Inpatient prescribing of dual antiplatelet therapy according to the guidelines: a prospective intervention study
Background: In dual antiplatelet therapy (DAPT), low-dose acetylsalicylic acid is combined with a P2Y12 inhibitor. However, combining antithrombotic agents increases the risk of bleeding. Guidelines on DAPT recommend using this combination for a limited period of between three weeks and 30 months. This implies the risk of DAPT being erroneously continued after the intended stop date.
Objective: The primary objective of this study is to assess the proportion of hospitalized patients treated with DAPT whose treatment deviated erroneously and unintentionally from the guidelines. We also assessed risk factors and the effect of a pharmacist intervention.
Methods: All patients admitted to the Spaarne Gasthuis (Haarlem/ Hoofddorp, the Netherlands) who used DAPT between March 25th, 2019, and June 14th, 2019, were, in addition to receiving regular care, reviewed to assess whether their therapy was in line with the guidelines’ recommendation and whether deviations were unintended and erroneous. In the event of an unintended deviation, the pharmacist intervened by contacting the prescriber by phone and giving advice to adjust the antithrombotic therapy in line with the guideline.
Results: We included 411 patients, of whom 21 patients (5.1%) had a treatment that deviated from the guidelines. For 11 patients (2.7%), the deviation was unintended and erroneous. The major risk factor for erroneous deviation was the use of DAPT before hospital admission (OR 18.7; 95%CI 4.79–72.7). In patients who used DAPT before admission, 18 out of 58 (31.0%) had a deviation from the guidelines of whom 8 (13.8%) were erroneous. For these eight patients, the pharmacist contacted the prescriber, and in these cases the therapy was adjusted in line with the guidelines.
Conclusions: Adherence to the guidelines recommending DAPT was high within the hospital. However, patients who used DAPT before hospital admission had a higher risk of erroneous prescription of DAPT. Intervention by a pharmacist increased adherence to guidelines and may reduce the number of preventable bleeding cases.
Leendertse AJ, Egberts AC, Stoker LJ, van den Bemt PM; HARM Study Group. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med. 2008;168(17):1890‐1896. https://doi.org/10.1001/archinternmed.2008.3
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344‐e418. https://doi.org/10.1161/str.0000000000000211
Federatie Medisch Specialisten. [Guideline database: Cerebral infarction and cerebral hemorrhage]. Available at: https://richtlijnendatabase.nl/richtlijn/herseninfarct_en_hersenbloeding/startpagina_herseninfarct_-bloeding.html (accessed Aug 18, 2019).
Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN; ESC Scientific Document Group; ESC Committee for Practice Guidelines (CPG); ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2018;39(3):213‐260. https://doi.org/10.1093/eurheartj/ehx419
Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Muñoz D, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739‐2791. https://doi.org/10.1093/eurheartj/ehx391
Aboyans V, et al. Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(3):305‐368. https://doi.org/10.1016/j.ejvs.2017.07.018
Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I; ESC Scientific Document Group. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Eur Heart J. 2018;39(9):763‐816. https://doi.org/10.1093/eurheartj/ehx095
Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary [published correction appears in J Vasc Surg. 2012 Mar;55(3):894]. J Vasc Surg. 2011;54(3):832‐836. https://doi.org/10.1016/j.jvs.2011.07.004
Federatie Medisch Specialisten. [Guideline database: Peripheral arterial disease]. Available at: https://richtlijnendatabase.nl/richtlijn/perifeer_arterieel_vaatlijden_pav/pav_-_startpagina.html (accessed Aug 18, 2019).
Sørensen R, Hansen ML, Abildstrom SZ, Hvelplund A, Andersson C, Jørgensen C, Madsen JK, Hansen PR, Køber L, Torp-Pedersen C, Gislason GH. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet. 2009;374(9706):1967‐1974. https://doi.org/10.1016/s0140-6736(09)61751-7
Bhatt DL, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354(16):1706‐1717. https://doi.org/10.1056/nejmoa060989
Donadini MP, Bellesini M, Squizzato A. Aspirin Plus Clopidogrel vs Aspirin Alone for Preventing Cardiovascular Events Among Patients at High Risk for Cardiovascular Events. JAMA. 2018;320(6):593‐594. https://doi.org/10.1001/jama.2018.9641
van Rein N, Heide-Jørgensen U, Lijfering WM, Dekkers OM, Sørensen HT, Cannegieter SC. Major Bleeding Rates in Atrial Fibrillation Patients on Single, Dual, or Triple Antithrombotic Therapy. Circulation. 2019;139(6):775‐786. https://doi.org/10.1161/circulationaha.118.036248
Costa F, Valgimigli M. The optimal duration of dual antiplatelet therapy after coronary stent implantation: to go too far is as bad as to fall short. Cardiovasc Diagn Ther. 2018;8(5):630‐646. https://doi.org/10.21037/cdt.2018.10.01
Ferrante G, Condorelli G, Pagnotta P, Reimers B. Dual Antiplatelet Therapy Continuation Beyond 1 Year After Drug-Eluting Stents: A Meta-Analysis of Randomized Trials. Circ Cardiovasc Interv. 2017;10(5):e004139. https://doi.org/10.1161/circinterventions.116.004139
Warlé-Van Herwaarden MF, Roukens M, Pop GA, Lamfers EJ, De Smet PA, Kramers C. Adherence to guidelines for the prescribing of double and triple combinations of antithrombotic agents. Eur J Prev Cardiol. 2014;21(2):231‐243. https://doi.org/10.1177/2047487312451253
Breuckmann F, Hochadel M, Darius H, Giannitsis E, Münzel T, Maier LS, Schmitt C, Schumacher B, Heusch G, Voigtländer T, Mudra H, Senges J. Guideline-adherence and perspectives in the acute management of unstable angina - Initial results from the German chest pain unit registry. J Cardiol. 2015;66(2):108‐113. https://doi.org/10.1016/j.jjcc.2014.11.003
Nelson Worel J. Venous thromboembolism: what is preventing achievement of performance measures and consensus guidelines?. J Cardiovasc Nurs. 2009;24(6 Suppl):S14‐S19. https://doi.org/10.1097/jcn.0b013e3181b85c7b
Lisowska A, Makarewicz-Wujec M, Dworakowska AM, Kozłowska-Wojciechowska M. Adherence to guidelines for pharmacological treatment of young adults with myocardial infarction in Poland: Data from Polish Registry of Acute Coronary Syndromes (PL-ACS). J Clin Pharm Ther. 2019;44(3):471‐478. https://doi.org/10.1111/jcpt.12813
Engel J, Damen NL, van der Wulp I, de Bruijne MC, Wagner C. Adherence to Cardiac Practice Guidelines in the Management of Non-ST-Elevation Acute Coronary Syndromes: A Systematic Literature Review. Curr Cardiol Rev. 2017;13(1):3‐27. https://doi.org/10.2174/1573403x12666160504100025
Copyright (c) 2020 Pharmacy Practice and the Authors
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The authors hereby transfer, assign or otherwise convey to Pharmacy Practice (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print or epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to Pharmacy Practice with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Author Self-Archiving Policy
Pharmacy Practice permits and encourages authors to post and archive the final PDFs of their respective articles submitted to the journal on personal websites or institutional repositories after publication, while providing bibliographic details that credit its publication in this journal.