No abstract

Background Polypharmacy in older adults leads to increased risks of side effects and drug‐drug interactions, affecting their health outcomes and quality of life. Deprescribing, the act of simplifying medication regimens, is challenging due to the lack of consensus guidelines. Hypothesis To offer some guidance on managing medication regimens for older cardiovascular patients. Methods We reviewed the most recent pertinent guidelines and literature. Results This review provides practical considerations for appropriate prescribing in the older population with cardiovascular disease in order to strike a balance between unnecessary or harmful medications and therapies with proven long‐term benefits. Conclusion On‐going dialogue between healthcare providers and patients allows close monitoring of medication effectiveness and prevention of side effects. Medication regimens require individualization, as patients' goals of care change with advancing age.

Background: Use of an anticoagulant after transcatheter aortic valve replacement (TAVR) has been increasing in practice after noted leaflet thrombosis on dual antiplatelet therapy. As the use of anticoagulation increases so does the number of poor warfarin candidates or warfarin intolerant patients. While direct oral anticoagulant (DOAC) use is increasing for other indications, there is a paucity of data for use after TAVR. The objective of this case series is to add to the available evidence for patients who may require a DOAC after TAVR. Methods: A single-center, retrospective observational case series was conducted including adults 18 years of age and older who received a DOAC after TAVR between November 2008 and June 2018 at Mayo Clinic Hospital—Rochester. All patients were identified as part of the Society of Thoracic Surgeons database. Results: Twenty-one patients were identified as having received a DOAC after TAVR. Median age was 83.5 years (interquartile range 77–87), with 71% males. Within this cohort, 20 patients (95.2%) had an alternative indication for anticoagulation of either atrial fibrillation or atrial flutter. Apixaban was prescribed in 66.7% of patients, followed by rivaroxaban (14.3%), dabigatran (9.5%), and edoxaban (4.8%). No thromboembolic events were reported. Three patients experienced a bleeding event, of which only 2 occurred in the 3 months immediately after TAVR. Conclusions: DOAC therapy after TAVR was generally safe and well tolerated. Taken in context of other retrospective studies, these data suggest that the presence of valvular heart disease, specifically TAVR in this case, should not preclude the use of DOACs.

Objective: To evaluate usability of a quality improvement tool that promotes guideline-based care for patients with peripheral arterial disease (PAD). Patients and Methods: The study was conducted from July 19, 2018, to August 21, 2019. We compared the usability of a PAD cohort knowledge solution (CKS) with standard management supported by an electronic health record (EHR). Two scenarios were developed for usability evaluation; the first for the PAD-CKS while the second evaluated standard EHR workflow. Providers were asked to provide opinions about the PAD-CKS tool and to generate a System Usability Scale (SUS) score. Metrics analyzed included time required, number of mouse clicks, and number of keystrokes. Results: Usability evaluations were completed by 11 providers. SUS for the PAD-CKS was excellent at 89.6. Time required to complete 21 tasks in the CKS was 4 minutes compared with 12 minutes for standard EHR workflow (median, P ¼ .002). Completion of CKS tasks required 34 clicks compared with 148 clicks for the EHR (median, P ¼ .002). Keystrokes for CKS task completion was 8 compared with 72 for EHR (median, P ¼ .004). Providers indicated that overall they found the tool easy to use and the PAD mortality risk score useful. Conclusions: Usability evaluation of the PAD-CKS tool demonstrated time savings, a high SUS score, and a reduction of mouse clicks and keystrokes for task completion compared to standard workflow using the EHR. Provider feedback regarding the strengths and weaknesses also created opportunities for iterative improvement of the PAD-CKS tool.