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The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

POINTS CLES En 2016, au Canada (a l’exclusion du Quebec), 270 204 personnes ont ete admises a l’hopital pour un trouble cardiaque, un accident vasculaire cerebral (AVC) ou un deficit cognitif d’origine vasculaire; de ce nombre, 107 391 etaient des femmes, 162 813 etaient des hommes

KEY POINTS In 2016, 270 204 people in Canada (excluding Quebec) were admitted to hospital for heart conditions, stroke and vascular cognitive impairment, including 107 391 women and 162 813 men, of whom 91 524 died.[1][1] This equates to 1 out of every 3 deaths in Canada and outpaces other diseases

Low-dose acetylsalicylic acid (ASA) is recommended in patients with established cardiovascular disease. However, the role of ASA in those without cardiovascular disease (i.e., primary prevention) is less clear, which has led to discordance among Canadian guidelines. In 2018, 3 double-blind, randomized controlled trials were published that evaluated ASA 100 mg daily versus placebo in patients without established cardiovascular disease. In the ASPREE trial, ASA did not reduce the risk of all-cause death, dementia, or persistent physical disability in patients ≥70 years of age but increased the risk of major bleeding. In the ARRIVE trial, ASA failed to lower the risk of a composite of cardiovascular events but increased any gastrointestinal bleeding in patients at intermediate risk of cardiovascular disease. In the ASCEND trial, ASA significantly reduced the primary composite cardiovascular outcome in patients with diabetes for a number needed to treat of 91 over approximately 7.4 years. Yet major bleeding was increased with ASA for a number needed to harm of 112. Therefore, in most situations, ASA should not be recommended for primary cardiovascular prevention. However, there are additional indications for ASA beyond cardiovascular disease. Thus, a sequential algorithm was developed based on contemporary evidence to help pharmacists determine the suitability of ASA in their patients and play an active role in educating their patients about the potential benefits (or lack thereof) and risks of ASA. Can Pharm J (Ott) 2020;153:xx-xx.

tudy Objective To test a brief intervention for preventing statin nonadherence among community pharmacy patrons. Design Prospective, cluster-randomized, controlled trial (the Community Pharmacists Assisting in Total Cardiovascular Health [CPATCH] trial). Setting Thirty community pharmacies in Saskatchewan, Canada. Patients Participating pharmacies were randomized to 15 intervention pharmacies where a brief statin adherence intervention was delivered by pharmacists (intervention group [907 patients]) or 15 usual care pharmacies where no statin adherence intervention was delivered (usual care group [999 patients]) to new users of statins (defined as less than 1 yr of statin therapy). Intervention Staff (pharmacy managers, staff pharmacists, and technicians) from intervention pharmacies attended a 2.5-hour workshop on the CPATCH program that prepared pharmacists to deal with the adherence barriers most likely associated with statin use (e.g., safety, cost, patient–provider relationship, and tolerability). Intervention pharmacists screened for new statin users and assessed these adherence barriers. Pharmacists were then instructed to tailor their follow-up plan based on the individual patient's situation. Investigators contacted the intervention pharmacies monthly to assess their compliance with the protocol and to offer additional support to motivate ongoing participation. Measurements and Main Results The primary outcome was mean difference in statin adherence between the intervention and usual care groups. Adherence was measured by the proportion of days covered (PDC) between 6 and 12 months following the original prescription fill date. General estimating equations were used to evaluate the difference in mean adherence between groups. Secondary outcomes included the percentage of new statin users exhibiting optimal adherence (defined as PDC of 80% or higher) and the percentage exhibiting nonpersistence (defined as the cessation of all statin dispensations within 3 mo of the first dispensation). Among 1906 eligible patients, no significant differences in mean adherence were observed between those receiving the intervention and those receiving usual care (71.6% vs 70.9%, p=0.64), the percentage of patients achieving optimal adherence (57.3% vs 55.9%, p=0.51), or the percentage exhibiting nonpersistence (9.4% vs 8.3%, p=0.41). However, compliance to the study protocol was extremely low in several intervention pharmacies. In a post hoc analysis, a higher level of protocol compliance among intervention pharmacies was significantly associated with higher adherence (p

