"All I have to do is plug some information into an app and I know what anticoagulant to put them on"

[intubesteak]

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If you don't like rants...best not read any further.

We have this BS interdisciplinary class with school of nursing, pharmacy, PAs, and medicine. The other day one of the topics was about "making sure every patient with A-fib is on anticoagulants" (see where this is going yet?). A question posed to the class was how every discipline can take part in reaching this "goal". That's when the pharmacy professor started talking about how pharmacists, nurses, etc. should be evaluating patients with "A-Fib" for anticoagulation.

I cannot pretend to be an expert on this but I did work for a cardiologist and in an ED. From what I experienced atrial fibrillation is a very complex issue and best left to the cardiologist for definitive management. Come to think of it, I cannot remember a case of new onset or refractory atrial fibrillation in the ED that cardiology was not at some point at least called to establish follow up--at a bare minimum. Do pharmacists and nurses HONESTLY think they should be putting every patient with atrial fibrillation on Warfarin?! Do people really think an app in the hands of a nurse or pharmacist can make complex medical decisions?!

 

[deleted763299]

BS interdisciplinary class with school of nursing, pharmacy, PAs, and medicine.

Oh those were so much fun

From what I experienced atrial fibrillation is a very complex issue

The part that can be complicated is the very first part of the decision tree. Should the patient be anticoagulated? Should they be cardioverted? Sometimes cardiology is asked for help on these fronts. The vast majority of Afib however is not managed in the long run by cardiologists, it's done by internists, family physicians, and midlevels. The decisions after those first two, are a lot easier.

Do people really think an app in the hands of a nurse or pharmacist can make complex medical decisions?!

Yes... yes they do.

 

[Doctor Strange]

The majority of a-fib does not need to be managed by a cardiologist, though they probably see a cardiologist every now and then. The idea presented is a legitimate one, though. Every patient with a-fib should be evaluated to see if they require anticoagulation, and it's not exactly hard to do the initial triage of a patient with a-fib. Ever heard of the CHADS score? If not, you'll hear about it pretty much every day on your medicine clerkships.

 

[intubesteak]

The majority of a-fib does not need to be managed by a cardiologist, though they probably see a cardiologist every now and then. The idea presented is a legitimate one, though. Every patient with a-fib should be evaluated to see if they require anticoagulation, and it's not exactly hard to do the initial triage of a patient with a-fib. Ever heard of the CHADS score? If not, you'll hear about it pretty much every day on your medicine clerkships.

That makes sense. I have heard about a CHADS score but not much beyond that. I do remember the cardiologist I worked for being pretty anal about how many/what kind of cardioversion attempts needed to be made before giving up on converting them. It would go on for years with some patients. It was very systematic and complex, including what anticoagulant to put them on.

What Irked me was the idea that afib can be treated by any healthcare professional and all that is needed is an app, some Coumadin, and some discharge papers, which was the take home point whether intended or not. Unfortunately the doc who usually is part of the class was not there to help clarify the misconception that pharmacists should be reflexively prescribing everyone warfarin.

Thanks for chiming in guys.

 

[intubesteak]

"The part that can be complicated is the very first part of the decision tree. Should the patient be anticoagulated? Should they be cardioverted? Sometimes cardiology is asked for help on these fronts. The vast majority of Afib however is not managed in the long run by cardiologists, it's done by internists, family physicians, and midlevels. The decisions after those first two, are a lot easier. "

Shouldn't a cardioversion be attempted at least once in just about everybody? I understand the whole don't shock em without a TEE or anticoagulant deal after 24 hours or so...but I feel like at some point a cardiologist needs to be a part of the care to get any of that done. But I have limited experience and would definitely like to learn what the real deal is here.

 

[Doctor Strange]

"The part that can be complicated is the very first part of the decision tree. Should the patient be anticoagulated? Should they be cardioverted? Sometimes cardiology is asked for help on these fronts. The vast majority of Afib however is not managed in the long run by cardiologists, it's done by internists, family physicians, and midlevels. The decisions after those first two, are a lot easier. "

Shouldn't a cardioversion be attempted at least once in just about everybody? I understand the whole don't shock em without a TEE or anticoagulant deal after 24 hours or so...but I feel like at some point a cardiologist needs to be a part of the care to get any of that done. But I have limited experience and would definitely like to learn what the real deal is here.

