WHAT IS PEER TO PEER?
Med-IQ's complimentary, certified continuing medical education (CME) activity,
Peer to Peer: A New Model for Improving Guideline- and Evidence-Based ACS Care, is connecting healthcare professionals from across the country. This exciting, first-of-its-kind CME series provides participants with access to acute coronary syndrome (ACS) faculty experts during personalized sessions focusing on improving ACS patient care in their practices. This real-time exchange of ideas has helped address some of the major challenges that clinical practices face in managing ACS cases.

WHAT ARE E-BRIEFS?
Each month, Med-IQ will publish a short e-brief to highlight real-world questions, opportunities for improvement, and front-line perspectives gained from these ACS Peer to Peer teleconferences. Below, you'll find the twelfth, final e-brief; in this installment, our expert faculty answer questions about specific clinical challenges in ACS.

Discharge planning is a critical element in the secondary prevention of ACS. A commonly encountered problem in the emergency department (ED) and at discharge is pharmacologic management of the ACS patient who also requires warfarin. Below, our faculty review guideline recommendations for these patients. They also explore strategies for improving medication adherence, approaches to patient education, and possible roles of C-reactive protein (CRP) testing.

Special Considerations for Patients on Warfarin
Question: Should I treat a patient with chest pain who is on warfarin for atrial fibrillation differently than other patients presenting with chest pain?

Answer: It is very common to encounter patients presenting to the ED with ACS symptoms who are also taking warfarin to prevent thromboembolism secondary to other conditions, such as atrial fibrillation. However, the use of antiplatelet and anticoagulant agents in conjunction with warfarin increases bleeding risk. Thus, pharmacologic therapies may need to be adjusted according to clinical judgment and evaluation of the patient.

For acute management, the first step is to assess whether the patient is therapeutically anticoagulated with warfarin (ie, is the international normalized ratio [INR] 2.0 or above?).¹ If the INR is less than 2.0, then all standard recommendations for the acute use of antiplatelet or antithrombin therapies apply, and no adjustments are necessary.¹ If the INR is within or above the therapeutic range, however, pharmacologic choices must be more carefully considered.

Guidelines indicate that antiplatelet therapy with aspirin and clopidogrel should be initiated even in patients who are therapeutically anticoagulated with warfarin, especially if an invasive strategy is planned and stent implantation is anticipated.¹ However, the use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely.^1,2 GP IIB/IIIA inhibitors should be avoided because they have not been studied in this population and could increase the risk of bleeding. Generally, heparin should not be used in patients who are taking therapeutic doses of warfarin; however, whether to use heparin depends on your assessment of the patient (ie, how severe are the patient's symptoms and what is the bleeding risk?). For example, if the INR is well above the target therapeutic range, if the bleeding risk is very high, or if the patient needs urgent surgical intervention, it may be worthwhile to consider reversing the anticoagulant effect of warfarin.

At discharge, warfarin should be continued in ACS patients who have established indications, such as atrial fibrillation, left ventricular thrombus, and mechanical prosthetic heart valves.¹ Warfarin may be given in addition to aspirin therapy and clopidogrel. The guidelines, however, indicate that triple anticoagulant therapy requires close monitoring and that aspirin and clopidogrel should be given at the lowest effective doses and for the shortest period of time necessary for protective effects (eg, 30 days following a bare-metal stent). The decision to use triple anticoagulant therapy should be made only if the benefit of doing so outweighs the risk of bleeding. In patients requiring triple anticoagulant therapy, current ACC/AHA STEMI and UA/NSTEMI guidelines recommend aspirin doses of 75 mg to 81 mg, a clopidogrel dose of 75 mg, and a reduced INR of 2.0-2.5.^1,2 In patients with bare-metal stents or in those who are treated medically, a minimum of 30 days of treatment with clopidogrel may be sufficient. In patients with drug-eluting stents, however, clopidogrel treatment is recommended for one year. In these patients, treatment decisions need to be individualized based on the patient's risk of bleeding.

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Potential Role of CRP Testing
Question: What is the potential role for high-sensitivity CRP (hsCRP) testing in the ACS patient?