Chronic obstructive pulmonary disease (COPD) is an incurable disease that affects 4.2% of Canadians 35 years of age and older.1-3 Pharmacotherapy for COPD is prescribed to achieve 2 main goals of therapy: symptomatic improvement/quality of life and reduction in frequency and severity of exacerbations.4 Administration of medication via inhalation is the preferred route of drug delivery for respiratory disease treatment.3,4 The inhalation route allows for medications to be delivered directly to the intended site of action with minimal systemic absorption, resulting in enhanced clinical benefit and reduced risk of systemic adverse effects.3,5

Dabigatran is widely used for stroke prevention in atrial fibrillation. Dabigatran is no longer patent-protected in Canada and 2 generic formulations were recently approved by Health Canada. Branded dabigatran uses a complex formulation to maintain the acidic microenvironment required for maximal absorption. Consequently, food does not influence its bioavailability and the efficacy and safety of dabigatran are similar with or without concomitant intake of proton pump inhibitors (PPIs). Unfortunately, current bioequivalence criteria do not mandate testing of the generic formulations with food or with concomitant intake of PPIs; thus, the only data available for the approved generic products are in fasted, healthy volunteers. Without confirmation that the bioavailability of the generic dabigatran products is maintained in the presence of food or with coadministration of PPIs, it is uncertain whether they will afford patients the same protection from stroke as the branded product. Clinicians and patients must be made aware of this limitation to make informed prescribing decisions. The rules for establishing bioequivalence have not kept pace with the increasing complexity of pharmaceutical products; we urge regulators to update the regulatory process to ensure the therapeutic equivalence of generic products.

Background: Documentation of information in the health record by pharmacists is vital to patient care. Failure to document, or failure to document appropriately, may have negative effects on patients.Objectives: The primary objective was to determine pharmacists’ competency in 18 elements of chart note documentation at 2 tertiary care centres and 1 rehabilitation centre. The secondary objectives were to quantify the number of episodes of documentation by pharmacists, to characterize the clinical activities associated with this documentation, and to determine whether there were differences in level of competency according to years of hospital experience, additional clinical training, and note type.Methods: This study used prospective audit methodology. Notes documented during a 6-week study period (February to April 2015) were assessed using a rubric specifically created to evaluate 18 of the essential elements of documentation, as defined by the Canadian Society of Hospital Pharmacists. Four of the elements of chart note documentation were assessed on a yes/no basis, and Bloom’s taxonomy was used to define the level of competency for the other 14 elements. Values were assigned to each level and were then used to calculate mean scores.Results: A total of 115 pharmacist notes, created by 29 of the 35 pharmacists included in the study, were assessed. The mean competency score per pharmacist was 2.2 (standard deviation [SD] 0.3; maximum score 3). Elements of documentation with the highest level of competency were diplomatic tone, conciseness, and clarity; elements with the lowest level of competency were medication list, note title, monitoring, and drugrelated problem statements. The most frequent note types concerned drug-related problems (50 [43%]), pharmacokinetics (25 [22%]), and patient education (19 [17%]). Levels of competency were highest for notes related to patient education (mean 2.4, SD 0.2) and lowest for notes concerning drug-related problems (mean 2.1, SD 0.3) and notes providing clarification (mean 2.1, SD 0.3). The level of competency was not significantly affected by additional clinical training or years of hospital experience.Conclusions: Pharmacists in this study documented concisely, clearly, and in a diplomatic tone; however, there was room for improvement in the frequency and elements of chart note documentation in the patient health record.RÉSUMÉContexte : La consignation d’information par les pharmaciens dans les dossiers de santé est essentielle aux soins des patients. Négliger de consigner l’information ou le faire inadéquatement peut avoir des effets négatifs pour les patients.Objectifs : L’objectif principal était de déterminer le niveau de compétence des pharmaciens en ce qui concerne 18 éléments de consignation aux dossiers médicaux de patients dans deux établissements de soins tertiaires et dans un établissement de réadaptation. Les objectifs secondaires étaient de quantifier le nombre de cas de consignation par les pharmaciens, d’offrir un portrait des activités cliniques associées à cette prise de notes et de déterminer s’il y avait des différences quant au niveau de compétence selon le nombre d’années d’expérience en hôpital, la formation clinique supplémentaire et le type de notes.Méthodes : La présente étude a employé l’audit prospectif comme méthodologie. Les notes consignées durant une période de 6 semaines (de février à avril 2015) ont été jugées à l’aide d’une grille conçue spécialement pour évaluer 18 des éléments essentiels de la prise de notes tels qu’ils sont définis par la Société canadienne des pharmaciens d’hôpitaux. Une évaluation dichotomique (soit oui soit non) a été utilisée pour quatre des éléments de la prise de notes et la taxonomie de Bloom a servi à définir le niveau de compétence pour les 14 autres éléments. Des valeurs ont été attribuées à chaque niveau et ont ensuite été utilisées pour calculer les scores moyens.Résultats : Au total, 115 notes rédigées par 29 des 35 pharmaciens vises par l’étude ont été analysées. Le score moyen de compétence par pharmacien était de 2,2 (écart-type de 0,3; score maximum de 3). Les éléments de la prise de notes présentant le niveau de compétence le plus élevé étaient : le ton diplomatique, la concision et la clarté. Les éléments affichant le plus bas niveau de compétence étaient : la liste des médicaments, le titre de la note, le suivi et l’énonciation des problèmes liés à la pharmacothérapie. Les types de notes les plus fréquents traitaient : de problèmes liés à la pharmacothérapie (50 [43 %]), de la pharmacocinétique (25 [22 %]) et des conseils aux patients (19 [17 %]). Les niveaux de compétence étaient plus élevés pour les notes à propos des conseils aux patients (moyenne de 2,4, écart-type de 0,2) et les niveaux étaient plus faibles pour les notes concernant les problèmes liés à la pharmacothérapie (moyenne de 2,1, écart-type de 0,3) et celles fournissant un éclaircissement (moyenne de 2,1, écart-type de 0.3). Le niveau de compétence n’était pas significativement influencé par une formation clinique supplémentaire ou les années d’expérience en hôpital.Conclusion : Les pharmaciens évalués dans la présente étude consignaient leurs notes de façon concise et claire sur un ton diplomatique. Par contre, il y avait lieu d’améliorer la fréquence et les éléments des notes consignées dans les dossiers médicaux des patients.

