Improving aspirin prophylaxis in a primary care diabetic population

STUDY OBJECTIVE: To evaluate and improve adherence to American Diabetes Association guidelines for prophylactic aspirin therapy in ambulatory patients with diabetes using a pharmacy-directed intervention. DESIGN: Unblinded, single intervention. SETTING: Rural, primary care clinic. SUBJECTS: Eighty-five patients with a diagnosis of diabetes mellitus. INTERVENTION: Patients with diabetes were identified from database searches and routine clinic visits. Medical records were screened for aspirin use, allergies, adverse events, and contraindications. During routine clinic visits or structured telephone interviews, patients with indications for aspirin therapy were advised to begin enteric-coated aspirin 81 mg/day A follow-up survey assessed adherence. MEASUREMENTS AND MAIN RESULTS: At baseline, 28 (33%) of 85 patients were receiving aspirin therapy An additional 8 patients had contraindications to aspirin, and 2 patients had no indications for aspirin therapy Aspirin was recommended to 27 patients during clinic interventions and to 15 patients during telephone interventions. Two patients declined the recommendation. At the completion of this intervention, 70 (82%) of 85 patients were receiving daily aspirin or had accepted the recommendation to begin therapy. CONCLUSIONS: A pharmacy-directed intervention increased prophylactic aspirin therapy in patients with diabetes from 33% of patients at baseline to 82% at the end of the study The intervention, which has a simple, patient-focused design, serves as a template for improving aspirin prophylaxis among patients with diabetes in other ambulatory settings.     

Warfarin and aspirin give more benefit than aspirin alone but also more bleeding after myocardial infarction

The anticoagulant, warfarin, and the antiplatelet agent, aspirin, have been shown to have similar benefits after myocardial infarction. As these agents have different mechanisms of action, the beneficial effects of warfarin and aspirin may be additive after myocardial infarction. In the Warfarin, Aspirin, Reinfarction Study (WARIS II), the main outcome was a composite of death, non-fatal reinfarction or thromboembolic stroke, whichever came first over 4 years. Compared to aspirin alone (160 mg/day), the risk reduction was 19% (p = 0.03) with warfarin alone (INR of 2.8 IU) and 29% (p = 0.001) with the combination of aspirin and warfarin (aspirin, 75 mg/day; warfarin, INR of 2.2 IU). This difference in the first event with warfarin alone or the combination, represented a reduction in reinfarction and thromboembolic stroke rather than death. For reinfarction, compared to aspirin alone (117 of 1206), there was a reduction with warfarin alone (90 of 1216) and a further reduction with the combination (69 of 1208). For thromboembolic stroke, compared to aspirin (32 of 1206), there were similar reductions with warfarin and the combination. There were more major and minor bleeding in the warfarin groups than the aspirin group, with major bleeding occurring in 8, 33 and 28 patients taking aspirin, warfarin and aspirin and warfarin, respectively. In conclusion, as compared with aspirin alone, therapy with moderate-intensity warfarin combined with aspirin and high-intensity warfarin alone, resulted in a reduced risk of reinfarction and ischemic stroke but a higher risk of bleeding.     

Improving pharmacotherapy after myocardial infarction by group academic detailing using feedback data on a patient level

STUDY OBJECTIVE: To develop and evaluate a peer review group (PRG) meeting using feedback data on a patient level to improve the quality of drug therapy for prevention of recurrent myocardial infarction. DESIGN: Prospective follow-up study. DATA SOURCE: General practitioners' computerized patients records (intervention patients) and the PHARMO record linkage system (controls). PATIENTS: Forty patients in the intervention group and 1030 control patients; both groups had documented myocardial infarction. INTERVENTION: The intervention, which was based on the principles of group academic detailing, consisted of scoring current cardiovascular treatment on separate forms for each patient, presenting an overview of, and discussing, evidence-based treatment after myocardial infarction, defining the target population, formulating a binding consensus, and identifying patients who were eligible for improvement of pharmacotherapy. MEASUREMENTS AND MAIN RESULTS: Drug therapy and adherence to the newly formulated PRG consensus were assessed at baseline and 1 year after the intervention. Of the patients who received the intervention and were not treated according to the PRG consensus at baseline, 40% received treatment according to the consensus 12 months after the PRG meeting. In the control group, the proportion of patients was 9.5% (prevalence ratio 4.2, 95% confidence interval 1.8-9.7). CONCLUSION: Peer review group meetings can be a valuable tool for improving pharmacotherapy after myocardial infarction.     

