Anticoagulation Hub

Bridge therapy for warfarin patients undergoing invasive therapy is unnecessary for most, said investigators who found an increased risk of bleeding associated with the use of short-acting anticoagulant at the time of the procedure.

A retrospective cohort study of 1,812 procedures in 1,178 patients – most of whom were considered to be at low risk of venous thromboembolism recurrence – showed a 17-fold increase in the risk of clinically relevant bleeding in the group that received bridge anticoagulant therapy, compared with the group that didn’t (2.7% vs. 0.2%).

There was, however, no significant difference in the rate of recurrent venous thromboembolism between the bridge-therapy and non–bridge-therapy groups (0 vs. 3), and no deaths were observed in either group, according to an article published online May 26 (JAMA Intern. Med. [doi:10.1001/jamainternmed.2015.1843].

“Our results confirm and strengthen the findings of those previous studies and highlight the need for a risk categorization scheme that identifies patients at highest risk for recurrent VTE who may benefit from bridge therapy,” wrote Thomas Delate, Ph.D., from Kaiser Permanente Colorado, and coauthors.

The study was conducted and supported by Kaiser Permanente Colorado. One author reported consultancies with Astra-Zeneca, Boehringer-Ingelheim, Pfizer, and Sanofi.

Bridge therapy for warfarin patients undergoing invasive therapy is unnecessary for most, said investigators who found an increased risk of bleeding associated with the use of short-acting anticoagulant at the time of the procedure.

A retrospective cohort study of 1,812 procedures in 1,178 patients – most of whom were considered to be at low risk of venous thromboembolism recurrence – showed a 17-fold increase in the risk of clinically relevant bleeding in the group that received bridge anticoagulant therapy, compared with the group that didn’t (2.7% vs. 0.2%).

There was, however, no significant difference in the rate of recurrent venous thromboembolism between the bridge-therapy and non–bridge-therapy groups (0 vs. 3), and no deaths were observed in either group, according to an article published online May 26 (JAMA Intern. Med. [doi:10.1001/jamainternmed.2015.1843].

“Our results confirm and strengthen the findings of those previous studies and highlight the need for a risk categorization scheme that identifies patients at highest risk for recurrent VTE who may benefit from bridge therapy,” wrote Thomas Delate, Ph.D., from Kaiser Permanente Colorado, and coauthors.

The study was conducted and supported by Kaiser Permanente Colorado. One author reported consultancies with Astra-Zeneca, Boehringer-Ingelheim, Pfizer, and Sanofi.

Bridge therapy for warfarin patients undergoing invasive therapy is unnecessary for most, said investigators who found an increased risk of bleeding associated with the use of short-acting anticoagulant at the time of the procedure.

A retrospective cohort study of 1,812 procedures in 1,178 patients – most of whom were considered to be at low risk of venous thromboembolism recurrence – showed a 17-fold increase in the risk of clinically relevant bleeding in the group that received bridge anticoagulant therapy, compared with the group that didn’t (2.7% vs. 0.2%).

There was, however, no significant difference in the rate of recurrent venous thromboembolism between the bridge-therapy and non–bridge-therapy groups (0 vs. 3), and no deaths were observed in either group, according to an article published online May 26 (JAMA Intern. Med. [doi:10.1001/jamainternmed.2015.1843].

“Our results confirm and strengthen the findings of those previous studies and highlight the need for a risk categorization scheme that identifies patients at highest risk for recurrent VTE who may benefit from bridge therapy,” wrote Thomas Delate, Ph.D., from Kaiser Permanente Colorado, and coauthors.

The study was conducted and supported by Kaiser Permanente Colorado. One author reported consultancies with Astra-Zeneca, Boehringer-Ingelheim, Pfizer, and Sanofi.

The Autar scale is a successful tool for identifying orthopedic surgery patients at risk for deep vein thrombosis (DVT) – and can prevent DVT when patients follow prophylactic measures corresponding with their DVT risk level, according to researchers.

The study comprised 216 patients who were undergoing orthopedic surgery to the lower extremities in Henan, China. They were divided into a control group and an intervention group, consisting of 106 and 110 patients, respectively. Researchers used the Autar scale to assess the risk of a DVT occurring in all of the patients.

The scale is used mainly for evaluating the probability of DVT in a hospitalized patient undergoing surgery. It includes seven risk categories and 41 items, and is used to assign scores to patients indicating whether they are at no, low, moderate, or high risk of DVT.

Specific preventive measures were implemented among the intervention group’s members based on the Autar scale scores of each of these patients. The scores of patients in the control group were not used to implement DVT prophylaxis. Such patients, however, did receive routine nursing and mechanical and pharmacological prophylactic measures, if clinical experience and basic information caused their health care providers to identify them as being at high risk for DVT.

The Autar scale’s efficacy was confirmed by the fact that “the number of patients with DVT was in line with the number of high-risk patients in both groups,” according to Hui-Zhen Yin and Professor Ci-Ming Shan of Zhengzhou (China) University.

The numbers of DVTs that occurred in each group were significantly different from each other; 1.82% of patients in the intervention group got DVTs, compared to 9.43% of patients in the control group. Therefore, the study showed that the Autar scale is useful not only for predicting DVT, but also for preventing its incidence when patients receive the appropriate prophylactic and nursing interventions, the researchers noted.

They recommend wide use of the scale, because they believe it is “a comprehensive and valid instrument that improves the consistency of nursing assessment and creates a reference for preventing DVT in nursing practice.”

Read the full study in International Journal of Nursing Sciences (doi:10.1016/j.ijnss.2015.04.003).

The Autar scale is a successful tool for identifying orthopedic surgery patients at risk for deep vein thrombosis (DVT) – and can prevent DVT when patients follow prophylactic measures corresponding with their DVT risk level, according to researchers.

The study comprised 216 patients who were undergoing orthopedic surgery to the lower extremities in Henan, China. They were divided into a control group and an intervention group, consisting of 106 and 110 patients, respectively. Researchers used the Autar scale to assess the risk of a DVT occurring in all of the patients.

The scale is used mainly for evaluating the probability of DVT in a hospitalized patient undergoing surgery. It includes seven risk categories and 41 items, and is used to assign scores to patients indicating whether they are at no, low, moderate, or high risk of DVT.

Specific preventive measures were implemented among the intervention group’s members based on the Autar scale scores of each of these patients. The scores of patients in the control group were not used to implement DVT prophylaxis. Such patients, however, did receive routine nursing and mechanical and pharmacological prophylactic measures, if clinical experience and basic information caused their health care providers to identify them as being at high risk for DVT.

The Autar scale’s efficacy was confirmed by the fact that “the number of patients with DVT was in line with the number of high-risk patients in both groups,” according to Hui-Zhen Yin and Professor Ci-Ming Shan of Zhengzhou (China) University.

The numbers of DVTs that occurred in each group were significantly different from each other; 1.82% of patients in the intervention group got DVTs, compared to 9.43% of patients in the control group. Therefore, the study showed that the Autar scale is useful not only for predicting DVT, but also for preventing its incidence when patients receive the appropriate prophylactic and nursing interventions, the researchers noted.

They recommend wide use of the scale, because they believe it is “a comprehensive and valid instrument that improves the consistency of nursing assessment and creates a reference for preventing DVT in nursing practice.”