Author Contributions:T.J. Bungard drafted the initial manuscript and revised it along the way. J. Bolt participated in writing the initial draft and reviewing the final draft. P. Thomson participated in initiating the checklist project, writing the initial draft and reviewing the final draft. W. Semchuk participated in writing the initial draft and reviewing checklists. J. Lowerison participated in initiating the checklist project, writing the initial draft and reviewing the final draft. Declaration of Conflicting Interests:Tammy J. Bungard has received honoraria from Bayer, Boehringer Ingelheim and Bristol Myers Squibb-Pfizer within the past 2 years. Jennifer Bolt has received honoraria from Boehringer Ingelheim in the past 2 years. Peter Thomson has received speaker honoraria from Bayer, Boehringer Ingelheim, Pfizer and Sanofi within the past 2 years. He has served as a consultant or on an Advisory Board for Boehringer Ingelheim, Pfizer and Sanofi within the past 2 years. William Semchuk has received honoraria from Bayer, Pfizer, Bristol Myers Squibb and Boehringer Ingelheim within the past 2 years. He has served as a consultant or on an Advisory Board for Bayer and Pfizer/Bristol Myers Squibb in the last 2 years and has received a research grant from Pfizer in the last 2 years. Jennifer Lowerison has nothing to disclose. Funding:The authors received no financial support for the research, authorship and/or publication of this article.

The initial Canadian Cardiovascular Society (CCS) Guidelines on the Use of Antiplatelet Therapy1 covered chronic antiplatelet therapy for a number of diseases and patient subgroups. The 2012 Focused Update2 specifically addressed the issues of antiplatelet therapy for secondary prevention in the first year after acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and the interaction between clopidogrel and proton pump inhibitors (PPIs). The updating of these topics and the prominence of the newer antiplatelet agents in the guidelines make them of particular relevance to pharmacists. The intent of this publication is to highlight components of the guidelines that are most likely to affect the practice of pharmacists and provide practical information to assist pharmacists in managing patients on antiplatelet therapy.