Answer: Research has demonstrated that patients with suspected ACS who have elevated hsCRP levels on admission but no biochemical evidence of MI have an increased risk of adverse outcomes.¹ It has been proposed that hsCRP testing, as part of a multimarker approach to risk stratification of UA/NSTEMI, may have potential advantages over single biomarker assessment in ACS patients.¹ However, the role of hsCRP testing in the ACS setting is still regarded as limited because specific management changes based on hsCRP have not been established. Its use in monitoring response to statin therapy has been evaluated in studies, and it has been found to be a good predictor of cardiovascular events.³ Furthermore, the JUPITER study found that adding a potent statin in patients with elevated hsCRP led to a substantial reduction in cardiovascular events.⁴ Again, specific recommendations based on hsCRP results do not exist. Thus, guidelines have yet to recommend its routine use in evaluating patients with ACS.

CRP testing may play a role in assessing a healthy individual's risk of CAD. In particular, it may be most useful in the risk assessment of patients with one to two risk factors, or in patients with borderline cholesterol levels. In addition, some patients may request the test. If they are sufficiently motivated to incorporate preventive lifestyle modifications based on CRP results, then the test may have some value.

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Approaches to Patient Education
Question: What are some ways to educate my patients with ACS about the importance of lifestyle modifications, medications, and other aspects of ACS?

Answer: Patient education is a key component of successful outcomes in ACS. In addition to providing standard patient education materials at discharge, it may also be helpful to refer patients to credible Internet sources. For example, Cardiosmart (www.cardiosmart.org) is the patient-education Web site of the ACC and offers information on cardiovascular disease in multimedia formats. The AHA also offers a variety of interactive patient education materials including information on lifestyle modifications, such as nutrition, physical activity, and stress management (www.hearthub.org).

In addition to Internet sources, a book for patients has recently been released: The New Heart Disease Handbook: Everything You Need to Know to Effectively Reverse and Manage Heart Disease (Cannon CP and Vierck E, Fair Winds: Quayside, 2009). This text covers major heart diseases such as myocardial infarction and angina, but also includes information on lifestyle modification.

One effective and simple tool for directly involving patients in their own care is to have them keep a log of basic health information such as weight, blood pressure, cholesterol levels, or hemoglobin A1C (in diabetes patients). Clinicians and patients can review this information together at follow-up visits.

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Strategies for Improving Medication Adherence
Question: Medication adherence is something that we always struggle with in our center. Are there best practices that we can initiate during discharge planning?

Answer: Successful medication adherence begins with the discharge protocol. Clinicians should review medications with the patient and family and send the patient home with a list of medications and instructions for taking those medications. In addition, the discharge summary—including medication information—should be sent to the patient's primary care physician.

Even when patients receive excellent discharge instructions, a large percentage will have difficulty or questions regarding their medications once they are home. Thus, one of the most important elements of medication adherence—and successful post-discharge myocardial infarction (MI) care in general—is patient follow-up. Telephone follow-up 3 to 4 days after discharge is an effective strategy to assess any medication difficulties. Nurses can contact the patient and ask direct questions such as "Are you clear about the medicines you are supposed to be taking?" or "Is there anything confusing about your medications?" One commonly encountered issue is that patients sometimes forget to inform the discharge team about medications they have been previously prescribed that are from the same class as newly prescribed medications. For example, a patient may have been taking an ACE inhibitor prior to admission and, post-discharge, was prescribed a different ACE inhibitor. Patients may also struggle with side effects. Often, however, these problems may be quickly resolved via a telephone consult with the physician or pharmacist.

In addition to a telephone follow-up, a follow-up evaluation at a cardiology clinic or in primary care should be scheduled for 7 to 10 days after discharge.

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REFERENCES

1. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction. J Am Coll Cardiol. 2007;50(7):e1-e157.

2. Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: J Am Coll Cardiol. 2008;51(2):210-247.

3. Ridker PM, Cannon CP, Morrow D, et al. C-reactive protein levels and outcomes after statin therapy. N Engl J Med. 2005;352:20-28.

4. Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated c-reactive protein. N Engl J Med. 2008;359:2195-2207.

Now Available at www.Cardiology-IQ.com: More Than 25 Credit Hours of Complimentary, Certified CME/CE for Cardiologists It's all about choices—yours. Select the certified CME activities that most interest you. Med-IQ is currently offering complimentary, certified CME activities in ACS, atrial fibrillation, VTE, and heart failure at www.Cardiology-IQ.com.

This activity is supported by an educational grant from sanofi-aventis U.S.

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