Read the full study in International Journal of Nursing Sciences (doi:10.1016/j.ijnss.2015.04.003).

The Autar scale is a successful tool for identifying orthopedic surgery patients at risk for deep vein thrombosis (DVT) – and can prevent DVT when patients follow prophylactic measures corresponding with their DVT risk level, according to researchers.

The study comprised 216 patients who were undergoing orthopedic surgery to the lower extremities in Henan, China. They were divided into a control group and an intervention group, consisting of 106 and 110 patients, respectively. Researchers used the Autar scale to assess the risk of a DVT occurring in all of the patients.

The scale is used mainly for evaluating the probability of DVT in a hospitalized patient undergoing surgery. It includes seven risk categories and 41 items, and is used to assign scores to patients indicating whether they are at no, low, moderate, or high risk of DVT.

Specific preventive measures were implemented among the intervention group’s members based on the Autar scale scores of each of these patients. The scores of patients in the control group were not used to implement DVT prophylaxis. Such patients, however, did receive routine nursing and mechanical and pharmacological prophylactic measures, if clinical experience and basic information caused their health care providers to identify them as being at high risk for DVT.

The Autar scale’s efficacy was confirmed by the fact that “the number of patients with DVT was in line with the number of high-risk patients in both groups,” according to Hui-Zhen Yin and Professor Ci-Ming Shan of Zhengzhou (China) University.

The numbers of DVTs that occurred in each group were significantly different from each other; 1.82% of patients in the intervention group got DVTs, compared to 9.43% of patients in the control group. Therefore, the study showed that the Autar scale is useful not only for predicting DVT, but also for preventing its incidence when patients receive the appropriate prophylactic and nursing interventions, the researchers noted.

They recommend wide use of the scale, because they believe it is “a comprehensive and valid instrument that improves the consistency of nursing assessment and creates a reference for preventing DVT in nursing practice.”

Read the full study in International Journal of Nursing Sciences (doi:10.1016/j.ijnss.2015.04.003).

Cardiac and vascular surgery patients should receive deep vein thrombosis (DVT) prophylaxis before and after surgery, say researchers who found a high incidence of postoperative DVT in these patients compared to general surgery patients.

The retrospective study of 2,669,772 surgery patients from the American College of Surgeons National Surgical Quality Improvement Program database found that 18,670 patients developed a DVT within 30 days of the operation.

The incidence of DVT according to the type of surgery was 2% for cardiac surgery, 0.99% for vascular surgery and 0.66% for general surgery, reported Dr. Faisal Aziz and his colleagues at Pennsylvania State University (Ann. Vasc. Surg. 2015; 29: 661-9).

Vascular surgery patients were at 1.5 times the risk of a postop DVT and cardiac surgery patients were at 3 times the risk compared with general surgery patients, a significant difference.

Preoperative factors associated with increased risk of developing DVT in the postoperative period included inpatient admission status (OR 7.8), general anesthesia (OR 2), and dyspnea at rest (OR 5).

“Despite the fact that most arterial surgery operations involve administration of therapeutic doses of anticoagulation therapy during the operations, incidence of postoperative DVT is high in these patients,” the study authors wrote.

“Intraoperative anticoagulation is not protective against development of DVT in the postoperative period” they said.

“Physicians should ensure adequate DVT prophylaxis in postoperative vascular surgery and cardiac surgery patients, according to established evidence based guidelines,” they concluded.

The authors did not report any financial disclosures.

Cardiac and vascular surgery patients should receive deep vein thrombosis (DVT) prophylaxis before and after surgery, say researchers who found a high incidence of postoperative DVT in these patients compared to general surgery patients.

The retrospective study of 2,669,772 surgery patients from the American College of Surgeons National Surgical Quality Improvement Program database found that 18,670 patients developed a DVT within 30 days of the operation.

The incidence of DVT according to the type of surgery was 2% for cardiac surgery, 0.99% for vascular surgery and 0.66% for general surgery, reported Dr. Faisal Aziz and his colleagues at Pennsylvania State University (Ann. Vasc. Surg. 2015; 29: 661-9).

Vascular surgery patients were at 1.5 times the risk of a postop DVT and cardiac surgery patients were at 3 times the risk compared with general surgery patients, a significant difference.

Preoperative factors associated with increased risk of developing DVT in the postoperative period included inpatient admission status (OR 7.8), general anesthesia (OR 2), and dyspnea at rest (OR 5).

“Despite the fact that most arterial surgery operations involve administration of therapeutic doses of anticoagulation therapy during the operations, incidence of postoperative DVT is high in these patients,” the study authors wrote.

“Intraoperative anticoagulation is not protective against development of DVT in the postoperative period” they said.

“Physicians should ensure adequate DVT prophylaxis in postoperative vascular surgery and cardiac surgery patients, according to established evidence based guidelines,” they concluded.

The authors did not report any financial disclosures.

Cardiac and vascular surgery patients should receive deep vein thrombosis (DVT) prophylaxis before and after surgery, say researchers who found a high incidence of postoperative DVT in these patients compared to general surgery patients.

The retrospective study of 2,669,772 surgery patients from the American College of Surgeons National Surgical Quality Improvement Program database found that 18,670 patients developed a DVT within 30 days of the operation.

The incidence of DVT according to the type of surgery was 2% for cardiac surgery, 0.99% for vascular surgery and 0.66% for general surgery, reported Dr. Faisal Aziz and his colleagues at Pennsylvania State University (Ann. Vasc. Surg. 2015; 29: 661-9).

Vascular surgery patients were at 1.5 times the risk of a postop DVT and cardiac surgery patients were at 3 times the risk compared with general surgery patients, a significant difference.

Preoperative factors associated with increased risk of developing DVT in the postoperative period included inpatient admission status (OR 7.8), general anesthesia (OR 2), and dyspnea at rest (OR 5).

“Despite the fact that most arterial surgery operations involve administration of therapeutic doses of anticoagulation therapy during the operations, incidence of postoperative DVT is high in these patients,” the study authors wrote.

“Intraoperative anticoagulation is not protective against development of DVT in the postoperative period” they said.

“Physicians should ensure adequate DVT prophylaxis in postoperative vascular surgery and cardiac surgery patients, according to established evidence based guidelines,” they concluded.

The authors did not report any financial disclosures.

Risk factors of upper-extremity deep vein thrombosis associated with peripherally inserted central catheters include a history of venous thromboembolism and a larger-gauge catheter, according to Dr. Vineet Chopra and his associates at the University of Michigan Health System, Ann Arbor.

Compared to 4-Fr gauge PICCs, 5-Fr and 6-Fr PICCs significantly increased PICC-DVT risk, with odds ratios of 2.7 and 7.4, respectively. The OR for patients with a prior history of VTE was 1.7. While any surgery with a PICC in place increased risk, the OR was higher in surgery lasting less than 2 hours (2.75 vs. 2.17). PICCs inserted into the brachial or cephalic vein also increased PICC-DVT risk, compared with the basilic vein, with ORs of 6.8 and 5.8, respectively.

Patients who received both aspirin and statins were at a significantly lower risk of PICC-DVT than those who received only one drug or neither, with an OR of 0.31 for those who got both, compared with 0.77 for aspirin and 0.61 for statins. Pharmacologic VTE prophylaxis also benefited patients with an OR of DVT at 0.72.

