Adherence To NOAC Therapy: A Case Study

Currently, Heart disease is the leading cause of death among women in the United States (Haskell et al., 2014). In the 2016 Update of the Heart Disease and Stroke Statistics report from the American Heart Association, women, in general, have a 32% prevalence rate for LDL issues vs. 31% for men. Likewise, in older women vs older men, the prevalence for hypertension rates for women were 57% vs. 54% in men (Mozaffarian et al., 2016). Within the VA, there is an even bigger gap for management of LDL’s and heart disease. 79.47% of women vs. 88.89% of men have LDL levels within the normal limits. Similarly, 79.34% of women vs. 85.67% of men with diabetes had an LDL within normal limits (Whitehead et al., 2014). Both high LDL and hypertension are proven risk factors for heart disease and stroke. When paired with diabetes, risk of peripheral artery disease, heart failure, and irregular heartbeat can also be factors (Mozaffarian et al., 2016).

Many organizations have developed practice guidelines for a myriad of clinical scenarios which include the use of specific drugs or classes of medications, typically in a step-wise pattern. These “Best Practice” guidelines are built on evidence based criteria and systematic reviews. It has been shown that these clinical guidelines, with their list of essential medications, improve the quality of care and lead to better outcomes, but have not been shown to reduce costs.4,5 The practice of medicine has moved dramatically towards the use of these guidelines in recent years. For example, best practices for diabetic care recommends that all patients be placed on an ACE (angiotensin converting enzyme) inhibitor or ARB (angiotensin receptor blocker) for prevention of diabetic nephropathy and a statin for prevention of coronary artery disease. However, each patient’s insurance may cover a different medication in this class

I agree with you, the patients we treat should be just as responsible in their healthcare plans as we are in rendering treatment plans; however, providing care to non-adherent patients can place everyone at certain risk if not handled appropriately. The best way to protect the clinic and your staff when dealing with non-adherent patients is to not only document non-adherence issues identified, but also be specific as to which strategies were implemented to help the high risk patient in becoming compliant with proposed medical guidelines ( CMPA, 2013). The CMPA recommends that having open communication with patients is important and providers need to assess potential obstacles ( socio-economic, education levels, language barriers, and attitudes) early on; therefore, begin to provide available resources to assist the patient in hopes to mitigate foreseeable complications. Foreseeability entails "guarding against that which is probable and likely to happen, not against that which is only remotely possible" ( Pozar, 2016, p.

Well written paper on beta blockers in controlling hypertension. In my experience, I had seen more than 80% of patients are prescribed with antihypertensive drugs in their medical chart. A beta blocker is one of the most common drugs in a geriatric setting especially atenolol. Beta blockers are the standard of therapy for many cardiovascular conditions and it is the main line of treatment in decreasing risk of stroke. According to Ladage, Schwinger, and Brixius (2013) beta blocker was more effective in decreasing mortality and morbidity rate in acute coronary syndrome patients. Atenolol is a water soluble and had longer half-lives with non-metabolized actions and excreted via the kidneys (Ladage et al., 2013). The exercise capacity increases in patients who are on beta-blockers, like bisoprolol, nebivolol, carvedilol (Ladage et al., 2013). A recent meta-analysis study showed patients who are untreated with hypertension, they are at risk of developing chronic kidney diseases, cardiovascular complications, and cerebrovascular complications (Butt & Harvey, 2015). In one study, mainly geriatric population who are taking atenolol had shown greater mortality rate and increase arterial pressure (Testa et al., 2014).

This report is an analysis of an anonymous patient’s medications and how they relate to his health issues. Please note that the patient will be referred to as patient Afib in order to protect his privacy. Patient Afib is a 58 year old male with a recent onset of atrial fibrillation (AF) that has been cured using ablation and antiarrhythmic medications. This report discusses how physicians treated patient Afib’s AF, the medications patient Afib is currently taking and their mechanism of action, and how these medications relate to the patient’s disease. Medications discussed in this analysis include Proair HFA, Multaq, Toprol XL, and Coumadin. Proair HFA, a rescue inhaler used to treat asthma, was prescribed to patient Afib in order to determine if AF or underlying asthma caused his shortness of breath. Multaq is an antiarrhythmic drug used to keep patient Afib in a normal sinus rhythm. Toprol XL is a medication used in the treatment of hypertension that also exhibits rate controlling properties which prove beneficial for patient Afib. Coumadin, an anticoagulant, is used to reduce the risk of stroke for patient Afib should his AF ever spontaneously return without his knowledge. Patient Afib does not like the regime of pills he is required to take but understands their necessity.