ObjectiveTo report the proportion of patients discharged directly from the emergency department (ED) on traditional therapy (parenteral anticoagulant±warfarin) or a direct oral anticoagulant (DOAC) for the management of acute venous thromboembolism (VTE).DesignRetrospective medical record review across four EDs in Edmonton, Alberta, two in Regina, Saskatchewan and three in rural Alberta.SettingEDs from April 2014 through March 2015.ParticipantsDischarged directly from the ED with acute VTE. Patients were excluded if they had another indication for anticoagulants, were pregnant/breastfeeding or anticipated lifespan Primary and secondary outcome measuresPrimarily, the proportion of patients discharged directly from the ED that were prescribed traditional therapy or a DOAC, with comparisons between Edmonton, Regina and rural Alberta. Secondarily, therapy selection was compared based on deep vein thrombosis (DVT) versus pulmonary embolism (PE) and clot burden. Dosing of DOACs was assessed (when applicable) and follow-up in the community was compared.ResultsAfter screening 1723 patients, 417 (24.2%) were included with DVT and PE occurring in 65.5% and 34.5%, respectively. More patients with PE were discharged from EDs in Edmonton (43%) than Regina (7%). Overall, the majority of patients were discharged on traditional therapy (70.7%), with 27.8% receiving a DOAC. Uptake of DOAC use was highest in rural Alberta (53.3%) compared with Edmonton (29.6%) and Regina (12.1%). DOACs were more commonly prescribed for PE (34.0%) than DVT (24.5%) (p=0.04), proximal versus distal DVT (28.4% and 17.3%; pConclusionsRegional variation in discharging patients directly from the ED with PE is evident. While traditional therapy is most common, uptake of DOACs was modest given the timing of indication approval.

ObjectiveTo compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada.DesignRetrospective medical record review.SettingHospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015.ParticipantsAll patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan Primary and secondary outcomesPrimarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge.Results387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; pConclusionsTraditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

ObjectiveTo determine anticoagulant therapy at hospital discharge for patients with acute venous thromboembolism (VTE) and secondarily, to describe factors affecting choice of therapy.DesignA retrospective chart review.SettingCanadian hospitals in Edmonton, Alberta (n=4), Regina, Saskatchewan (n=2) and rural Alberta (n=3) from April 2014 to March 2015.ParticipantsAll patients discharged with an acute VTE were screened. Those with atypical clots, another indication for anticoagulation, pregnancy/breast feeding or lifespan Primary and secondary outcomesPrimarily, we identified the proportion of patients discharged from hospital with acute VTE that were prescribed either traditional therapy (parenteral anticoagulant±warfarin) or a direct oral anticoagulant (DOAC). Secondarily, management based on setting, therapy choice based on deep vein thrombosis (DVT) versus pulmonary embolism (PE), clot burden and renal function was compared. DOAC dosing was assessed (when prescribed), length of hospital stay based on therapy was compared and planned follow-up in the community was described.ResultsAmong the 695 patients included, most were discharged following a diagnosis of PE (82.9%) on traditional therapy (parenteral anticoagulant±warfarin) (70.2%) with follow-up by either a family doctor (51.5%) or specialist/clinic (46.9%) postdischarge. Regional variation was most evident between urban and rural sites. Of those prescribed a DOAC (28.3%), the majority were dosed appropriately (85.8%). DOAC use did not differ between those with DVT and PE, was proportionately higher for less severe clots and declined with worsening renal function. Patients prescribed DOACs versus traditional therapy had a shorter length of stay (4 vs 7 days, respectively).ConclusionsUptake of DOAC therapy for acute VTE was modest and may have been influenced by the timing of the audit in relation to the approval of these agents for this indication. Future audits should occur to assess temporal changes and ongoing appropriateness of care delivery.

Clinical pharmacy is defined as “a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention” and “embraces the philosophy of pharmaceutical care.” 1 The role of the clinical pharmacist is to promote safe, effective, and cost-conscious drug therapy and improve patient outcomes. 2 Published evidence from observational studies, randomized controlled trials, and systematic reviews has shown that clinical pharmacist activities improve patient, medication, and surrogate outcomes; reduce health resource utilization and costs; reduce morbidity and mortality; and improve patients’ quality of life. 3-6 Despite published evidence supporting the benefits of clinical pharmacy services for health and economic outcomes, quantitative expressions that describe whether or how often a process of care or outcome of care occurs, also known as performance indicators, must be monitored to ensure that these services are delivered consistently. However, until recently, there was no established consensus as to which activities are key indicators of clinical pharmacy performance. A grass-roots collaborative of Canadian hospital pharmacists recently addressed this unanswered question by systematically establishing clinical pharmacy key performance indicators (cpKPIs) using a Delphi technique. 7 Some questions remain, including “What activities do pharmacists perform, and how consistently do they perform them?” To answer these questions, we first must understand what cpKPIs are; why cpKPIs should be measured and reported; who will be affected by these measurements; where and how cpKPIs can be measured, reported, and utilized: and when we should begin to capture cpKPIs. This article aims to address these questions about cpKPI adoption and measurement from multiple perspectives (including those of front-line pharmacists, leadership, external stakeholders, and the public), supplemented by examples from the authors’ experience. WHAT ARE cpKPIs? Key performance indicators are quantifiable measures of quality that can be used to track an organization’s progress toward achieving intended goals related to process inputs, process outputs, or outcomes. 8 These indicators are discrete events that, when they occur for an individual patient, have been proven to result in a positive outcome for that person. The US Agency for Healthcare Research and Quality (AHRQ) defines a process measure as “a health care-related activity performed for, on behalf of, or by a patient” and assesses the activities carried out by health care professionals to deliver services. 9 These types of measures are most useful when there is strong evidence associating processes with clinically important outcomes. The AHRQ defines an outcome measure as “a health state of a patient resulting from health care”, noting that such measures can encompass a vast range of health states, including physiologic measurements, laboratory test results, or a patient’s symptoms, morbidity, functional state, and quality of life. 10 Many “outcome measures”