“Given the existence of other supportive data regarding the influence of VTE prophylaxis on PICC-DVT and a potentially protective role of statins on thrombosis, further controlled studies of VTE prophylaxis, antiplatelet treatment, and statins to prevent PICC-DVT appear warranted,” the investigators recommended.

Find the full study in Thrombosis Research (doi:10.1016/j.thromres.2015.02.0120).

Risk factors of upper-extremity deep vein thrombosis associated with peripherally inserted central catheters include a history of venous thromboembolism and a larger-gauge catheter, according to Dr. Vineet Chopra and his associates at the University of Michigan Health System, Ann Arbor.

Compared to 4-Fr gauge PICCs, 5-Fr and 6-Fr PICCs significantly increased PICC-DVT risk, with odds ratios of 2.7 and 7.4, respectively. The OR for patients with a prior history of VTE was 1.7. While any surgery with a PICC in place increased risk, the OR was higher in surgery lasting less than 2 hours (2.75 vs. 2.17). PICCs inserted into the brachial or cephalic vein also increased PICC-DVT risk, compared with the basilic vein, with ORs of 6.8 and 5.8, respectively.

Patients who received both aspirin and statins were at a significantly lower risk of PICC-DVT than those who received only one drug or neither, with an OR of 0.31 for those who got both, compared with 0.77 for aspirin and 0.61 for statins. Pharmacologic VTE prophylaxis also benefited patients with an OR of DVT at 0.72.

“Given the existence of other supportive data regarding the influence of VTE prophylaxis on PICC-DVT and a potentially protective role of statins on thrombosis, further controlled studies of VTE prophylaxis, antiplatelet treatment, and statins to prevent PICC-DVT appear warranted,” the investigators recommended.

Find the full study in Thrombosis Research (doi:10.1016/j.thromres.2015.02.0120).

Risk factors of upper-extremity deep vein thrombosis associated with peripherally inserted central catheters include a history of venous thromboembolism and a larger-gauge catheter, according to Dr. Vineet Chopra and his associates at the University of Michigan Health System, Ann Arbor.

Compared to 4-Fr gauge PICCs, 5-Fr and 6-Fr PICCs significantly increased PICC-DVT risk, with odds ratios of 2.7 and 7.4, respectively. The OR for patients with a prior history of VTE was 1.7. While any surgery with a PICC in place increased risk, the OR was higher in surgery lasting less than 2 hours (2.75 vs. 2.17). PICCs inserted into the brachial or cephalic vein also increased PICC-DVT risk, compared with the basilic vein, with ORs of 6.8 and 5.8, respectively.

Patients who received both aspirin and statins were at a significantly lower risk of PICC-DVT than those who received only one drug or neither, with an OR of 0.31 for those who got both, compared with 0.77 for aspirin and 0.61 for statins. Pharmacologic VTE prophylaxis also benefited patients with an OR of DVT at 0.72.

“Given the existence of other supportive data regarding the influence of VTE prophylaxis on PICC-DVT and a potentially protective role of statins on thrombosis, further controlled studies of VTE prophylaxis, antiplatelet treatment, and statins to prevent PICC-DVT appear warranted,” the investigators recommended.

Find the full study in Thrombosis Research (doi:10.1016/j.thromres.2015.02.0120).

Among patients taking anticoagulants after venous thromboembolism, mortality due to ischemic events is twice that due to recurrent pulmonary embolism, according to a report published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders. “In clinical practice in patients with VTE, most of the physician’s attention is often focused on the resolution of VTE signs and symptoms, whereas less attention is paid to the prevention of ischemic events,” said Dr. Olga Madridano of Hospital Universitario Infanta Sofia, Madrid, and her associates.

These study findings show that when prescribing anticoagulation for these patients, it is crucial to identify those who may also require concomitant antiplatelet therapy to prevent ischemic events, the investigators noted.

Dr. Madridano and her colleagues analyzed data from an international registry of VTE cases to determine how often major ischemic events – stroke, MI, limb amputation, or mesenteric ischemia – occur during anticoagulant therapy. They assessed the case reports of 23,370 consecutive patients in 10 European countries, Canada, and Ecuador who were enrolled in the registry during a 5-year period.

During a mean of 9.2 months of anticoagulation treatment, 597 patients developed recurrent VTE: 267 had pulmonary embolism and 330 had deep vein thrombosis. A total of 162 developed major ischemic events: 86 had stroke, 53 had MI, 13 required limb amputation, and 11 had mesenteric ischemia. There were 21 deaths from PE recurrences and 53 from ischemic events.

Thus, the number of PE recurrences was greater than that of ischemic events, but the mortality from PE recurrences was only half that from ischemic events. “We hypothesize that some patients who subsequently died of MI or stroke might have benefited from concomitant therapy with antiplatelets,” Dr. Madridano and her associates said (J. Vasc. Surg.: Venous Lymph. Dis. 2015;3:135-41). However, it is important to note that mortality due to bleeding complications (83 deaths) was even higher than mortality due to PE recurrence and ischemic events put together (74 deaths). Earlier discontinuation of anticoagulant therapy might have reduced the rate of major bleeding, they added.

The VTE registry is supported by an unrestricted grant from Sanofi Spain and by Bayer Pharma AG. Dr. Madridano and her associates reported having no financial disclosures.

Among patients taking anticoagulants after venous thromboembolism, mortality due to ischemic events is twice that due to recurrent pulmonary embolism, according to a report published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders. “In clinical practice in patients with VTE, most of the physician’s attention is often focused on the resolution of VTE signs and symptoms, whereas less attention is paid to the prevention of ischemic events,” said Dr. Olga Madridano of Hospital Universitario Infanta Sofia, Madrid, and her associates.

These study findings show that when prescribing anticoagulation for these patients, it is crucial to identify those who may also require concomitant antiplatelet therapy to prevent ischemic events, the investigators noted.

Dr. Madridano and her colleagues analyzed data from an international registry of VTE cases to determine how often major ischemic events – stroke, MI, limb amputation, or mesenteric ischemia – occur during anticoagulant therapy. They assessed the case reports of 23,370 consecutive patients in 10 European countries, Canada, and Ecuador who were enrolled in the registry during a 5-year period.

During a mean of 9.2 months of anticoagulation treatment, 597 patients developed recurrent VTE: 267 had pulmonary embolism and 330 had deep vein thrombosis. A total of 162 developed major ischemic events: 86 had stroke, 53 had MI, 13 required limb amputation, and 11 had mesenteric ischemia. There were 21 deaths from PE recurrences and 53 from ischemic events.

Thus, the number of PE recurrences was greater than that of ischemic events, but the mortality from PE recurrences was only half that from ischemic events. “We hypothesize that some patients who subsequently died of MI or stroke might have benefited from concomitant therapy with antiplatelets,” Dr. Madridano and her associates said (J. Vasc. Surg.: Venous Lymph. Dis. 2015;3:135-41). However, it is important to note that mortality due to bleeding complications (83 deaths) was even higher than mortality due to PE recurrence and ischemic events put together (74 deaths). Earlier discontinuation of anticoagulant therapy might have reduced the rate of major bleeding, they added.

The VTE registry is supported by an unrestricted grant from Sanofi Spain and by Bayer Pharma AG. Dr. Madridano and her associates reported having no financial disclosures.

