Direct oral anticoagulants (DOACs) are gaining popularity for patients with nonvalvular atrial fibrillation (AF) for stroke prevention. Less bleeding risk with comparable stroke prevention compared to warfarin was shown. DOACs have predictable anticoagulant effects, infrequent monitoring requirements and less drug-food interactions compared to warfarin. However, safety and efficacy data of DOACs in patients with chronic kidney disease (CKD) are limited. This is a retrospective study to evaluate thromboembolic and bleeding events in patients with AF (with/without CKD) in October 2010 and July 2017. A total of 495 patients were included and only 150 patients had CKD. Our study found that patients with renal impairment on a DOAC do not have a higher incidence of bleeding events. It showed significant increase in thromboembolic events in CKD patients with dabigatran compared to CKD patients with apixaban with odds ratio of 6.58 (95%CI 1.35–32.02, p = 0.02).

Vasopressors and inotropes (Vs/Is) are widely used in the treatment of cardiogenic shock (CS). Despite improvements in hemodynamic variables and end-organ perfusion, these agents have been associated with an increase in mortality, potentially due to the increased risk of tachyarrhythmias—which we hypothesize may be mitigated by beta-blockers (BBs). We conducted a retrospective chart review of patients who received a V/I (dobutamine, milrinone, dopamine, and norepinephrine) for CS. The primary objective was to assess the effect of BB in patients receiving Vs/Is for CS. In our final analysis of 227 patients, those in the BB group were younger, were more likely to have acute coronary syndrome as the reason for admission, had more reduced left ventricular ejection fraction, were more likely to have coronary artery disease and atrial fibrillation as pre-existing co-morbidities, and had a lower rate of in-hospital mortality. Nevertheless, in our multivariable logistic regression analysis, concurrent BB usage with a V/I was not associated with a reduction in in-hospital mortality. Our present study sheds light on the importance and urgency of large, carefully designed clinical studies to optimize inpatient medical therapy, particularly evaluating the combination of V/I and BB, in this high-risk patient population.

Purpose: American expert consensus publications recommend discontinuation of antiplatelet agents 6 to 12 months after Percutaneous Coronary Intervention (PCI) in patients with Atrial Fibrillation (AF) who require chronic anticoagulation, and use of oral anticoagulant monotherapy thereafter. This study aimed to assess real-world long-term antithrombotic therapy management practices and factors associated with the continuation of antiplatelet agents past 12 months post-PCI in patients with AF requiring chronic anticoagulation. Methods: Patients with AF and a history of PCI greater than 12 months before their most recent encounter with physicians at an outpatient electrophysiology clinic were identified by chart review. Patient demographics, clinical characteristics, and current antithrombotic regimen were collected from encounters that occurred between July 2019 and June 2022. The independent predictive factors associated with the continuation of antiplatelet agents were identified using univariate and regression analyses. Results: Out of 66 patients, 67% continued antiplatelet therapy for greater than 12 months post-PCI. Patients on antiplatelets were significantly less likely to have bare metal stents (p = 0.006), be greater than five years post-PCI (p = 0.002), and have a HASBLED score of two or less (p = 0.028) when compared to patients on oral anticoagulant monotherapy. Bare metal stent history (p = 0.045) and HASBLED score of two or less (p = 0.016) were also significant in regression analysis. Conclusion: This study found that most patients with AF and a history of PCI continued antiplatelet therapy longer than 12 months post-PCI, often despite the high bleeding risk.

Introduction: There is limited evidence supporting the use of intravenous (IV) diuretics in the outpatient setting for patients with acute decompensated heart failure (ADHF). In January 2023, our heart failure clinic implemented a protocol to administer IV furosemide for patients presenting with signs of fluid overload during clinic visits. Outpatient IV furosemide may serve as an alternative to hospitalization for ADHF management, potentially reducing the burden on inpatient resources; however, its real-world impact remains unclear. The objective of this study was to evaluate the impact of outpatient IV furosemide protocol implementation at the clinic level, rather than to assess individual patient-level treatment effectiveness. This study aimed to evaluate whether protocol implementation was associated with changes in ADHF-related hospitalizations and mortality.Methodology: This was a single-center, retrospective, pre- and post-implementation study of outpatient IV furosemide included adult heart failure patients followed by the heart failure clinic between 01/01/2022–07/31/2022 (pre-implementation) and 01/01/2024–07/31/2024 (post-implementation). Patients were included if they were receiving loop diuretics (≥ 40 mg oral furosemide or equivalent) and presented with symptoms of fluid overload. Exclusion criteria included a history of heart transplantation, left ventricular assist device insertion, or outpatient inotrope use. The outcomes of the study were the number of hospitalizations and mortality within 30 and 90 days of the clinic visit.Results: A total of 402 patients were included with 200 patients in the pre-implementation cohort and 202 in the post-implementation group, of whom 14 (7%) received outpatient IV furosemide. At 30 days, ADHF-related hospitalizations occurred in 6% of patients in the pre-implementation cohort and 7.9% in the post-implementation group (p = 0.449), while at 90 days, the proportions were 10% in both groups (p = 0.892). Thirty-day mortality was 1% in both groups (p = 0.994).Discussion: A higher number of both ADHF-related and all-cause hospitalizations were observed in the post-implementation group. Several factors may explain the limited benefit observed, including a small proportion of post-implementation patients receiving outpatient IV furosemide (7%), baseline differences between groups, and potential residual impacts of the COVID-19 pandemic. Conclusion: The implementation of an outpatient IV furosemide protocol did not result in a significant reduction in heart failure-related hospitalizations or mortality in this study. These findings reflect real-world implementation challenges rather than definitive evidence against outpatient IV diuretics. Further research is needed to evaluate the optimal patient population and timing for outpatient IV diuresis.