Strokes occurring as a result of atrial fibrillation are common and typically result in severe disability or death. Over the past half century, therapeutic options for stroke prophylaxis, based on either antiplatelet (typically acetylsalicylic acid) or warfarin therapy, have remained virtually unchanged. However, as of mid-2011, promising data have emerged and Health Canada has approved a novel oral anticoagulant, dabigatran. This article provides a systematic 4-step process to guide clinicians in assessing, implementing and monitoring stroke prophylaxis for individual patients. First, identify the patient's risk of stroke with user-friendly scoring systems (CHADS2 and CHA2DS2-VASc). Second, determine the patient's risk of major bleeding with a validated scoring system (HAS-BLED) and ongoing clinical evaluation. Third, balance these benefits and the risks of available agents as they pertain to the individual patient. Fourth, select the appropriate antithrombotic therapy, with an understanding of the key features of available agents, as well as the patient's characteristics and preferences. Regular monitoring and patient adherence with therapy are necessary to ensure the long-term appropriateness of therapy, given that most patients with atrial fibrillation will require lifelong stroke prophylaxis and an individual's stroke risk generally increases with age. The pharmacist is in an excellent position to provide this type of assessment and follow-up.

Background Venous thromboembolism (VTE), comprised of both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common complication for hospitalized patients. Clear guidance is available to practitioners in regard to risk factors for the development of VTE as well as strategies to decrease its prevalence. Despite knowing who is at risk and how to prevent VTE, practitioners provide adequate measures to only half of the patients who are eligible for VTE prophylaxis. Pharmacy practitioners within the Regina Qu'Appelle Health Region (RQHR) have been actively involved in improving VTE prophylaxis for inpatients over the past 10 years. Objective To improve the rate of VTE prophylaxis within the RQHR, thereby improving patient safety. Methods The strategy involved 3 phases: a preparation phase, an active intervention phase, and a maintenance and improvement phase. The preparation phase included education and participation in a national registry along with a residency project. The intervention phase consisted of a number of strategies in conjunction with 1-day VTE prophylaxis audits, and the maintenance phase consisted of ongoing educational initiatives and audits. Results From January 2005 to January 2009, the percentage of patients being appropriately managed for VTE prophylaxis within the RQHR improved from 62% to 94% ( P < .005). Looking specifically at our medical and surgical populations, rates increased from 47% to 90% ( P < .005) and 79% to 97% ( P < .005), respectively. Conclusion The strategy was successful in improving VTE prophylaxis in the inpatient population.