替格瑞洛联合阿托伐他汀和阿司匹林对急性ST段抬高型心肌梗死PCI术后心肌血流灌注的影响

目的 探讨替格瑞洛联合阿托伐他汀和阿司匹林对急性ST段抬高型心肌梗死（STEMI）经皮冠状动脉介入术（PCI）术后心肌血流灌注的影响,为其临床诊治提供参考。方法 选择2015年5月-2019年3月郑州市第一人民医院收治的100例行PCI手术的STEMI的患者作为研究对象,按照治疗方法将患者分为对照组和观察组,各50例。对照组口服阿托伐他汀钙片,20 mg/次,1次/d;阿司匹林肠溶片,100 mg/次,1次/d。观察组患者在对照组治疗基础上口服替格瑞洛片,180 mg/次为初始剂量,之后90 mg/次,2次/d。共治疗2个月,随访半年。比较两组患者PCI术后即刻冠状动脉血流及心肌血流灌注指标,分析两组患者住院期间及随访6个月的心功能指标及主要不良心血管事件（MACE）。比较两组患者治疗前后血清心肌肌钙蛋白I（cTnI）、血管性血友病因子（vWF）、肌酸激酶同工酶（CK-MB）及血管内皮生长因子（VEGF）水平变化。结果 治疗后,观察组患者PCI术后ST段回落率、TIMI血流分级3级以及TMPG3级患者均明显高于对照组,而cTFC值比对照组降低（P<0.05）。两组患者治疗后LVEF、E/A明显升高,LVEDD明显降低（P<0.05）;且观察组患者治疗后上述指标改善更为显著（P<0.05）。治疗后,两组患者的血清CK-MB水平明显降低,血清VEGF、vWF及cTnI水平均明显升高（P<0.05）。治疗后,观察组患者CK-MB水平显著低于对照组,VEGF、vWF和cTnI水平显著高于对照组（P<0.05）。观察组住院期间及术后随访MACE发生率低于对照组（P<0.05）。结论 替格瑞洛联合阿托伐他汀和阿司匹林可以更好改善PCI术后STEMI患者的凝血纤溶系统和心肌血流灌注,保护心功能,减少预后MACE事件的发生率,具有一定的临床应用价值。     

Feasibility of early hospital discharge directly from coronary care unit after primary angioplasty for uncomplicated acute myocardial infarction

Current European and American guidelines recommend early discharge for patients with uncomplicated acute myocardial infarction (AMI). However, this concept has not been widely accepted, and experience with direct discharge from the coronary care unit is limited. We aimed to investigate safety and cost effectiveness of early discharge directly from coronary care unit following successful percutaneous coronary angioplasty (PTCA) in patients with uncomplicated AMI. We included consecutive thirty-one patients with uncomplicated AMI and successful PTCA admitted to coronary care unit of a university hospital. Uncomplicated course was defined as absence of reinfarction, ischemia, VF/VT, repeated PTCA, and heart failure within first 72 hours. Incidence of death, reinfarction, VF/VT, need for revascularisation, and hospitalisation due to heart failure at 1, 6, and 12 months was compared with 56 randomly selected AMI patients with successful PTCA but longer hospitalisation. Average hospital stay was 4 days in early and 6.7 days in control group (p<0.05). Control group had more extensive coronary disease (54% two or more vessels vs. 28% in early discharge, p<0,05). During follow up, none of the early discharged patients died, the only observed event was repeat PTCA due to angina pectoris. In the control group, mortality at 12 months was 3.5% (p<0.05). Cumulative 12 month event free survival was 96% in early discharge group and 87% in control group, but difference was not significant (p=0.15, Cox-Mantel test). Cost reduction of early discharge amounted to 1100 Euro per patient. In conclusions, our study confirmed that for a selected population of patients with AMI, successful PTCA, and uncomplicated clinical course during first 72 hours, discharge as early as three days following the admission is safe.     

