Anticoagulation stewardship: Considerations for patients with cardiovascular disease
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Anticoagulants are one of the most commonly prescribed medication classes, and the utilization of these agents is on the rise.
Anticoagulants are prescribed for many indications, including prevention and treatment of venous and arterial thromboembolic diseases and hypercoagulable states. Anticoagulants are considered narrow therapeutic index drugs with a precarious balance between thromboembolism and bleeding. Selected anticoagulants, such as heparin or parenteral direct thrombin inhibitors (DTIs), require dose titration using nomograms with coagulation testing for optimization. There are many complexities associated with anticoagulation therapy, including an increasing number of available agents, dosing differences for the same agent for different indications or unique populations, and growing awareness and potential use of reversal options when bleeding occurs.
Recently, there are growing data on approaches to anticoagulation in special populations, such as those with extremes in body weight, renal, liver or heart impairment, pediatrics and frailty in older people who require more precision-based approaches to develop and successfully implement an optimal regimen. Annual anticoagulant-associated ED visits for adverse events have now surpassed both antibiotics and opioids, highlighting the need for stewardship programs to reduce preventable harm and optimize care.
Anticoagulation stewardship
The primary objectives of anticoagulation stewardship programs are to reduce preventable adverse events and to make sure patient monitoring and care occurs in follow-up as appropriate for the anticoagulant prescribed.
Reducing preventable adverse events requires application of available evidence adaptable to each patient’s unique situation to ensure that prescribing, dispensing and administration practices are optimized.
Anticoagulation stewardship can occur at any point of the anticoagulation management process. It has evolved over the years. It was initially seeded in clinics and acute care practitioners assisting patients on warfarin or heparin therapy. The need for support and oversight increased with the addition of new anticoagulants including reversal agents, ways to measure their effects and increasing regulatory mandates including specific goals set forth by The Joint Commission.
Many multidisciplinary stewardship programs now support the nuances of anticoagulation therapy, including the initiation, assessment and necessary revisions to the treatment or prevention of thromboembolic or select CVDs across the care continuum. Support from these programs can also free up time for cardiology practitioners to accomplish other tasks with the additional benefit of providing more systemwide insights on approaches to managing CV-related diseases. Anticoagulant management has been included in the national action plan for adverse drug event prevention by HHS, and anticoagulation stewardship is supported by several U.S. federal agencies and professional societies.
Health care settings with stewardship services have seen:
- reductions in anticoagulation-related adverse events;
- reductions in reversal approaches (full or partial);
- bridging with other anticoagulants and antiplatelet agents when indicated;
- smoother care transitions between and within settings;
- less misuse and misinterpretation of laboratory measures;
- verification of insurance coverage and patient ability to afford copays;
- patient education of their medication regimen;
- facilitated discharge and shorter length of stay in both the acute and critical care settings; and
- reduction in overall costs.
The core elements of anticoagulation stewardship are listed in Table 1.
For cardiologists, cardiology nurse practitioners and physician assistants, this can touch numerous situations involving their specialized care, and facilitate the inclusion of their expertise in optimizing management. This can include developing:
- practice approaches;
- decision support tools;
- policy and guidance processes that encourage best practice;
- adherence among clinicians;
- perioperative antithrombotic guidance and policy support;
- reversal regimens;
- bridging for anticoagulants and antiplatelet therapy;
- de-escalating of antiplatelet therapy;
- order sets development;
- recognition of adverse drug events such as heparin-induced thrombocytopenia;
- adjustments for hypercoagulable states or high-risk bleeding situations;
- implementation of thromboprophylaxis;
- adjusting for organ system impairment and drug interactions; and
- interpretation and usage of laboratory measurement.
At times, it may drive the inclusion of a cardiology practitioner in management decisions that could directly include the need for continued antiplatelet therapy after recent cardiac stent placement, bridging select mechanical heart valves, interpretation of select echocardiography and ECG readings or overall management of atrial fibrillation.
Anticoagulation stewardship can oversee the use of antiplatelet agents, especially when combined with anticoagulants. In many instances, patients may be prescribed combination anticoagulant and antiplatelet therapy for longer than necessary.
Stewardship programs that include inpatient management may also be involved in shorter-term anticoagulation courses, such as for cardiac ablation; perioperative or periprocedural use for cardiac surgery, cardiac catheterization and other cardiac procedures requiring anticoagulation; or mechanical support devices including percutaneous ventricular assist devices and extracorporeal life support. Additional management support can occur with CVDs requiring concurrent use of antithrombotic agents for extended durations such as patients with left ventricular thrombus, mechanical heart valves and the complexities of management depending on valve location(s) and type, LV assist devices, AF and venous thromboembolism.