This is a discussion that is beyond the scope of this thread and will be addressed in your clinical rotations. In short, no, cardioversion is not always indicated, especially in your 90 year old lady with like a bunch of other medical problems. If you're really interested, do a cardiology elective.

 

[HG1HH217]

So long as you have a specific question that is common enough to have been widely studied, and assuming you can collect and correctly input all relevant data, evidence-based medicine means that more often than not an algorithm can be constructed that should provide sufficient guidance for most patients, at least for initial treatment. I'd argue an app could very well implement such an algorithm, without the need for extensive knowledge or understanding by the user. However, there would be the question of whether requiring such extensive information would be too cumbersome to implement in practice for complex decision making. For a good example, see CHOP pathways for pediatrics: Clinical Pathways | Children's Hospital of Philadelphia (with the caution that even these algorithms are not inclusive enough to drive correct decision making all the time -- to account for every anomaly would be cumbersome and subvert the usefulness of such a tool so long as human users are the ones employing it).

As for this particular case, I agree with the poster above that they were likely taught how to calculate a CHA2DS2-VASc score, a tool developed for primary care / EM with solid data behind it.

 

[PharmLyfe17]

That makes sense. I have heard about a CHADS score but not much beyond that. I do remember the cardiologist I worked for being pretty anal about how many/what kind of cardioversion attempts needed to be made before giving up on converting them. It would go on for years with some patients. It was very systematic and complex, including what anticoagulant to put them on.

What Irked me was the idea that afib can be treated by any healthcare professional and all that is needed is an app, some Coumadin, and some discharge papers, which was the take home point whether intended or not. Unfortunately the doc who usually is part of the class was not there to help clarify the misconception that pharmacists should be reflexively prescribing everyone warfarin.

Thanks for chiming in guys.

I don't know of any pharmacist that has the idea that "afib can be treated by any healthcare professional and all that is needed is an app, some coumadin, and some discharge papers". Firstly, what app are you talking about? Secondly, you don't treat afib with coumadin. You treat afib with an antiarrhythmic or you can cardiovert them. That decision is always left to the physician. Coumadin (or another anticoagulant) is normally needed to help prevent an embolism. You calculate the patient's risk of developing a clot with the CHADS score. You can also calculate the risk of bleeding with the HAS-BLED score. Deciding upon anticoagulation for a patient is about weighing risks vs benefits in each individual patient. Some afib patients will not be on anticoagulation. The decision of whether or not to anticoagulate a patient is always left to the physician. The role of the pharmacist is to ensure that the patient is on anticoagulation (if needed) and to monitor the drug therapy chosen by the physician.

 

[deleted763299]

Shouldn't a cardioversion be attempted at least once in just about everybody? I understand the whole don't shock em without a TEE or anticoagulant deal after 24 hours or so...but I feel like at some point a cardiologist needs to be a part of the care to get any of that done. But I have limited experience and would definitely like to learn what the real deal is here.

I'm only an intern, so my clinical experience is limited too. I can't honestly speak to how often cardioversion should or should not be done. What I can say is, at least in my institution, it is almost never done (unless hemodynamically unstable). Patients admitted with new onset Afib get worked up for an underlying cause. When you don't find one, you give them... warfarin and discharge papers (as long as their CHADS2-VASC score says so). Most of the time without cardiology consultation.

 

[intubesteak]

This is a discussion that is beyond the scope of this thread and will be addressed in your clinical rotations. In short, no, cardioversion is not always indicated, especially in your 90 year old lady with like a bunch of other medical problems. If you're really interested, do a cardiology elective.

I think the fact that I am so fixated on this tells me I probably should.

 

[intubesteak]

I don't know of any pharmacist that has the idea that "afib can be treated by any healthcare professional and all that is needed is an app, some coumadin, and some discharge papers". Firstly, what app are you talking about? Secondly, you don't treat afib with coumadin. You treat afib with an antiarrhythmic or you can cardiovert them. That decision is always left to the physician. Coumadin (or another anticoagulant) is normally needed to help prevent an embolism. You calculate the patient's risk of developing a clot with the CHADS score. You can also calculate the risk of bleeding with the HAS-BLED score. Deciding upon anticoagulation for a patient is about weighing risks vs benefits in each individual patient. Some afib patients will not be on anticoagulation. The decision of whether or not to anticoagulate a patient is always left to the physician. The role of the pharmacist is to ensure that the patient is on anticoagulation (if needed) and to monitor the drug therapy chosen by the physician.