An audit of thrombolysis and adjunct drug use in acute myocardial infarction

This study looked at outcomes of acute myocardial infarction patients following administration of streptokinase or alteplase. For 150 patients (155 thrombolytic drug administrations), the median time delay between onset of symptoms and thrombolytic therapy was 3.6 hours. Only 65 per cent of streptokinase-treated patients tolerated the recommended dose, compared with 85 per cent of those treated with alteplase. Aspirin usage was uncommon (9 per cent) prior to admission but rose to 68 per cent on discharge. However, β-blocker usage only increased from 16 per cent to 24 per cent. Parenteral and oral anticoagulant usage was numerically greater in the alteplase group. There was no significant difference between streptokinase or alteplase in the incidence of any observed adverse effects. There were no allergic type reactions in the alteplase group. The incidence of such reactions in the streptokinase group was not affected by pre-treatment with anti-allergy drugs. Patients in both thrombolytic drug groups experienced similar falls in blood pressure but severe hypotension was more common in the streptokinase group.     

阿司匹林辅助瑞替普酶治疗急性心肌梗死30例观察

目的:评价阿司匹林辅助瑞替普酶用于急性心肌梗死的疗效.方法:将60例急性心肌梗死患者随机分为2组,对照组30例给予瑞替普酶静脉滴注,观察组30例在静滴瑞替普酶的基础上加服阿司匹林,比较2组疗效.结果:经治疗后观察组ST段恢复、胸痛消失时间、2 h内出现再灌注心律失常情况、血清CK-MB酶峰值出现时间均优于对照组.结论:阿司匹林辅助瑞替普酶用于急性心肌梗死优于单用瑞替普酶者,值得推广.     

Medication errors when transferring elderly patients between primary health care and hospital care

Objective: The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care.Method: Elderly primary health care patients (> 65years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital.Main outcome measure: Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not.Results: There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specific medication dispensing system constituted a significant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added.Conclusion: Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients medications could reduce these errors. The specific medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication.     

Economic evaluation of triflusal and aspirin in the treatment of acute myocardial infarction

OBJECTIVE: To compare the costs to the Spanish healthcare system of 35 days' treatment with triflusal (600 mg/day) and aspirin (300 mg/day) in patients with confirmed acute myocardial infarction within 24 hours of onset of symptoms. DESIGN: A cost minimisation analysis based on the results of the Triflusal in Acute Myocardial Infarction study (TIM) was conducted. The hypothesis was that despite a higher acquisition cost of triflusal, savings would result because of differences in efficacy and safety outcome (non-fatal cerebrovascular event and haemorrhagic events). Diagnostic Related Groups were used as a proxy for determining hospital costs in Spain and the values were obtained from different sources and refer to year 2000 costs. Only direct medical costs were considered for the economic analysis. RESULTS: Although the acquisition cost of triflusal was more expensive than that of aspirin, the cost of prevented events - non-fatal ischaemic cerebrovascular events and cerebral haemorrhages - entirely compensated for the cost of triflusal. The overall cost of treating patients with triflusal, compared with aspirin, represented a net saving of 28.4% per patient treated. CONCLUSION: Our study showed that triflusal is cost saving compared with aspirin in the treatment of the acute phase of myocardial infarction.     

急性心肌梗死就地与转院后行直接冠脉介入治疗的对比分析

目的 探讨从基层医院转运急性心肌梗死（AMI）患者至心脏中心行直接冠脉介入治疗（PCI）的可行性。方法统计我院2003年1月至2005年10月期间收治的行PCI的AMI患者具有完整病历资料共64例，其中从各镇医院转运的25例（转运组），首诊本院39例（本院组）。对比分析两组患者的造影成功率，住院期间、4周以及半年的主要心血管事件（MACE）发生率等。结果转运途中无一例发生MACE，转运组与本院组相比分别是：首诊至血管开通时间139min vs 90min，造影成功率96．0％vs97．4％，住院期间MACE12．0％vs15．4％，随诊率80.0％vs79．5％。4周MACE16．0％vs15．4％，半年MACE16．0％vs17．9％，均P值〉0．05，差异无统计学意义。结论从基层医院转运AMI患者是安全、可行的，与首诊本院患者一样，转运行直接PCI可挽救更多濒死心肌，减少近期及远期MACE的发生率，改善患者的预后。