Clinical Research
Cannon, CP. et. al. Automated Heparin-Delivery System to Control Activated Partial Thromboplastin Time (PDF). Circulation. 1999;99:751-756.) Summary: This article describes the results of a prototype automated heparin control system (AutoHep) in which a computer-based titration algorithm adjusted the heparin infusion to reach a target aPTT. The results suggest that the AutoHep system has the potential to significantly improve aPTT control of intravenous heparin compared with current clinical practice.
Cheng, Susan, et. al. Predictors of Initial Nontherapeutic Anticoagulation With Unfractionated Heparin in ST-Segment Elevation Myocardial Infarction (PDF). Circulation.2009;119:1195-1202. Although weight-based nomograms have improved the efficacy and safety of dosing unfractionated heparin in ST-segment elevation myocardial infarction, achieving therapeutic anticoagulation in practice remains challenging. Despite the use of a standard weight-based unfractionated heparin nomogram in ST-segment elevation myocardial infarction, nontherapeutic anticoagulation is frequent and more likely among certain vulnerable patient groups,
Krishnaswamy, A. et. al. The Use and Limitations of Unfractionated Heparin (PDF). Critical Pathways in Cardiology. 2010; 9:35-40. Summary: Attaining therapeutic anticoagulation using unfractionated heparin is complicated. As a result, a minority of patients in major clinical trials achieve an activated partial thromboplastin time within the target window in an appropriate time-frame despite the use of weight-based titration nomograms. The resultant under- or over-therapeutic anticoagulation is associated with increased risks of ischemic and bleeding complications, suggesting the importance of maintaining heparin anticoagulation within a relatively narrow therapeutic range.
Smith, SB. Early Anticoagulation is Associated with Reduced Mortality for Acute Pulmonary Embolism (PDF). Chest; Prepublished online January 15, 2010. Summary: Intravenous (IV) heparin reduces mortality and recurrence of acute pulmonary embolism, particularly for patients who achieved a therapeutic aPTT within 24 hours. Patients who achieved a therapeutic aPTT within 24 hours had lower in-hospital (1.5% versus 5.6%, p=0.093) and 30-day (5.6% versus 14.8%, p=0.037) mortality rates as compared to patients who achieved a therapeutic aPTT after 24 hours.
Becker, RC. A Randomized, Multicenter Trial for Weight-adjusted Intravenous Heparin Dose Titration and Point-of-care Coagulation Monitoring in Hospitalized Patients with Active Thromboembolic Disease. American Heart Journal 1999; 137:59-71. Summary: Weight-adjusted heparin dosing according to a standardized titration nomogram combined with point-ofcare coagulation monitoring represents an effective and widely generalizable strategy for managing patients with thromboembolic disease that fosters the rapid achievement of a desired range of anticoagulation. Additional work is needed, however, to improve on existing patient-specific strategies that can more effectively sustain a therapeutic state of anticoagulation.
Medication Errors
Fanikos, J. Medication Errors Associated with Anticoagulant Therapy in the Hospital (PDF). American Journal of Cardiology. 2004; 94: 532–535. Summary: Brigham and Women’s Hospital, a 725 tertiary care facility, reviewed consecutively reported, anticoagulation-related medication errors over a 3 1⁄2-year period. We identified 130 medication errors. There were 1.67 medication errors for every 1,000 patients treated with anticoagulants. These were most often associated with unfractionated heparin (66.2%), followed by warfarin (21.5%), low-molecular-weight heparin (9.2%), argatroban (1.5%), and lepirudin (1.5%). Approximately 6.2% of patients required medical intervention and 1.5% needed prolonged hospitalization.
Landro, L. Hospitals Tackle High-Risk Drugs To Reduce Errors (PDF). Wall Street Journal. March 5, 2008 D1. Summary: Hospitals are working to overhaul their safety practices following recent studies that identified eight medications, including heparin, which account for 31% of all medication errors that harm patients. This article describes the growing awareness of medication mistakes and steps by hospitals to prevent such errors.
Peterson, C. et. al. Improving Heparin Safety: A Multidisciplinary Invited Conference (PDF). Hospital Pharmacy; 2008: 43(6) 491–497. Summary: Data from a number of sources indicate UF heparin is one of the drugs most frequently associated with adverse events and medication errors, many of which are serious. This article summarizes 21 presentations with a primary focus on types and frequency of heparin errors as well as identified opportunities to improve heparin safety.
Smith, S. Medical Mistakes No Longer Billable (PDF). The Boston Globe. June 19, 2008. Summary: This article outlines a new Massachusetts state healthcare policy. Hospitals cannot receive reimbursement from the state of Massachusetts or its largest private health insurer for costs related to a medication error.
The Joint Commission. Preventing Errors Relating to Commonly Used Anticoagulants (PDF). Sentinel Event Alert. 2008: 41 Sept. 24. Summary: The Joint Comission (TJC, formerly JCAHO) issued a sentinel alert for UF heparin and other anticoagulants cited most frequently in medication error reports. This article summarizes contributing factors and describes and risk reduction strategies.