Among patients taking anticoagulants after venous thromboembolism, mortality due to ischemic events is twice that due to recurrent pulmonary embolism, according to a report published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders. “In clinical practice in patients with VTE, most of the physician’s attention is often focused on the resolution of VTE signs and symptoms, whereas less attention is paid to the prevention of ischemic events,” said Dr. Olga Madridano of Hospital Universitario Infanta Sofia, Madrid, and her associates.

These study findings show that when prescribing anticoagulation for these patients, it is crucial to identify those who may also require concomitant antiplatelet therapy to prevent ischemic events, the investigators noted.

Dr. Madridano and her colleagues analyzed data from an international registry of VTE cases to determine how often major ischemic events – stroke, MI, limb amputation, or mesenteric ischemia – occur during anticoagulant therapy. They assessed the case reports of 23,370 consecutive patients in 10 European countries, Canada, and Ecuador who were enrolled in the registry during a 5-year period.

During a mean of 9.2 months of anticoagulation treatment, 597 patients developed recurrent VTE: 267 had pulmonary embolism and 330 had deep vein thrombosis. A total of 162 developed major ischemic events: 86 had stroke, 53 had MI, 13 required limb amputation, and 11 had mesenteric ischemia. There were 21 deaths from PE recurrences and 53 from ischemic events.

Thus, the number of PE recurrences was greater than that of ischemic events, but the mortality from PE recurrences was only half that from ischemic events. “We hypothesize that some patients who subsequently died of MI or stroke might have benefited from concomitant therapy with antiplatelets,” Dr. Madridano and her associates said (J. Vasc. Surg.: Venous Lymph. Dis. 2015;3:135-41). However, it is important to note that mortality due to bleeding complications (83 deaths) was even higher than mortality due to PE recurrence and ischemic events put together (74 deaths). Earlier discontinuation of anticoagulant therapy might have reduced the rate of major bleeding, they added.

The VTE registry is supported by an unrestricted grant from Sanofi Spain and by Bayer Pharma AG. Dr. Madridano and her associates reported having no financial disclosures.

While effective in outpatient settings, the Wells score was not effective at detecting deep vein thrombosis in an inpatient setting, according to Dr. Patricia Silveira and her associates from Harvard Medical School, Boston.

Of 1,135 patients included in the study, 137 had proximal DVT. DVT incidence in the low, medium, and high pretest probability groups were 5.9%, 9.5%, and 16.4%, respectively. Although statistically significantly different, this is a very narrow range, in contrast to findings in previous studies, where incidence among the three groups was 3.0%, 16.6%, and 74.6% respectively.

The AUC for the accuracy of the Wells score was 0.6, only slightly better than chance. The failure rate in the low pretest group was 5.9%, and the efficiency was 11.9%.

“In inpatients,Wells DVT scores are inflated by comorbidities and nonspecific physical findings common among hospitalized patients, leaving very few patients in the low-probability Wells score category, and many patients without DVT in the moderate- and high-probability categories,” Dr. Erika Leemann Price and Dr. Tracy Minichiello wrote in a related editorial.

Find the full study and editorial in JAMA Internal Medicine (doi:10.1001/jamainternmed.2015.1687; doi:10.1001/jamainternmed.2015.1699).

While effective in outpatient settings, the Wells score was not effective at detecting deep vein thrombosis in an inpatient setting, according to Dr. Patricia Silveira and her associates from Harvard Medical School, Boston.

Of 1,135 patients included in the study, 137 had proximal DVT. DVT incidence in the low, medium, and high pretest probability groups were 5.9%, 9.5%, and 16.4%, respectively. Although statistically significantly different, this is a very narrow range, in contrast to findings in previous studies, where incidence among the three groups was 3.0%, 16.6%, and 74.6% respectively.

The AUC for the accuracy of the Wells score was 0.6, only slightly better than chance. The failure rate in the low pretest group was 5.9%, and the efficiency was 11.9%.

“In inpatients,Wells DVT scores are inflated by comorbidities and nonspecific physical findings common among hospitalized patients, leaving very few patients in the low-probability Wells score category, and many patients without DVT in the moderate- and high-probability categories,” Dr. Erika Leemann Price and Dr. Tracy Minichiello wrote in a related editorial.

Find the full study and editorial in JAMA Internal Medicine (doi:10.1001/jamainternmed.2015.1687; doi:10.1001/jamainternmed.2015.1699).

While effective in outpatient settings, the Wells score was not effective at detecting deep vein thrombosis in an inpatient setting, according to Dr. Patricia Silveira and her associates from Harvard Medical School, Boston.

Of 1,135 patients included in the study, 137 had proximal DVT. DVT incidence in the low, medium, and high pretest probability groups were 5.9%, 9.5%, and 16.4%, respectively. Although statistically significantly different, this is a very narrow range, in contrast to findings in previous studies, where incidence among the three groups was 3.0%, 16.6%, and 74.6% respectively.

The AUC for the accuracy of the Wells score was 0.6, only slightly better than chance. The failure rate in the low pretest group was 5.9%, and the efficiency was 11.9%.

“In inpatients,Wells DVT scores are inflated by comorbidities and nonspecific physical findings common among hospitalized patients, leaving very few patients in the low-probability Wells score category, and many patients without DVT in the moderate- and high-probability categories,” Dr. Erika Leemann Price and Dr. Tracy Minichiello wrote in a related editorial.

Find the full study and editorial in JAMA Internal Medicine (doi:10.1001/jamainternmed.2015.1687; doi:10.1001/jamainternmed.2015.1699).

WASHINGTON – A streamlined emergency care service and a low-cost, tablet-based mobile telestroke system are two examples of shortening the time it takes for acute ischemic stroke patients to receive thrombolytic therapy that were presented at the annual meeting of the American Academy of Neurology.

American Heart Association/American Stroke Association guidelines recommend a door-to-needle (DTN) time of 60 minutes or less and set a goal for participating hospitals to administer tissue plasminogen activator (TPA) to at least 50% of their patients with acute ischemic stroke within 60 minutes of arriving at the hospital.

©Jack Cote/UVA

Dr. Judd Jensen described the efforts of Swedish Medical Center, Englewood, Colo. to streamline the emergency care of patients suspected of having an acute ischemic stroke after a task force determined that their previous “sequential, step-by-step process” wasted time. The median DTN time at the hospital’s stroke center had dropped from 46 minutes in 2010 to 39 minutes in 2013, which was better than the national average, “but we felt we could do better,” said Dr. Jensen, a neurologist at the hospital.

The process was modified so that more of the activities take place simultaneously, which includes immediately sending patients for a CT scan before entering the emergency department and administering IV TPA in the CT area to eligible patients, he explained. Previously, these patients were taken to a bed in the ED on arrival, registered, then examined by the emergency physician and neurologist and transported for a CT scan and then transported back to the ED where TPA was administered, if indicated, after several other steps were completed, including interpreting the CT scan, deciding about treatment, acquiring consent, and contacting the pharmacy to mix the TPA.

This process was improved by increasing pre-hospital notification by emergency medical services (EMS) and establishing a “launchpad” area in the back of the ED where the stroke team meets after EMS notification. On arrival, patients are transferred directly to the CT room where they are examined. The pharmacy is instructed to mix the TPA if an ischemic stroke is suspected, and the TPA is brought to the CT room where a stroke neurologist evaluates the CT scan and TPA is administered if indicated.