Health care professionals involved in stewardship programs can be particularly helpful in providing advice regarding complex patients when the evidence is limited, and optimal management is uncertain. The expertise and support of anticoagulation stewardship providers in such situations can increase the likelihood of optimal outcomes.
Goal to enhance success
Successful stewardship programs strive not to take over patient care but rather to engage key stakeholders for collaboration, including practitioners involved in CVD management, to assist in the development of policies and guidelines for safe and effective anticoagulant use. Building the optimal stewardship infrastructure can make many tasks easier on all involved, including the multidisciplinary development that can include insights from cardiologists of tools to support hospital or system-wide care decisions. Effective, safe and evidence-based management of patients requiring antithrombotic therapies is a multidisciplinary team process. Fruitful stewardship programs create success by reducing avoidable adverse events, reducing related morbidity and mortality, shortening length of stay, reducing critical laboratory values, improving warfarin time in the therapeutic range and contributing to smoother transition of care processes.
Examples of potential cardiology-focused stewardship activities and innovations are listed in Table 2.
Not all programs are the same, and successful programs adapt to the needs of patient populations and providers at their respective institutions. They also seek to identify gaps in care provision and education and provide the necessary support based on the input from key stakeholders. The overall goal of stewardship programs is to enhance the success of patient management and those charged with it.
References:
- Anticoagulation Forum. https://acforum.org/web/downloads/ACF_Evidence.pdf. Published Aug. 24, 2022. Accessed Oct. 14, 2024.
- Anticoagulation Forum. https://acforum.org/web/downloads/ACF_Profiles_in_Progress_4.20.pdf. Published Aug. 24, 2022. Accessed Oct. 14, 2024.
- Barnes GD, et al. Am J Med. 2015;doi:10.1016/j.amjmed.2015.05.044.
- Bicarbonate purge solution to support Impella devices for patients with clinically suspected or confirmed heparin-induced thrombocytopenia. https://scholarlycommons.henryford.com/cgi/viewcontent.cgi?article=1034&context=pharmacy_mtgabstracts. Published June 1, 2021. Accessed Oct. 14, 2024.
- Budnitz DS, et al. JAMA, 2021;doi:10.1001/jama.2021.13844.
- Dager WE, et al. Crit Care Med. 2013;doi:10.1097/CCM.0b013e31827caaa3.
- Dager WE, et al. Jt Comm J Qual Patient Saf. 2020;doi:10.1016/j.jcjq.2019.12.004.
- Ha N, et al. J Pharm Technol. 2024;doi:10.1177/87551225231226431.
- Nagle EL, et al. Ann Pharmacother. 2011;doi:10.1345/aph.1P785.
- National action plan for adverse drug event prevention. https://health.gov/sites/default/files/2019-09/ADE-Action-Plan-Anticoagulants.pdf. Published 2019. Accessed Oct. 14, 2024.
- National Quality Forum. Advancing Anticoagulation Stewardship: A Playbook. https://acforum-excellence.org/Resource-Center/resource_files/1977-2022-08-24-063128.pdf. Published Aug. 24, 2022. Accessed Oct. 14, 2024.
- Tsu LV, et al. Ann Pharmacother. 2012;doi:10.1345/aph.1R497.
- Willeford A, et al. J Am Coll Clin Pharm. 2021;doi:10.1002/jac5.1503.
For more information:
William E. Dager, PharmD, BCPS, MCCM, FACCP, FASHP, FCSHP, is a pharmacist in the department of pharmacy at University of California (UC) Davis Medical Center, clinical professor of pharmacy at UC San Francisco School of Pharmacy and clinical professor of medicine at UC Davis School of Medicine.
Kathryn E. Dane, PharmD, BCPS, is a clinical pharmacy specialist, Benign Hematology and Cardiology and co-director of the hemostatic and antithrombotic stewardship program at The Johns Hopkins Hospital.
Sydney Graboyes, PharmD, MBA, BCCP, is a senior clinical pharmacist in the department of pharmacy at UC Davis Medical Center and volunteer assistant clinical professor of pharmacy at UC San Francisco School of Pharmacy.
Sarah A. Spinler, PharmD, FCCP, FAHA, FASHP, AACC, BCPS (AQ Cardiology), is the Healio | Cardiology Today Pharmacology Consult column editor. Spinler is professor and chair of the department of pharmacy services in the School of Pharmacy and Pharmaceutical Sciences at Binghamton University. Spinler can be reached at sspinler@binghamton.edu.
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