Periop anticoagulation in afib, patient-to-intensivist ratios, and more

Summaries from ACP Hospitalist Weekly.

New decision pathway for periop anticoagulation in afib

The American College of Cardiology recently published an expert consensus decision pathway for the periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation.

With comprehensive flowcharts, the pathway provides guidance on whether, when, and how to interrupt anticoagulation (vitamin K antagonists [VKA] or direct-acting oral anticoagulants [DAOC]) before a procedure. It also offers recommendations on whether and how to periprocedurally bridge with a parenteral agent and outlines the process of restarting anticoagulation after a procedure. The full pathway was published online on Jan. 9 by the Journal of the American College of Cardiology.

When deciding whether to interrupt anticoagulation, the pathway recommends considering VKA versus DOAC therapy, evaluating the patient's bleed risk, evaluating procedural bleed risk, and using clinical judgment. In addition to assessing a patient's risk with the HAS-BLED score, clinicians should also consider any bleed events in the past three months, platelet abnormalities, increased international normalized ratio (INR), and history of bleeding from previous bridging or with a similar procedure, according to the pathway.

If a patient does not have an increased risk of bleeding and procedural bleed risk is not clinically important or low, VKA therapy should not be interrupted; with DOAC therapy, the procedure may occur without interruption but should be timed at DOAC interval trough.

If VKA therapy must be interrupted and INR is at goal level five to seven days before the procedure (2.0 to 2.5 or 2.0 to 3.0), it should be discontinued five days prior to the procedure; if INR is subtherapeutic, discontinue three to four days prior; if supratherapeutic, discontinue for five or more days prior. Clinicians should recheck INR 24 hours before the procedure.

The experts found insufficient data on best practices for interrupting DOAC therapy. Clinicians should consider the type of DOAC, measure creatinine clearance, and use clinical judgment to determine how long to interrupt therapy.

When deciding whether to bridge a patient on VKA therapy, clinicians should assess the risk of bleeding before determining thrombotic risk using the CHA2DS2-VASc score. If thrombotic risk is low, bridging should not be used; if moderate or high, recent history of thromboembolic events, major bleeds, or intracranial hemorrhage should be considered and clinical judgment should be used when deciding whether to bridge. Parenteral bridging is not indicated for DOACs.

The pathway says clinicians should strongly consider bridging for patients on VKA therapy if thrombotic risk is high and bleed risk is low, with no thromboembolic events within the past three months. When bridging, clinicians should consider creatinine clearance, heparin allergy or recent heparin-induced thrombocytopenia, and risk of stroke and bleeding to determine whether to administer therapeutic unfractionated heparin or low-molecular-weight heparin or use another strategy.

After the procedure, clinicians should consider VKA versus DOAC, type of surgery, postoperative bleeding risk, bleeding complications, hemostasis, and tolerance of oral medications to determine when and how to restart the original anticoagulant.

Ideal patient-to-intensivist ratio varies in U.K. ICUs

The ideal ratio of patients to intensivists among a cohort of ICU patients in the United Kingdom was 7.5, a recent study found.

Researchers used data from a national case-mix program as well as data from staffing surveys to perform a retrospective cohort analysis of patients 16 years of age and older who were admitted to U.K. ICUs from 2010 to 2013. The ICUs were each staffed by one intensivist during the daytime. The goal of the study was to determine whether the patient-to-intensivist ratio (PIR) varied significantly across the U.K. and whether higher PIRs were associated with higher hospital mortality for patients in the ICU. PIRs were calculated for each patient as the number of patients the intensivists cared for each day averaged over the patient's entire ICU stay. PIR variation across ICUs was calculated according to standard summary statistics. The primary outcome was the association between PIR and hospital mortality at ultimate discharge from the acute care hospital (whether from the original hospital or from a subsequent hospital to which the patient was transferred). Secondary outcomes included ultimate ICU mortality, original ICU mortality, and original hospital mortality. The study results were published in the March JAMA Internal Medicine.