The impact of the revised process was evaluated in a prospective study of 262 acute ischemic stroke patients who received IV TPA between January 2010 and December 2014 at the hospital. They had a mean age of 73 years, 44% were male, and 84% were white. Their mean initial National Institutes of Health Stroke Scale (NIHSS) score was 12. The median DTN times dropped to a median of 31 minutes in 2014, Dr. Jensen said.

In 2014, almost 50% of the patients received TPA in 30 minutes or less, compared with about 25% in 2011, 2012, and 2013, he added, noting that 11 minutes was the fastest DTN time in 2014. Patients with an excellent discharge modified Rankin Scale (mRS) score (0 or 1) improved from 31% in 2010 and 30% in 2013 to 46% in 2014. During the time period studied, two patients had a symptomatic intracerebral hemorrhage, one in 2010 and another in 2012.

Dr. Jensen described the process as a multidisciplinary team effort, noting that it is important that emergency room physicians feel comfortable with the administration of TPA in the CT scan area, “because it is still their patient being administered a potentially fatal drug outside of the ED.”

At the meeting, Matthew Padrick, a medical student at the University of Virginia, Charlottesville, presented the results of a pilot study that targeted the EMS transport time as an “untapped treatment window” to improve the time to thrombolytic treatment using a low-cost mobile telestroke system to evaluate patients in the ambulance on their way to the hospital.

Because the catchment area covered by UVA includes a large rural area, transport times to the stroke center can be as long as 30 to 60 minutes, Mr. Padrick said.

In the “Improving Treatment with Rapid Evaluation of Acute Stroke via mobile Telemedicine” (iTREAT) study, he and his associates evaluated the feasibility and reliability of performing acute stroke assessments (with the NIHSS) in the ambulance. The iTREAT system, which includes an Apple iPad with retina display attached to the patient stretcher with an extendable clamp, a secure video conferencing application, a high-speed 4G LTE modem, a magnetic antenna on top of the ambulance, and the regional cellular network, “providing seamless connectivity,” he said. At a total cost of under $2,000, the system is designed so that the neurologist can evaluate the patient remotely, via the iPad.

Acting as patients, three medical students were given two unique stroke scenarios each, with stories and specific instructions; vascular neurologists did a face-to-face assessment and a remote iTREAT assessment from the hospital as the students traveled along the major routes to UVA Medical Center. NIHSS scores in the ambulance with the iTREAT system and with face-to-face assessments correlated well, with an overall intraclass correlation of 0.98, Mr. Padrick reported.

The ratings of audio-video quality during the iTREAT evaluations were judged to be ”good” or “excellent” and the NIHSS correlations and audio-video quality ratings improved with time, he added.

“We currently have IRB approval to move forward with real, live patient encounters and we are currently outfitting and training our local EMS agencies” with the system, Mr. Padrick said in an interview after the meeting.

Mr. Padrick has received research support from the American Heart Association. Dr. Judd had nothing to disclose.

[email protected]

WASHINGTON – A streamlined emergency care service and a low-cost, tablet-based mobile telestroke system are two examples of shortening the time it takes for acute ischemic stroke patients to receive thrombolytic therapy that were presented at the annual meeting of the American Academy of Neurology.

American Heart Association/American Stroke Association guidelines recommend a door-to-needle (DTN) time of 60 minutes or less and set a goal for participating hospitals to administer tissue plasminogen activator (TPA) to at least 50% of their patients with acute ischemic stroke within 60 minutes of arriving at the hospital.

©Jack Cote/UVA

Dr. Judd Jensen described the efforts of Swedish Medical Center, Englewood, Colo. to streamline the emergency care of patients suspected of having an acute ischemic stroke after a task force determined that their previous “sequential, step-by-step process” wasted time. The median DTN time at the hospital’s stroke center had dropped from 46 minutes in 2010 to 39 minutes in 2013, which was better than the national average, “but we felt we could do better,” said Dr. Jensen, a neurologist at the hospital.

The process was modified so that more of the activities take place simultaneously, which includes immediately sending patients for a CT scan before entering the emergency department and administering IV TPA in the CT area to eligible patients, he explained. Previously, these patients were taken to a bed in the ED on arrival, registered, then examined by the emergency physician and neurologist and transported for a CT scan and then transported back to the ED where TPA was administered, if indicated, after several other steps were completed, including interpreting the CT scan, deciding about treatment, acquiring consent, and contacting the pharmacy to mix the TPA.

This process was improved by increasing pre-hospital notification by emergency medical services (EMS) and establishing a “launchpad” area in the back of the ED where the stroke team meets after EMS notification. On arrival, patients are transferred directly to the CT room where they are examined. The pharmacy is instructed to mix the TPA if an ischemic stroke is suspected, and the TPA is brought to the CT room where a stroke neurologist evaluates the CT scan and TPA is administered if indicated.

The impact of the revised process was evaluated in a prospective study of 262 acute ischemic stroke patients who received IV TPA between January 2010 and December 2014 at the hospital. They had a mean age of 73 years, 44% were male, and 84% were white. Their mean initial National Institutes of Health Stroke Scale (NIHSS) score was 12. The median DTN times dropped to a median of 31 minutes in 2014, Dr. Jensen said.

In 2014, almost 50% of the patients received TPA in 30 minutes or less, compared with about 25% in 2011, 2012, and 2013, he added, noting that 11 minutes was the fastest DTN time in 2014. Patients with an excellent discharge modified Rankin Scale (mRS) score (0 or 1) improved from 31% in 2010 and 30% in 2013 to 46% in 2014. During the time period studied, two patients had a symptomatic intracerebral hemorrhage, one in 2010 and another in 2012.

Dr. Jensen described the process as a multidisciplinary team effort, noting that it is important that emergency room physicians feel comfortable with the administration of TPA in the CT scan area, “because it is still their patient being administered a potentially fatal drug outside of the ED.”

At the meeting, Matthew Padrick, a medical student at the University of Virginia, Charlottesville, presented the results of a pilot study that targeted the EMS transport time as an “untapped treatment window” to improve the time to thrombolytic treatment using a low-cost mobile telestroke system to evaluate patients in the ambulance on their way to the hospital.

Because the catchment area covered by UVA includes a large rural area, transport times to the stroke center can be as long as 30 to 60 minutes, Mr. Padrick said.

In the “Improving Treatment with Rapid Evaluation of Acute Stroke via mobile Telemedicine” (iTREAT) study, he and his associates evaluated the feasibility and reliability of performing acute stroke assessments (with the NIHSS) in the ambulance. The iTREAT system, which includes an Apple iPad with retina display attached to the patient stretcher with an extendable clamp, a secure video conferencing application, a high-speed 4G LTE modem, a magnetic antenna on top of the ambulance, and the regional cellular network, “providing seamless connectivity,” he said. At a total cost of under $2,000, the system is designed so that the neurologist can evaluate the patient remotely, via the iPad.

Acting as patients, three medical students were given two unique stroke scenarios each, with stories and specific instructions; vascular neurologists did a face-to-face assessment and a remote iTREAT assessment from the hospital as the students traveled along the major routes to UVA Medical Center. NIHSS scores in the ambulance with the iTREAT system and with face-to-face assessments correlated well, with an overall intraclass correlation of 0.98, Mr. Padrick reported.

The ratings of audio-video quality during the iTREAT evaluations were judged to be ”good” or “excellent” and the NIHSS correlations and audio-video quality ratings improved with time, he added.