Exactly. My issue was that it was a very offhand comment and did not address any of what you are describing. I'm sure if I asked this professor outside of class they would explain all of this. But it definitely came off as pharmacists and nurses can "treat afib with anticoagulants".

Idk what app. They just said "an app I have". Assuming its ones that calculates some of the above mentioned scores.

 

[Taddy Mason]

@Doctor Strange is giving more tactful responses than I would, but he's spot on. In my research gig/job prior to med school I worked with the coumadin clinic pharmacists on an almost daily basis at the hospital where I was employed - there's a reason they exist. As far as the computer algorithm/app comment, yeah they use those, because managing coumadin is pretty algorithmic...However, they regularly exercised clinical judgment on top of that. In 9 years of being involved in healthcare, I have yet to see the anticoag component of A-fib not be managed by pharmacists. Cardioversion, rate management, or valvular a-fib is where cards/IM comes in.

 

[HG1HH217]

.

 

[intubesteak]

I'm only an intern, so my clinical experience is limited too. I can't honestly speak to how often cardioversion should or should not be done. What I can say is, at least in my institution, it is almost never done (unless hemodynamically unstable). Patients admitted with new onset Afib get worked up for an underlying cause. When you don't find one, you give them... warfarin and discharge papers (as long as their CHADS2-VASC score says so). Most of the time without cardiology consultation.

Interesting. In the hospital system I worked at they shocked the hell out of patients all the time, sometimes multiple times. I am in a different part of the country now and it will be interesting to see how things differ.

 

[Taddy Mason]

Interesting. In the hospital system I worked at they shocked the hell out of patients all the time, sometimes multiple times. I am in a different part of the country now and it will be interesting to see how things differ.

were those patients hemodynamically stable...?

 

[intubesteak]

were those patients hemodynamically stable...?

Sometimes. A few times the ER doc would call the patients cardiologist who would then give them the green light to shock em, or not. The rule of thumb I understood was clear onset less than 24 hours ago=shock in ED, regardless of hemodynamically stable or not. There were some cardiologists in the local group that were fine with this, others that were not. This was a few years ago fwiw

 

[Taddy Mason]

Sometimes...

Were you the physician determining this?

 

[intubesteak]

Were you the physician determining this?

I'm not sure what you are getting at. For anyone interested there are also some links to journal club blogs on the topic and stuff at the bottom

EBQ:Ottawa Aggressive ED Cardioversion Protocol - WikEM

 

[link2swim06]

A few points.

1. Trying cardioversion is generally a good idea. This is support by plenty of literature.
2. If it is over 48 hours, you probably should get a TEE before cardioversion first (unless they are unstable)
3. I (as an ER doctor) have no problem electively cardioverting someone in the ED who clearly had a fib onset less than 48 hours. The procedure is pretty simple (you press a button)
4. After you cardiovert back to sinus, for many people it isn't "fixed." They have a high chance of going back into a fib. And therefore probably need to be started on anticoagulation even if they are in sinus now
5. Some hospitals commonly admit new onset a fib, some don't if the pt is asymptomatic
6. Honestly, if the pt should get anticoagulation (based on their CHADS VASC score); the actual choice sometimes has to do more with insurance and other social non-medical issues. But remember the stroke risk is very very low day to day (the anticoagulation is to reduce their stroke risk really over the next several years...not a few days).

 

[WingedOx]

If you don't like rants...best not read any further.

We have this BS interdisciplinary class with school of nursing, pharmacy, PAs, and medicine. The other day one of the topics was about "making sure every patient with A-fib is on anticoagulants" (see where this is going yet?). A question posed to the class was how every discipline can take part in reaching this "goal". That's when the pharmacy professor started talking about how pharmacists, nurses, etc. should be evaluating patients with "A-Fib" for anticoagulation.

I cannot pretend to be an expert on this but I did work for a cardiologist and in an ED. From what I experienced atrial fibrillation is a very complex issue and best left to the cardiologist for definitive management. Come to think of it, I cannot remember a case of new onset or refractory atrial fibrillation in the ED that cardiology was not at some point at least called to establish follow up--at a bare minimum. Do pharmacists and nurses HONESTLY think they should be putting every patient with atrial fibrillation on Warfarin?! Do people really think an app in the hands of a nurse or pharmacist can make complex medical decisions?!