Community pharmacies vary widely in terms of ownership structures, location, and dispensing policies. It is unknown if an association exists between the type of community pharmacy and the degree of medication adherence exhibited by patrons-patients.To describe adherence to statin therapy among subjects patronizing different types of community pharmacy categories (department- mass merchandise, chain-franchise, and independent-banner) in Saskatchewan, Canada, between 2000 and 2005.Study data were obtained from the Saskatchewan Drug Plan and Extended Benefits database, which is maintained by the government of Saskatchewan, Canada. The study included all subjects who (a) filled a statin prescription within selected community pharmacies between January 1, 2000, and December 31, 2005; (b) had no record of statin prescriptions during the year prior to the first statin prescription, according to the records of the Saskatchewan Drug Plan and Extended Benefits; and (c) demonstrated active utilization in the drug plan database for at least 1 year after the first statin prescription. The proxy criterion for activity was any dispensing record for statin or nonstatin medications at least 1 year following the index claim. Statin adherence level was estimated as tablets per day, defined as the total number of tablets dispensed divided by the total number of days of observation. Each subject's observation period began on the index date and ended on the earlier of (a) 30 days after the last recorded fill for any type of prescription medication (statin or nonstatin), or (b) December 31, 2005. The primary end point was the proportion of subjects within each pharmacy category who maintained an adherence level of 80% or greater during their individual observation period. Additional adherence calculations were performed for each of 3 time periods, beginning on the index date and ending on days 365, 729, and 1094 (i.e., 1, 2, and 3 years). Patients were included in the analysis for each time period if they met a proxy criterion for availability for observation, defined as the dispensing of any drug at least 1 day after the end date of each period. Pearson chi square tests were used to assess the significance of differences in baseline characteristics and adherence proportions, comparing pharmacy categories. Logistic regression analysis estimated the odds of an adherence level of at least 80% during the individual observation period, adjusting for pharmacy category, sex, age 65 years or older, known low-income drug coverage, number of distinct drug classes filled concurrently during the first year of observation, loyalty to index pharmacy, and length of observation. Using similar methods, we also estimated "pharmacy loyalty" by calculating the proportion of subjects who refilled 75% or more of their statin prescriptions at the pharmacy that dispensed their first statin prescription.From an initial sample of 12,818 subjects who had at least 1 pharmacy claim for a statin in the period from January 1, 2000, through December 31, 2005, 8699 subjects met the inclusion criteria. Subjects were observed for a mean (SD, range) of 3.7 (1.7, 1.0-7.0) years after the index statin prescription. During the first year following the index claim, statin adherence rates were at least 80% for 1799 of 3761 (47.8%) patrons of department-mass merchandise, 1778 of 3235 (55.0%) patrons of chain-franchise, and 921 of 1703 (54.1%) patrons of independent-banner stores (P0.001). Measured from the index date through day 1094, 869 of 2292 (37.9%), 874 of 1887 (46.3%), and 457 of 975 (46.9%) subjects in the department-mass merchandise, chain-franchise, and independent banner categories, respectively, had a statin adherence level of at least 80% (P0.001). In logistic regression analysis, pharmacy category type was significantly associated with statin adherence; subjects in the chain franchise and independent-banner categories were more likely to be adherent to their statin medications during their observation periods than were those in the department-mass merchandise category (adjusted odds ratio [OR] = 1.36, 95% CI = 1.23-1.50, P0.001 and OR = 1.39, 95% CI = 1.24-1.57, P0.001, respectively). From the index date through day 1094, 1752 of 2292 (76.4%), 1475 of 1887 (78.2%), and 795 of 975 (81.5%) subjects remained pharmacy-loyal in the department-mass merchandise, chain franchise, and independent-banner categories, respectively (P = 0.006). Controlling for several potential confounders using logistic regression, independent-banner pharmacy patrons were more likely to remain pharmacy- loyal during their observation periods than were those patronizing department-mass merchandise (adjusted OR = 1.34, 95% CI = 1.16-1.54, P0.001) or chain-franchise stores (adjusted OR = 1.22, 95% CI = 1.06-1.42, P = 0.009).One year after their first statin fill, subjects demonstrated low rates of adherence, ranging from 48% to 55%, regardless of the type of pharmacy they patronized. Although the differences by type of pharmacy reached statistical significance, their clinical importance is not evident, reinforcing the fact that the problem of nonadherence appears to exist among all types of community pharmacies, regardless of their categorization.

Heart failure is a clinical syndrome associated with poor quality of life, frequent hospital admissions, and high mortality rates. Since the number of people with heart failure is continuing to ris...