“We currently have IRB approval to move forward with real, live patient encounters and we are currently outfitting and training our local EMS agencies” with the system, Mr. Padrick said in an interview after the meeting.

Mr. Padrick has received research support from the American Heart Association. Dr. Judd had nothing to disclose.

[email protected]

WASHINGTON – A streamlined emergency care service and a low-cost, tablet-based mobile telestroke system are two examples of shortening the time it takes for acute ischemic stroke patients to receive thrombolytic therapy that were presented at the annual meeting of the American Academy of Neurology.

American Heart Association/American Stroke Association guidelines recommend a door-to-needle (DTN) time of 60 minutes or less and set a goal for participating hospitals to administer tissue plasminogen activator (TPA) to at least 50% of their patients with acute ischemic stroke within 60 minutes of arriving at the hospital.

©Jack Cote/UVA

Dr. Judd Jensen described the efforts of Swedish Medical Center, Englewood, Colo. to streamline the emergency care of patients suspected of having an acute ischemic stroke after a task force determined that their previous “sequential, step-by-step process” wasted time. The median DTN time at the hospital’s stroke center had dropped from 46 minutes in 2010 to 39 minutes in 2013, which was better than the national average, “but we felt we could do better,” said Dr. Jensen, a neurologist at the hospital.

The process was modified so that more of the activities take place simultaneously, which includes immediately sending patients for a CT scan before entering the emergency department and administering IV TPA in the CT area to eligible patients, he explained. Previously, these patients were taken to a bed in the ED on arrival, registered, then examined by the emergency physician and neurologist and transported for a CT scan and then transported back to the ED where TPA was administered, if indicated, after several other steps were completed, including interpreting the CT scan, deciding about treatment, acquiring consent, and contacting the pharmacy to mix the TPA.

This process was improved by increasing pre-hospital notification by emergency medical services (EMS) and establishing a “launchpad” area in the back of the ED where the stroke team meets after EMS notification. On arrival, patients are transferred directly to the CT room where they are examined. The pharmacy is instructed to mix the TPA if an ischemic stroke is suspected, and the TPA is brought to the CT room where a stroke neurologist evaluates the CT scan and TPA is administered if indicated.

The impact of the revised process was evaluated in a prospective study of 262 acute ischemic stroke patients who received IV TPA between January 2010 and December 2014 at the hospital. They had a mean age of 73 years, 44% were male, and 84% were white. Their mean initial National Institutes of Health Stroke Scale (NIHSS) score was 12. The median DTN times dropped to a median of 31 minutes in 2014, Dr. Jensen said.

In 2014, almost 50% of the patients received TPA in 30 minutes or less, compared with about 25% in 2011, 2012, and 2013, he added, noting that 11 minutes was the fastest DTN time in 2014. Patients with an excellent discharge modified Rankin Scale (mRS) score (0 or 1) improved from 31% in 2010 and 30% in 2013 to 46% in 2014. During the time period studied, two patients had a symptomatic intracerebral hemorrhage, one in 2010 and another in 2012.

Dr. Jensen described the process as a multidisciplinary team effort, noting that it is important that emergency room physicians feel comfortable with the administration of TPA in the CT scan area, “because it is still their patient being administered a potentially fatal drug outside of the ED.”

At the meeting, Matthew Padrick, a medical student at the University of Virginia, Charlottesville, presented the results of a pilot study that targeted the EMS transport time as an “untapped treatment window” to improve the time to thrombolytic treatment using a low-cost mobile telestroke system to evaluate patients in the ambulance on their way to the hospital.

Because the catchment area covered by UVA includes a large rural area, transport times to the stroke center can be as long as 30 to 60 minutes, Mr. Padrick said.

In the “Improving Treatment with Rapid Evaluation of Acute Stroke via mobile Telemedicine” (iTREAT) study, he and his associates evaluated the feasibility and reliability of performing acute stroke assessments (with the NIHSS) in the ambulance. The iTREAT system, which includes an Apple iPad with retina display attached to the patient stretcher with an extendable clamp, a secure video conferencing application, a high-speed 4G LTE modem, a magnetic antenna on top of the ambulance, and the regional cellular network, “providing seamless connectivity,” he said. At a total cost of under $2,000, the system is designed so that the neurologist can evaluate the patient remotely, via the iPad.

Acting as patients, three medical students were given two unique stroke scenarios each, with stories and specific instructions; vascular neurologists did a face-to-face assessment and a remote iTREAT assessment from the hospital as the students traveled along the major routes to UVA Medical Center. NIHSS scores in the ambulance with the iTREAT system and with face-to-face assessments correlated well, with an overall intraclass correlation of 0.98, Mr. Padrick reported.

The ratings of audio-video quality during the iTREAT evaluations were judged to be ”good” or “excellent” and the NIHSS correlations and audio-video quality ratings improved with time, he added.

“We currently have IRB approval to move forward with real, live patient encounters and we are currently outfitting and training our local EMS agencies” with the system, Mr. Padrick said in an interview after the meeting.

Mr. Padrick has received research support from the American Heart Association. Dr. Judd had nothing to disclose.

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SAN DIEGO – Although cardiovascular disease is on the rise, incidence of ST-elevation myocardial infarction has steadily declined in recent years, with STEMI visits to emergency departments dropping by almost a third between 2006 and 2011, and STEMI-related hospitalizations down as well.

The decline is likely the result of better medical management of known cardiovascular disease, resulting in fewer STEMIs. It may also stem from the bypassing of emergency departments by emergency medical technicians, who can take patients straight to a catheterization lab when they detect STEMI, said Dr. Michael J. Ward, a leading researcher in emergency health care from Vanderbilt University in Nashville, Tenn., at the annual meeting of the Society for Academic Emergency Medicine.

© decade3d/Thinkstock

But this trend, while a good thing for most patients, presents potential pitfalls for emergency departments in achieving timely treatment, he said.

In a STEMI incidence study using data on about 1.43 million ED STEMI visits from the Nationwide Emergency Department Sample (NEDS) during 2006-2011, ED STEMI visits per 10,000 U.S. adults declined significantly, from 10.1 in 2006 to 7.3 in 2011. Declines were seen across all age groups and regions during the study period, Dr. Ward and colleagues found in their recently published study (Am. J. Cardiol. 2015;115:167-70).

In a separate analysis of the same data, transfer rates of STEMI patients increased from 15% in 2006 to 20.6% in 2011. Patients without insurance were 60% (adjusted odds ratio, 1.64) more likely to be transferred when presenting to an ED with STEMI than patients with insurance, the investigators found.

Both trends – the decline in presentations to the ED and the increase in transfers – could mean higher risk for patients presenting to EDs with STEMI, Dr. Ward said in an interview.

“You basically have 90 minutes from the time a STEMI patient presents to get the vessel open,” Dr. Ward said. “There’s really very little margin for error. If you’re seeing fewer STEMIs, are you and your staff going to be less practiced? And what if patients present unusually? What if it’s not the older male with chest pain, but a younger female with back pain or just not feeling well?”

The finding of an increase in transfers is problematic as well, he said. “Only about a third of ED facilities have catheterization capabilities. As EDs see fewer and fewer STEMI patients, they may not be able to maintain their ability to recognize and care for them, or develop a lower threshold for transfer.”