Question: what year of med school are you?

edit: I only ask because I'm curious what med schools are trying to do with this whole interdisciplinary education thing. It seems kind of useless for people w/o clinical experience.

 

[pre med 2014]

CHADS2

 

[NotYou20]

Question: what year of med school are you?

edit: I only ask because I'm curious what med schools are trying to do with this whole interdisciplinary education thing. It seems kind of useless for people w/o clinical experience.

My school did it 1st quarter of 1st year. Was lulzworthy, especially when they explained how great their idea was including evidence that patients with a better integrated healthcare team (how tf this was quantified I don't know) do better, but that there's no evidence that any classes, much less those directed at first year med, dental, PT etc students does anything positive.

Almost all my classmates came to the same conclusion as you

 

[WingedOx]

My school did it 1st quarter of 1st year. Was lulzworthy, especially when they explained how great their idea was including evidence that patients with a better integrated healthcare team (how tf this was quantified I don't know) do better, but that there's no evidence that any classes, much less those directed at first year med, dental, PT etc students does anything positive.

Almost all my classmates came to the same conclusion as you

I mean, having a well-integrated healthcare team IS a good idea, but you at this point don't know the first thing about being a physician, much less interacting with other roles in the hospital.

 

[neoevolution]

I thought even our group sessions with example patient cases weren't very useful first year. It wasn't until we learned more path/pharm/micro 2nd year that we started to get good discussions about DDx

 

[JamaicanHerb]

Strong backfire.

 

[intubesteak]

Question: what year of med school are you?

edit: I only ask because I'm curious what med schools are trying to do with this whole interdisciplinary education thing. It seems kind of useless for people w/o clinical experience.

1st year. Interdisciplinary interaction is an LCME requirement.

Yes, it really is useless. If they were talking to a group of 4th years, students would probably be able to understand why it would be good for nurses and pharmacists to do CHADS2 score or whatever on patients. For me, having minimal clinical experience but enough to know that what they are communicating is not accurate, it is frustrating. I mean the pharmacist made it sound like she was running around prescribing anticoagulants to all these patients. I am glad I ranted because I learned some things. But still. point of rant=this class is BS.

 

[Taddy Mason]

...having minimal clinical experience...

You admitted it.

...but enough to know that what they are communicating is not accurate...

...but you don't based on your comments in this thread.

 

[andrek82]

I'm only an intern, so my clinical experience is limited too. I can't honestly speak to how often cardioversion should or should not be done. What I can say is, at least in my institution, it is almost never done (unless hemodynamically unstable). Patients admitted with new onset Afib get worked up for an underlying cause. When you don't find one, you give them... warfarin and discharge papers (as long as their CHADS2-VASC score says so). Most of the time without cardiology consultation.

No beta blockers, calcium channel blockers, etc? Just anticoagulation?

 

[VA Hopeful Dr]

OK so I just looked at the ACC App, and holy cow that thing is awesome. I'll be honest, there's a 99% chance I'm going to start using it.

 

[nlax30]

To bump an old thread.....

Yea the app is great and I encourage people to use it.

To address the OP's premise (if they're still around): While I don't think AF should be primarily managed by a pharmacist, nurse, mid-levels, etc... I think it's completely fine for a multi-disciplinary group to discuss how they can improve adherence to some proven medical management for a specific condition. There are still a good number of AF patients who meet all indications for anticoagulation but are not treated with an anticoagulant because their Cardiologist/PCP, whoever, was lazy and they slip through the cracks. If one of these patients is admitted for some other reason and a nurse or pharmacist brings up the issue of whey they aren't on AC then I think that's a win and gives us a chance to have that conversation. Maybe there's a valid reason they aren't on one, maybe it was just due to laziness.

 

[Psai]

Or maybe they think that the risks of ac outweigh the benefits. We see plenty of head bleeds in the or for these patients and the outcomes aren't pretty.

 

[nlax30]

Well we have data to to roughly estimate yearly stroke risk in someone based on co-morbidities.

We don’t have a good way of risk stratifying someone in terms of how likely they are to develop say a head bleed.

Outside of some situations like an underlying amyloid angiopahy, prior bleed, or an obvious elderly patient who falls each week.... what would you do differently. I see a lot of folks who had a PCP or whoever subjectively consider them at “high risk of bleeding” with no obvious underlying pathology that would place them at high risk and they have a disabling stroke cause they weren’t on AC.

