intervention group (ACE inhibitors and ARBs plus isosorbide dinitrate and/or hydralazine) were included in the analysis. Patients in both groups had similar blood pressure at hospital discharge and similar decreases in intracardiac filling pressures. However, those in the intervention group had greater improvement in cardiac index and systemic vascular resistance, as well as lower rates of all-cause mortality (34% vs. 41%; odds ratio, 0.65 [95% CI, 0.43 to 0.99]; P = 0.04) and all-cause mortality combined with rehospitalization for heart failure (70% vs. 85%; odds ratio, 0.72 [95% CI, 0.54 to 0.97]; P = 0.03). Patients were followed for a mean duration of 26.3 months after the index hospital admission.

The authors noted that their study was limited by its retrospective design and the fact that it was conducted in an intensive care unit dedicated to heart failure patients. However, they concluded that isosorbide dinitrate and hydralazine can improve hemodynamic profiles and outcomes in patients with advanced decompensated heart failure when added to standard therapy, despite similar systemic blood pressure targets. The authors called for a controlled trial to evaluate this finding before these results are translated into routine clinical practice.

Aspirin plus clopidogrel associated with infection after CAB

Preoperative dual antiplatelet therapy with aspirin and clopidogrel was associated with an increased risk of infection after coronary artery bypass (CAB) surgery, a retrospective study found.

Researchers looked at 1,677 patients undergoing CAB and compared the preoperative use of aspirin plus clopidogrel versus aspirin alone. The cumulative incidence of infection at 30 days was 23.1% in patients receiving dual antiplatelet therapy compared with 16.1% for patients who received only aspirin, even after adjustment for demographic, socioeconomic, preoperative and intraoperative risk factors.

Transfusion rates were also higher among patients who were receiving dual antiplatelet therapy than among patients who were receiving aspirin monotherapy (68.4% vs. 60.4%; P = 0.04), but this did not have a significant impact on the risk of infection. Mortality rates at 30 days also were higher in the dual antiplatelet versus the aspirin group, 5.2% versus 3.1%, respectively, although the difference was not statistically significant. The results appear in the April 27 Archives of Internal Medicine.

The authors noted that the relationship between dual therapy and infection risk appeared to be independent of the severity of atherosclerosis or previous revascularization. In addition, blood loss, reoperation and transfusion had only a limited impact on the association between dual therapy and infection.

“The absence of randomized controlled trials that assess the risks and benefits of a short-term withdrawal of dual antiplatelet therapy in surgical patients has created considerable uncertainty regarding the appropriate management of antiplatelet therapy in the perioperative period,” the authors said. More research is needed, they concluded, to clarify the risks and benefits of uninterrupted dual antiplatelet therapy in surgical patients and others at high risk for infection.