A total of 49,686 adults in 94 ICUs were included in the study. The ICUs had a median of 10 beds. Median patient age was 66 years, 45.1% of patients were women, and median stay in the original ICU was 2.2 days. Most patients (62.1%) were admitted for respiratory, gastrointestinal, or cardiovascular system issues or for other medical reasons. The overall ultimate hospital mortality rate was 25.7%. For all patients, the median PIR was 8.5 (interquartile range, 6.9 to 10.8). PIR varied substantially by individual ICU, with medians ranging from 2 to 19.

The researchers found that each patient's PIR was significantly associated with ultimate hospital mortality after multivariable adjustment. A U-shaped association was seen, with the lowest mortality at a PIR of 7.5 and a significant increase in mortality with PIRs above or below that number. The average patient mortality rates were 22% for the lowest PIR, 15% for a PIR of 7.5, and 19% for the highest PIR. A similar association was found for PIR and ICU mortality, with the lowest mortality at a PIR of 7.8 (P<0.001).

The authors noted that they did not have any information about other potential members of the care teams who may have affected the intensivists' workload, that their results may not be generalizable outside the U.K., and that the PIR measure did not take into account more complex workload components. However, they concluded that based on their findings and the fact that intensivists are often in short supply, intensivist staffing models should be designed with caution.

“Responding to the increasing demand for ICU care by stretching available intensivist resources ever thinner may be detrimental to patients,” they wrote. “Conversely, having intensivists care for too few patients may also result in poor outcomes.” The study results suggest that there may be a “sweet spot” for the PIR, the authors wrote. They called for future studies to examine what drives optimal PIR values in different settings and determine whether varying the PIR will affect outcomes.

The authors of an accompanying invited commentary said the study offers additional information on a difficult problem but said it “urgently demands a follow-up to show how the optimal PIR varies by physician characteristics and characteristics of the ICU and hospital-system in which that physician practices.” The commentary authors said that it is essential to identify the ideal PIR given the trend toward having an intensivist present in the ICU at all times.

Prognostic value of sepsis criteria compared in ED and ICU

Two recent studies compared the prognostic accuracy of various criteria for identifying patients with sepsis.

Both studies were published in the Jan. 17 JAMA and compared the quick Sequential Organ Failure Assessment (qSOFA) score, which was introduced by the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), with the SOFA score and systemic inflammatory response syndrome (SIRS) criteria.

The first study was conducted in 30 European EDs between May and June 2016. The prospective cohort analysis included 879 patients with suspected infection who had an overall in-hospital mortality rate of 8%. The mortality rate was 3% in patients with a qSOFA <2 compared to 24% in those with a score ≥2. The qSOFA score was better at predicting in-hospital mortality than SIRS or severe sepsis, the study found. The results support the Sepsis-3 recommendations, the study authors wrote, noting that the low mortality rate observed in patients with qSOFA <2 supports the safety of replacing SIRS with qSOFA. They also noted that adding blood lactate levels to qSOFA did not improve prognostication. “This along with other current findings could result in a complete change of the current clinical approach because the severity of sepsis up until now has been assessed in ED patients using lactate levels,” the authors wrote. They did caution that the study was limited by its use of the worst qSOFA score during a patient's entire ED stay,and future research should assess the prognostic value of the score at ED entry.

The second study was a retrospective cohort analysis of 184,875 patients admitted to ICUs in Australia or New Zealand with an infection-related primary diagnosis. In-hospital mortality was 18.7%, and 55.7% of patients died or had an ICU length of stay of three days or more. During the first 24 hours in the ICU, the SOFA score increased by two or more points in 90.1% of patients, while 86.7% met two or more SIRS criteria, and 54.4% had a qSOFA ≥2. The researchers found that SOFA demonstrated significantly greater discrimination for in-hospital mortality than SIRS or qSOFA, also supporting the Sepsis-3 recommendations. Study authors cautioned that the data used were not primarily collected for the study's purpose, among other limitations.

An editorial accompanying the studies noted that the ICU study's findings were not surprising. Outside the ICU, based on the other study's results, “qSOFA appears a simple, rapid, inexpensive, and valid way to identify—among patients with suspected infection—those at a higher risk of having or developing sepsis,” the editorialists wrote. They did note limitations, including that 14% of patients recruited in the ED study were excluded due to missing values, and called for further research on qSOFA in lower-income settings and when used longitudinally.