Standard of Care in Anticoagulation Therapy


Manesh Patel, MD: What is the standard of care, and how do we get people to take really high-quality information and turn it into the standard of care?

Robert M. Califf, MD, MACC: Let me just pick on our profession for 1 second. We have a little tool at Verily that emanates from the architecture of Google search, so we can compare guideline recommendations very quickly, actually applied to a population of patients and what they’re getting. What really frustrated our engineers when they first looked at it is that the eminent authorities that make up the guidelines disagreed with one another a very high proportion of the time. We say, “Why don’t people believe the guidelines?” And then you say, “Wait a minute. It depends on which guidelines you look at and the different recommendations.” We have a professional responsibility to begin to harmonize better.

Manesh Patel, MD: Your point is very well taken, that 1 way to get past the standard of care is to agree on what’s the standard of care across multiple guidelines, whether European or in the US or other ways. I guess the first step for me is that they all agree you should be treating that AFib [atrial fibrillation] patient, and they all seem to agree that these drugs should be that. Maybe I’ll ask you, Sean. In our current practice, what is the current standard of care inpatient for somebody who comes with AFib? What do you do with the new drugs when somebody comes in? Do you continue them unless a procedure is done? Walk us through how you think about that.

Sean D. Pokorney, MD: It’s a really important question. The inpatient hospitalizations are really a critical time point to impact a patient’s care from a couple of different perspectives. No. 1, it’s a time where the patients are highly engaged in their health. They’re not focused on everything else that’s going on in the outpatient setting. It’s a great opportunity to address underuse and really emphasize to patients at a time when they’re focused on the health and they’re engaged, what the importance is of getting these patients on treatment and getting them on NOAC [new oral anticoagulant] therapy.

In addition to that, to your point, what do you do if patients come into the hospital on therapy? I think the key is really to continue it. Unless there is a clear procedure that’s coming during the hospitalization, a medication that should be continued. When you look at what the stop times need to be to pursue procedures—for a minimally invasive procedure, 24 hours; for a larger surgical procedure, 48 hours, and the drug is out of their system. What we see a lot of times is that patients come into the hospital, and the medications are stopped because people are saying it’s theoretically possible that somebody could have a procedure at some point. Sometimes they don’t even get restarted.

There are a lot of concerns around transitions of care. We’ve been trying to address this in the QUANTUM AF trial, where we’re targeting just this issue and trying to get patients on treatment while they’re in the hospital. I think making sure that patients stay on treatment in the hospital and at least receive treatment prior to discharge is key. We have other good data from chronic medical therapy showing that when patients are treated in the hospital with the medication, they’re more likely to fill that prescription when they leave the hospital and continue that therapy after discharge.

Manesh Patel, MD: That’s a teachable moment. Try to get them while you can teach them.

Transcript edited for clarity.

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