Hospital practice (1995)
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Hospital practice (1995) · Nov 2010
Comparative StudyEconomic impact of switching to bivalirudin for a primary percutaneous coronary intervention in a US hospital.
The addition of glycoprotein IIb/IIIa inhibitors (GPIs) to heparin in percutaneous coronary intervention (PCI) procedures has been demonstrated to reduce ischemic complications; however, GPI use is known to increase the risk of bleeding events, which are linked to increased mortality, longer hospital length of stay, greater medical resource utilization, and increased costs. New antithrombotic therapies have the potential to improve clinical outcomes and decrease costs. The Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) study of bivalirudin demonstrated significantly reduced clinical event rates (mortality and bleeding) compared with an unfractionated heparin (UFH)+GPI regimen. ⋯ Using a bivalirudin-based strategy in STEMI patients undergoing PPCI is associated with favorable clinical and economic outcomes when compared with an UFH+GPI-based strategy in a US hospital setting.
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Hospital practice (1995) · Nov 2010
Clinical impact of enhanced inhibition of P2Y12-mediated platelet aggregation in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention.
The combination of aspirin and clopidogrel at a loading dose of 300 mg followed by a maintenance dose of 75 mg daily is a well-established antiplatelet therapy for the secondary prevention of thrombotic complications in the settings of acute coronary syndrome and/or percutaneous coronary intervention (PCI). Despite the demonstrated clinical benefits associated with this antiplatelet therapy, there is accumulating evidence that a consistent proportion of patients persist in having high levels of platelet aggregation following standard clopidogrel dose. Importantly, the high platelet reactivity after clopidogrel treatment has been associated with higher risk for cardiovascular ischemic events, including stent thrombosis. ⋯ Several functional studies have shown that a higher clopidogrel loading dose (600 mg) compared with standard dose, and novel oral adenosine diphosphate platelet receptor (P2Y12) antagonists compared with clopidogrel achieve a faster onset of action, increased platelet inhibition, and a more predictable drug response. These more favorable pharmacodynamic characteristics are of particular interest in the setting of primary PCI for ST-segment elevation myocardial infarction (STEMI), in which rapid and consistent inhibition of platelet activation and aggregation is desirable for therapeutic success. The present article reviews data on the clinical impact of enhanced P2Y12 inhibition with either higher clopidogrel dosing or new oral antiplatelet agents, including prasugrel and ticagrelor, in the setting of STEMI, focusing on results in the setting of primary PCI.
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Hospital practice (1995) · Nov 2010
Neurologic complications of cardiac surgery and interventional cardiac procedures.
Neurologic complications of cardiac surgery and interventional cardiac procedures may affect the central nervous system or the peripheral nervous system. The most common central nervous system complications are strokes and seizures. This article provides a succinct neuroanatomic and pathophysiologic approach to a wide array of neurologic complications associated with cardiac procedures.
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Hospital practice (1995) · Nov 2010
Improving patient outcomes from acute cardiovascular events through regionalized systems of care.
ST-segment elevation myocardial infarction (STEMI), cardiac arrest, and ischemic stroke are a diverse group of cardiovascular illnesses linked by the necessity for timely intervention in order to maximize patient outcomes. Despite the known efficacies of therapies, such as emergent percutaneous coronary intervention (PCI), rapid administration of tissue plasminogen activator, and induction of therapeutic hypothermia after cardiac arrest, translating these discoveries into standard practice nationwide has proven difficult to achieve. Significant regional variations in practice are commonplace, and facilities with higher patient volumes of STEMI, cardiac arrest, and ischemic stroke consistently have better outcomes compared with lower-volume facilities. ⋯ Regionalized referral systems, such as designated PCI centers and designated stroke centers, are in existence, but have largely been reactive and local, and no mechanism is in place to ensure equitable distribution of such facilities across all geographic regions. As scientific advances in the treatment of these conditions continue to evolve, so too must the system of care that provides these therapies. Evidence suggests that regionalized systems of care for acute cardiovascular events may increase compliance with existing life-saving guidelines and improve patient outcomes.
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Hospital practice (1995) · Jun 2010
GuidelineImproving venous thromboembolism performance: a comprehensive guide for physicians and hospitalists.
Venous thromboembolism (VTE) is a major potentially preventable cause of hospital deaths and is associated with a substantial clinical and economic burden in the United States. Despite the availability of effective thromboprophylactic agents and evidence-based management guidelines, VTE prophylaxis is commonly underused and inappropriately prescribed in real-world practice. Several US organizations have developed quality improvement initiatives to close the gap between guideline recommendations and clinical practice, and thus reduce VTE-associated morbidity and mortality. ⋯ Hospitals are urged to develop an institution-wide policy to improve VTE prevention and employ several quality-improvement initiatives to overcome barriers and optimize prescribing practices. In particular, multiple integrated, active strategies are required to raise awareness of the need for appropriate VTE prophylaxis. Hospital-wide education, risk-assessment tools, electronic alerts, computerized decision-support systems, together with audit and feedback mechanisms, are valuable tools that can be used to promote the use of performance measures to drive improvement of VTE prophylaxis and clinical outcomes.