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Purpose. The pattern of clopidogrel loading in patients who had undergone percutaneous coronary intervention (PCI) was studied in a retrospective analysis of clinical records. Methods. A database of deidentified electronic medical records from hospitals and hospital-affiliated outpatient facilities throughout the United States was analyzed for PCI patients with or without a diagnosis of acute coronary syndrome (ACS) who received clopidogrel loading doses of ≥300 mg between 48 hours before and 6 hours after PCI. A high dose was defined as ≥600 mg, and pretreatment was defined as more than 6 hours before PCI for 300--599 mg and 2 or more hours before PCI for ≥600 mg. Results. Among 6253 PCI patients who met the criteria, there were 2331 with a diagnosis of ACS (ACS-PCI) and 3922 without an ACS diagnosis (elective PCI). Of the ACS-PCI patients, 1359 had ST-segment elevation myocardial infarction (STEMI) and 972 had unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI). A majority of ACS-PCI patients (57%) received a ≥600-mg loading dose, 34% received a 300-mg loading dose, and the rest received a loading dose between 300 and 600 mg. Loading consisted of a single bolus in 75% of patients, two doses in 21.5%, and three or more doses in 3.1%. The first dose was during or after PCI in 56% of the UA/NSTEMI group and in 71% of both the elective PCI and STEMI groups. Among the UA/NSTEMI group, only 33% met criteria for pretreatment. Conclusion. Reported practice patterns of clopidogrel administration before PCI for UA/NSTEMI were not consistent with evidence generated from published clinical trials and guidelines. Recommended pretreatment with clopidogrel was frequently not practiced. [ABSTRACT FROM AUTHOR]

Abstract: Background: Clinical guidelines for the management of atrial fibrillation and atrial flutter provide recommendations for anticoagulation based on patients'' overall risk of stroke. To determine the real-world compliance of physicians with these recommendations, we conducted a retrospective cohort study examining the utilization of warfarin in atrial fibrillation/flutter patients by stroke risk level. Methods: Patients with a qualifying atrial fibrillation/flutter diagnosis during ≥18 months'' continuous enrollment between January 2003 and September 2007, and with ≥6 months'' eligibility after the first atrial fibrillation/flutter diagnosis, were identified from the US MarketScan database (Thomson Reuters, New York, NY). Warfarin use within 30 days of the first diagnosis was assessed according to stroke risk, estimated using the Congestive heart failure, Hypertension, Age >75 years, Diabetes, Stroke (CHADS2) score. Results: Of 171,393 patients included in the analysis, 20.0% had a CHADS2 score of 0 (low risk), 61.6% a score of 1-2 (moderate risk), and 18.4% a score of 3-6 (high risk). Warfarin, recommended for high stroke-risk patients, was given to only 42.1% of those with a CHADS2 score of 3-6. A similar percentage of patients with moderate (43.5%) or low stroke risk (40.1%) received warfarin. Only 29.6% of high-risk, 33.3% of moderate-risk, and 34.1% of low-risk patients who were started on warfarin received uninterrupted therapy for 6 months following their initial prescription. Conclusions: These data suggest that guideline recommendations that anticoagulation should be provided in accordance with stroke risk in atrial fibrillation patients are not routinely followed in clinical practice. The causes and clinical implications of under-utilization of anticoagulation in atrial fibrillation patients with high stroke risk warrant further study. [Copyright &y& Elsevier]