Even after adjusting for confounders such as age, presentation at a rural facility, and presentation on a weekend, the likelihood for transfer among self-pay patients, compared with those with any form of insurance, including Medicare and Medicaid, was increased by 64%, Dr. Ward reported.

The findings show that STEMI patients without insurance “are much more likely to be transferred, receiving less timely and therefore lower quality care for the most severe form of heart attack,” Dr. Ward said.

The reasons for this are unknown, he said. “One may be that patients without insurance are presenting to facilities that don’t have the ability to treat them: rural facilities, or facilities without the capability to treat this particular type of emergency. The other possibility is that they’re presenting to one that does have the capability, yet they’re still being transferred.”

Even if a patient with STEMI presents to a facility without the capability to treat a STEMI, and there’s another next door that can, “it still introduces a significant delay,” and with that higher risks, he said.

Dr. Ward’s research was funded by grants from the National Institutes of Health. He disclosed no conflicts of interest.

SAN DIEGO – Although cardiovascular disease is on the rise, incidence of ST-elevation myocardial infarction has steadily declined in recent years, with STEMI visits to emergency departments dropping by almost a third between 2006 and 2011, and STEMI-related hospitalizations down as well.

The decline is likely the result of better medical management of known cardiovascular disease, resulting in fewer STEMIs. It may also stem from the bypassing of emergency departments by emergency medical technicians, who can take patients straight to a catheterization lab when they detect STEMI, said Dr. Michael J. Ward, a leading researcher in emergency health care from Vanderbilt University in Nashville, Tenn., at the annual meeting of the Society for Academic Emergency Medicine.

© decade3d/Thinkstock

But this trend, while a good thing for most patients, presents potential pitfalls for emergency departments in achieving timely treatment, he said.

In a STEMI incidence study using data on about 1.43 million ED STEMI visits from the Nationwide Emergency Department Sample (NEDS) during 2006-2011, ED STEMI visits per 10,000 U.S. adults declined significantly, from 10.1 in 2006 to 7.3 in 2011. Declines were seen across all age groups and regions during the study period, Dr. Ward and colleagues found in their recently published study (Am. J. Cardiol. 2015;115:167-70).

In a separate analysis of the same data, transfer rates of STEMI patients increased from 15% in 2006 to 20.6% in 2011. Patients without insurance were 60% (adjusted odds ratio, 1.64) more likely to be transferred when presenting to an ED with STEMI than patients with insurance, the investigators found.

Both trends – the decline in presentations to the ED and the increase in transfers – could mean higher risk for patients presenting to EDs with STEMI, Dr. Ward said in an interview.

“You basically have 90 minutes from the time a STEMI patient presents to get the vessel open,” Dr. Ward said. “There’s really very little margin for error. If you’re seeing fewer STEMIs, are you and your staff going to be less practiced? And what if patients present unusually? What if it’s not the older male with chest pain, but a younger female with back pain or just not feeling well?”

The finding of an increase in transfers is problematic as well, he said. “Only about a third of ED facilities have catheterization capabilities. As EDs see fewer and fewer STEMI patients, they may not be able to maintain their ability to recognize and care for them, or develop a lower threshold for transfer.”

Even after adjusting for confounders such as age, presentation at a rural facility, and presentation on a weekend, the likelihood for transfer among self-pay patients, compared with those with any form of insurance, including Medicare and Medicaid, was increased by 64%, Dr. Ward reported.

The findings show that STEMI patients without insurance “are much more likely to be transferred, receiving less timely and therefore lower quality care for the most severe form of heart attack,” Dr. Ward said.

The reasons for this are unknown, he said. “One may be that patients without insurance are presenting to facilities that don’t have the ability to treat them: rural facilities, or facilities without the capability to treat this particular type of emergency. The other possibility is that they’re presenting to one that does have the capability, yet they’re still being transferred.”

Even if a patient with STEMI presents to a facility without the capability to treat a STEMI, and there’s another next door that can, “it still introduces a significant delay,” and with that higher risks, he said.

Dr. Ward’s research was funded by grants from the National Institutes of Health. He disclosed no conflicts of interest.

SAN DIEGO – Although cardiovascular disease is on the rise, incidence of ST-elevation myocardial infarction has steadily declined in recent years, with STEMI visits to emergency departments dropping by almost a third between 2006 and 2011, and STEMI-related hospitalizations down as well.

The decline is likely the result of better medical management of known cardiovascular disease, resulting in fewer STEMIs. It may also stem from the bypassing of emergency departments by emergency medical technicians, who can take patients straight to a catheterization lab when they detect STEMI, said Dr. Michael J. Ward, a leading researcher in emergency health care from Vanderbilt University in Nashville, Tenn., at the annual meeting of the Society for Academic Emergency Medicine.

© decade3d/Thinkstock

But this trend, while a good thing for most patients, presents potential pitfalls for emergency departments in achieving timely treatment, he said.

In a STEMI incidence study using data on about 1.43 million ED STEMI visits from the Nationwide Emergency Department Sample (NEDS) during 2006-2011, ED STEMI visits per 10,000 U.S. adults declined significantly, from 10.1 in 2006 to 7.3 in 2011. Declines were seen across all age groups and regions during the study period, Dr. Ward and colleagues found in their recently published study (Am. J. Cardiol. 2015;115:167-70).

In a separate analysis of the same data, transfer rates of STEMI patients increased from 15% in 2006 to 20.6% in 2011. Patients without insurance were 60% (adjusted odds ratio, 1.64) more likely to be transferred when presenting to an ED with STEMI than patients with insurance, the investigators found.

Both trends – the decline in presentations to the ED and the increase in transfers – could mean higher risk for patients presenting to EDs with STEMI, Dr. Ward said in an interview.

“You basically have 90 minutes from the time a STEMI patient presents to get the vessel open,” Dr. Ward said. “There’s really very little margin for error. If you’re seeing fewer STEMIs, are you and your staff going to be less practiced? And what if patients present unusually? What if it’s not the older male with chest pain, but a younger female with back pain or just not feeling well?”

The finding of an increase in transfers is problematic as well, he said. “Only about a third of ED facilities have catheterization capabilities. As EDs see fewer and fewer STEMI patients, they may not be able to maintain their ability to recognize and care for them, or develop a lower threshold for transfer.”

Even after adjusting for confounders such as age, presentation at a rural facility, and presentation on a weekend, the likelihood for transfer among self-pay patients, compared with those with any form of insurance, including Medicare and Medicaid, was increased by 64%, Dr. Ward reported.

The findings show that STEMI patients without insurance “are much more likely to be transferred, receiving less timely and therefore lower quality care for the most severe form of heart attack,” Dr. Ward said.

The reasons for this are unknown, he said. “One may be that patients without insurance are presenting to facilities that don’t have the ability to treat them: rural facilities, or facilities without the capability to treat this particular type of emergency. The other possibility is that they’re presenting to one that does have the capability, yet they’re still being transferred.”

Even if a patient with STEMI presents to a facility without the capability to treat a STEMI, and there’s another next door that can, “it still introduces a significant delay,” and with that higher risks, he said.

Dr. Ward’s research was funded by grants from the National Institutes of Health. He disclosed no conflicts of interest.

Grip strength measurement is a quick and inexpensive way to stratify an individual’s risk of all-cause mortality, and can be a strong predictor of cardiovascular mortality and a moderately strong predictor of incident cardiovascular disease, according to new research in The Lancet.