In 2012, the phase 1 trials were published in The Journal of the American College of Cardiology. The phase 1 trials had two arms. Phase 1a were healthy subjects and phase 1b has subjects with hypercholestemia receiving stable statin therapy. The aim of this study was to evaluate the safety, tolerability and effects of AMG 145. Phase 1a had 56 subjects at 1 U.S. center, who were randomized to either get a single dose of placebo, 7mg to 420mg of AMG 145 subcutaneously or 21mg or 420mg via a one hour intravenous infusion. Percentagewise 69% of the subjects in the AMG 145 group experienced a treatment-emergent adverse event compared to 71% of the subjects in the placebo group. There was zero discontinuation due to adverse events in this arm of

According to a systematic review by James et al. (2014) on several RCT, there is strong evidence of the advantage of treating people aged 60 above with a blood pressure threshold of 160/90 and people aged less than 60 years with a threshold of 140/90 mmHg. This study also reported that there is moderate evidence to support HCTZ, ACE or ARB as the first line therapy for the nonblack hypertensive population to control hypertension and prevent cardiovascular events. This study also concluded with a strong evidence of starting thiazide diuretics as first-line therapy for black hypertensive patients (James et al., 2014). An RCT study by Krones et al. (2008) demonstrated that shared decision making (SDM) increased patient satisfaction and lowered decisional regret.

The main concerns regarding treating a patient with AF are rhythm control, rate control, and anticoagulation (Zak, 2010). For patient X, he was started on Metoprolol (beta blocker), Amiodarone (anti-dysrhythmic) and Warfarin (anticoagulation). Due to Warfarin’s ability to alter the INR of the blood, it is imperative to monitor the INR frequently to ensure that the level is therapeutic (Shea and Sears, 2008). Patient X had a full time job though making minimum wage. He was unable to take time off of work to get his blood drawn monthly for INR levels at his doctor’s office. This would result in sub therapeutic levels of anticoagulation and therefore noncompliance. He suffered a pulmonary embolus from the sub therapeutic anticoagulation and was hospitalized. After speaking with his cardiologist regarding other means of anticoagulation, the decision was made to change his medication from Warfarin to Pradaxa, an anticoagulant of a different

The European Society of Cardiology guidelines recommend that if the patient has a CHADS2 score of >2, oral anticoagulation therapy such as warfarin, dabagitran, or rivaroxaban should be prescribed. If the CHADS2 score is 0-1, other stroke risk modifiers could be considered such as

A retrospective descriptive study examined the duration of biologic use from veterans with rheumatoid arthritis (Tran et al., 2009). The values in Table 27-4 were extracted from a larger sample of veterans who had a history of biologic medication use (e.g., infliximab [Remicade], etanercept [Enbrel]). Table 27-4 contains simulated demographic data collected from 10 veterans who had stopped taking biologic medications. Age at study enrollment, duration of biologic use, race/ethnicity, gender (F = female), tobacco use (F = former use, C = current use, N = never used), primary diagnosis (3 = irritable bowel syndrome, 4 = psoriatic arthritis,

Preventative measures are complex and may include basic lifestyle modifications. Some modifications include increased physical activity, improved diet, drug treatments and smoking cessation. Drug treatments, such as a low dosage aspirin regimen, are widely used in clinical practice for secondary prevention after a patient experiences a stroke or myocardial infarction. Low-dose aspirin is used more often as a primary prevention measure for CVD to prevent the onset of life-threatening occurrences (Stegeman et al., 2015). However, aspirin use is advised to be monitored, especially in patients that are already at risk for CVD. Education regarding the usage of drugs for treatment should be enforced to ensure a user’s safety (Stegeman et al., 2015). Selective treatment of women around the age of 65 or older with aspirin has been observed to improve the risk of CVD (Van Kruijsdijk et al.,

I was extremely excited to do this chart audit since I am conducting my DNP project on this topic. In my first audit last year our clinic had only 45% compliance with the guidelines and we were still following JNC 6 Guideline. However, after starting the project, the compliance has increased to 80% and care has been improved. This audit had brought in numbers that I could discuss with him in a professional way and it reflects a vast difference in quality improvement. Initially, chart auditing did not seem very appealing to the doctor but now it has become a norm for our clinic to do chart audit periodically. We still have to work hard in the area of patient compliance to the medications to prevent hypertension

There were also several potential confounders that were not accounted for, such NYHA class and ejection fraction, hyperlipidemia, alcohol consumption, family history of CV disease, socio-economic status, body mass index (BMI), and use of other medications such as other antiplatelets (e.g. ADP/PY2 inhibitors), other anti-hyperlipidemia drugs (e.g. fibrates, nicotinic acid, etc). There were also unknown differences in treatment and lifestyle received during follow up period.

Participants who answered as “yes” for the following comorbidities were assumed to have them present by the time the survey was filled: obesity, respiratory problems, arthritis, thyroid problems, cancer, retinopathy, kidney failure, heart disease and

First goal: Patient will verbalize understanding of the importance of follow her heart medication regime as doctor prescribed it and describe the possible consequence of a non-compliance with her treatment by the end of her today’s appointment.