 

[FindMeOnTheLinks]

Well we have data to to roughly estimate yearly stroke risk in someone based on co-morbidities.

We don’t have a good way of risk stratifying someone in terms of how likely they are to develop say a head bleed.

Outside of some situations like an underlying amyloid angiopahy, prior bleed, or an obvious elderly patient who falls each week.... what would you do differently. I see a lot of folks who had a PCP or whoever subjectively consider them at “high risk of bleeding” with no obvious underlying pathology that would place them at high risk and they have a disabling stroke cause they weren’t on AC.

When I rotated on the neurology service, the residents commonly used the HAS-BLED score to weigh the risk of bleeding against the benefit of AC. The study that developed the hasbled score certainly has its limitations but at least it's one method to risk stratify these patients.

 

[Redpancreas]

Triage apps =/= medical practice. These are used as tools but once you try applying the diamond criteria to someone coming in chest pain, you’ll realize how useless these general rules and apps can be.

 

[intubesteak]

Clearly this is a simple issue best handled by nurses and pharmacists.

Really though, I don't think its a good use of time for nurses, pharmacists, etc to be plugging away into these MDM apps trying to second guess the physician. If you have a question about management, just ask the doctor. Can you picture a nurse waving some app in your face, telling you that your patient needs a blood thinner? Even if they were right it would not go over well. If everyone just focused on doing their own job well, we would be better off.

Regarding the MDM rule itself. My understanding is that these things help physicians justify why NOT to do something (ie order a head CT on a kiddo, get a CTA on every lady with pleuritic chest pain, etc). Maybe this one is different but this is what I was taught.

 

[PharmlyDoc]

4th year pharm student here, and I have a thrombophilia with h/o of VTE. I don’t see why anyone would want to be on warfarin. Andexenat alpha just became FDA approved for reversal of direct factor Xa inhibitors, which is another compelling reason why apixaban is starting to be used more for stroke prevention in Afib.

 

[mimelim]

4th year pharm student here, and I have a thrombophilia with h/o of VTE. I don’t see why anyone would want to be on warfarin. Andexenat alpha just became FDA approved for reversal of direct factor Xa inhibitors, which is another compelling reason why apixaban is starting to be used more for stroke prevention in Afib.

How effective is Andexenat alpha with Xa inhibitors vs. VitK/FFP for coumadin? How available will it be? I'm sure big trauma centers will have it, but community ERs? What about urgent care?

In the real world, the choice of anticoagulant (as well as the choice to be or not to be on anti-coagulation) depends on a heck of a lot of factors. I feel very comfortable with what a surgical field will look like therapeutic on coumadin and how reliably things will look better with full reversal. I have no idea what things will look like with Andexenat.

 

[IMreshopeful]

How effective is Andexenat alpha with Xa inhibitors vs. VitK/FFP for coumadin? How available will it be? I'm sure big trauma centers will have it, but community ERs? What about urgent care?

In the real world, the choice of anticoagulant (as well as the choice to be or not to be on anti-coagulation) depends on a heck of a lot of factors. I feel very comfortable with what a surgical field will look like therapeutic on coumadin and how reliably things will look better with full reversal. I have no idea what things will look like with Andexenat.

You’re gonna have to get used to Xa inhibitors as the gold standard. They’re by almost every guideline the drug of choice for AC and I’m putting all of my afib patients on them (excluding HCM, mitral stenosis, and mechanical valves of course). Just because warfarin is what you’re used to doesn’t mean that it should stay that way - Xa have better efficacy at AC, less bleeding risk, and now with a reversal agent. Availability definitely a concern but I imagine that given the prevalence of Xa inhibitors you will see them pretty much everywhere soon I imagine

 

[VA Hopeful Dr]

You’re gonna have to get used to Xa inhibitors as the gold standard. They’re by almost every guideline the drug of choice for AC and I’m putting all of my afib patients on them (excluding HCM, mitral stenosis, and mechanical valves of course). Just because warfarin is what you’re used to doesn’t mean that it should stay that way - Xa have better efficacy at AC, less bleeding risk, and now with a reversal agent. Availability definitely a concern but I imagine that given the prevalence of Xa inhibitors you will see them pretty much everywhere soon I imagine

Well that and FFP isn't instantaneous anyway. Could be the Xa reversal agents work faster since they reversibly inhibit anyway...