In a large, longitudinal population study, nearly 140,000 participants identified from the Prospective Urban-Rural Epidemiology (PURE) study were examined during 2003-2009. Grip strength was measured via handgrip dynamometer.

After adjustment, grip strength was inversely associated with all-cause mortality (hazard ratio per 5-kg reduction in grip strength 1.16), cardiovascular mortality (1.17), noncardiovascular mortality (1.17), myocardial infarction (1.07), and stroke (1.09). The results were highly statistically significant and largely similar across various socioeconomic groups, although risk of cancer and grip strength were positively associated more often among patients in higher-income countries than in middle- and lower-income countries, reported Dr. Darryl P. Leong of McMaster University, Hamilton, Ont., and his colleagues.

The researchers also attempted to assess the prognostic value of grip strength on other medical conditions, but “found no significant association” between grip strength and incident diabetes and no association between grip strength and risk of hospital admission for pneumonia or COPD, injury from fall, or fracture.

“Our study suggests that measurement of grip strength is a simple, inexpensive risk-stratifying method to assess risk of death, particularly in individuals who develop a major illness, and that muscle strength is a risk marker for incident cardiovascular disease in a number of countries and populations,” the investigators wrote.

Read the entire article here.

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Grip strength measurement is a quick and inexpensive way to stratify an individual’s risk of all-cause mortality, and can be a strong predictor of cardiovascular mortality and a moderately strong predictor of incident cardiovascular disease, according to new research in The Lancet.

In a large, longitudinal population study, nearly 140,000 participants identified from the Prospective Urban-Rural Epidemiology (PURE) study were examined during 2003-2009. Grip strength was measured via handgrip dynamometer.

After adjustment, grip strength was inversely associated with all-cause mortality (hazard ratio per 5-kg reduction in grip strength 1.16), cardiovascular mortality (1.17), noncardiovascular mortality (1.17), myocardial infarction (1.07), and stroke (1.09). The results were highly statistically significant and largely similar across various socioeconomic groups, although risk of cancer and grip strength were positively associated more often among patients in higher-income countries than in middle- and lower-income countries, reported Dr. Darryl P. Leong of McMaster University, Hamilton, Ont., and his colleagues.

The researchers also attempted to assess the prognostic value of grip strength on other medical conditions, but “found no significant association” between grip strength and incident diabetes and no association between grip strength and risk of hospital admission for pneumonia or COPD, injury from fall, or fracture.

“Our study suggests that measurement of grip strength is a simple, inexpensive risk-stratifying method to assess risk of death, particularly in individuals who develop a major illness, and that muscle strength is a risk marker for incident cardiovascular disease in a number of countries and populations,” the investigators wrote.

Read the entire article here.

[email protected]

Grip strength measurement is a quick and inexpensive way to stratify an individual’s risk of all-cause mortality, and can be a strong predictor of cardiovascular mortality and a moderately strong predictor of incident cardiovascular disease, according to new research in The Lancet.

In a large, longitudinal population study, nearly 140,000 participants identified from the Prospective Urban-Rural Epidemiology (PURE) study were examined during 2003-2009. Grip strength was measured via handgrip dynamometer.

After adjustment, grip strength was inversely associated with all-cause mortality (hazard ratio per 5-kg reduction in grip strength 1.16), cardiovascular mortality (1.17), noncardiovascular mortality (1.17), myocardial infarction (1.07), and stroke (1.09). The results were highly statistically significant and largely similar across various socioeconomic groups, although risk of cancer and grip strength were positively associated more often among patients in higher-income countries than in middle- and lower-income countries, reported Dr. Darryl P. Leong of McMaster University, Hamilton, Ont., and his colleagues.

The researchers also attempted to assess the prognostic value of grip strength on other medical conditions, but “found no significant association” between grip strength and incident diabetes and no association between grip strength and risk of hospital admission for pneumonia or COPD, injury from fall, or fracture.

“Our study suggests that measurement of grip strength is a simple, inexpensive risk-stratifying method to assess risk of death, particularly in individuals who develop a major illness, and that muscle strength is a risk marker for incident cardiovascular disease in a number of countries and populations,” the investigators wrote.

Read the entire article here.

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Obese patients on warfarin may be at greater risk of bleeding than those of normal weight, according to a study presented at the American Heart Association’s Arteriosclerosis, Thrombosis, and Vascular Biology/Peripheral Vascular Disease Scientific Sessions 2015.

Researchers followed 863 patients attending an anticoagulation clinic for 1 year and found that obesity (body mass index greater than 30 kg/m²) was associated with a statistically significant 84% increase in the risk of major bleeds, such as gastrointestinal, intracerebral, and retroperitoneal hemorrhage.

The study also showed that increasing obesity increased bleeding risk; there was a 30% increase in bleeding risk for patients with class I obesity but a 93% increase in patients with class III obesity.

“This result suggests that BMI plays a role in bleeding events in patients on warfarin [and] future studies are needed to understand the mechanism by which obesity increases bleeding risk for patients on warfarin, and whether similar risk exists for the novel oral anticoagulants,” said Dr. Adedotun A. Ogunsua of the University of Massachusetts, Worcester, and coauthors.

There were no conflicts of interest disclosed.

Obese patients on warfarin may be at greater risk of bleeding than those of normal weight, according to a study presented at the American Heart Association’s Arteriosclerosis, Thrombosis, and Vascular Biology/Peripheral Vascular Disease Scientific Sessions 2015.

Researchers followed 863 patients attending an anticoagulation clinic for 1 year and found that obesity (body mass index greater than 30 kg/m²) was associated with a statistically significant 84% increase in the risk of major bleeds, such as gastrointestinal, intracerebral, and retroperitoneal hemorrhage.

The study also showed that increasing obesity increased bleeding risk; there was a 30% increase in bleeding risk for patients with class I obesity but a 93% increase in patients with class III obesity.

“This result suggests that BMI plays a role in bleeding events in patients on warfarin [and] future studies are needed to understand the mechanism by which obesity increases bleeding risk for patients on warfarin, and whether similar risk exists for the novel oral anticoagulants,” said Dr. Adedotun A. Ogunsua of the University of Massachusetts, Worcester, and coauthors.

There were no conflicts of interest disclosed.

Obese patients on warfarin may be at greater risk of bleeding than those of normal weight, according to a study presented at the American Heart Association’s Arteriosclerosis, Thrombosis, and Vascular Biology/Peripheral Vascular Disease Scientific Sessions 2015.

Researchers followed 863 patients attending an anticoagulation clinic for 1 year and found that obesity (body mass index greater than 30 kg/m²) was associated with a statistically significant 84% increase in the risk of major bleeds, such as gastrointestinal, intracerebral, and retroperitoneal hemorrhage.

The study also showed that increasing obesity increased bleeding risk; there was a 30% increase in bleeding risk for patients with class I obesity but a 93% increase in patients with class III obesity.

“This result suggests that BMI plays a role in bleeding events in patients on warfarin [and] future studies are needed to understand the mechanism by which obesity increases bleeding risk for patients on warfarin, and whether similar risk exists for the novel oral anticoagulants,” said Dr. Adedotun A. Ogunsua of the University of Massachusetts, Worcester, and coauthors.

There were no conflicts of interest disclosed.