Introduction Despite the observation that age-specific mortality rates from coronary heart disease (CAD) have declined by nearly 40% in Canada over the past several decades, this disease continues to be the leading cause of death and morbidity for Canadians. Hyperlipidemia (especially an elevated low-density lipoprotein cholesterol [LDL-C] level and/or elevated total cholesterol to high-density lipoprotein cholesterol [TC:HDL-C] ratio) is recognized as a major independent risk factor for CAD. Recently, the large international case-controlled INTERHEART study demonstrated that an abnormal lipid profile was the most important modifiable risk factor associated with myocardial infarction. Consequently, national guidelines have been promulgated and regularly updated on the basis of accumulating clinical trial evidence to assist health care practitioners with diagnosis and treatment of patients with dyslipidemia. In Canada, these guidelines were updated and published in September 2006. Given advancements in pharmacy practice and current expectation that pharmacists take a more active role in and responsibility for medication management and patient health outcomes, pharmacists should be taking steps to identify and collaboratively manage patients with dyslipidemia. To emphasize where the knowledge and skills of pharmacists should be applied in the management of patients with dyslipidemia, the 2006 Canadian Cardiovascular Society [CCS] position statement (Recommendations for the Diagnosis and Treatment of Dyslipidemia and Prevention of Cardiovascular Disease) has been adapted and expanded. These Canadian pharmacist practice guidelines are a part of the continuing national effort to recognize and advance “the responsible and patient-centred role of the pharmacist” in chronic disease management. As key players in the health care system, pharmacists should use their knowledge, skills, and relationship with patients to improve the management of dyslipidemia and prevent cardiovascular disease. Consequently, these guidelines emphasize the role of the pharmacist in all aspects of managing the disease: • Identification and screening of patients • Individual cardiovascular (CV) risk assessment • Establishing appropriate lipid targets, based on CV risk • Lifestyle modification • Recommending and monitoring appropriate drug treatment • Ensuring patient adherence with treatment • Specialty clinic referral Readers interested in more detail or background on any of the above should refer to the full recommendations.

Objective: To assess the effect of intensive vs conventional training on pharmacist-suggested implementation of cardiac risk reduction efforts in community practice. Methods: Sixty-one volunteer pharmacists from 40 pharmacies were randomized to 1 of 2 educational groups: intensive or conventional training in cardiac risk reduction. With training complete, pharmacists identified and approached patients at high risk for coronary artery disease (CAD) at their practice sites to participate in the program. After a patient interview, pharmacists documented the relevant CAD risk factors and medication history, and then faxed this information, along with risk reduction recommendations, to the primary care physician. Patients were then encouraged to book a medical appointment for further assessment and treatment, if warranted. Follow-up occurred at 4, 16, and 24 weeks to determine if any pharmacist-suggested risk reduction measures had been implemented. Pharmacists were reimbursed $30 per patient accrued. Results: A total of 217 patients were enrolled in the study, and of those, 216 had follow-up data available for analysis. No significant differences were observed between the groups with respect to mean number of patients enrolled per pharmacist (4.3 vs 2.7) and the proportion of pharmacists completing at least 1 patient (17/27 vs 14/34). Feedback from pharmacists on program delivery indicated no significant difference in satisfaction with the training provided. The recommendations forwarded by pharmacists of the intensive group (35.8%) received greater acceptance by physicians than those in the conventional group (23.8%). Conclusion: Although results are preliminary, intensive training for pharmacists was more likely to result in improvements in cardiovascular risk reduction therapy than when conventional training was used.

Objectives: Although there are guidelines for managing patients at high vascular risk, many people remain undertreated. This community-based study was designed to 1) measure the ability of the pharmacist—physician collaboration to affect a broad array of drug-related endpoints and 2) to compare 2 methods of training community pharmacists to collaborate with physicians on cardiac patient care. This paper focuses on the first outcome, and a companion paper will address the second outcome. Methods: We used a before-and-after design to assess pharmacists' ability to affect drug-related endpoints. We identified patients by various methods, one of which was medication profiles. Those providing consent were educated on risk factor modification and encouraged to consult their physicians. Pharmacists subsequently faxed the details of their assessments to the primary care physician, along with suggestions for therapy changes. Our outcome measure was the proportion of patients who achieved a composite of either a dose increase or a new target medication as a result of pharmacist recommendations during the study. Results: A total of 61 pharmacists recruited 217 patients, and of these, follow-up was completed on 216. Of the patients for whom a pharmacist made a suggestion, pharmacologic risk reduction therapy was initiated or enhanced in 53.7%. Conclusion: This community pharmacist—based program improved utilization of the therapies known to decrease vascular risk in patients considered high risk.

Purpose The non–vitamin K antagonist oral anticoagulants (NOACs), dabigatran, rivaroxaban, and apixaban, provide several advantages over vitamin K antagonists, such as warfarin. Little is known about the trends of prescribing OACs in Canada. In this study we analyzed changes in prescription volumes for OAC drugs since the introduction of the NOACs in Canada overall, by province and by physician specialty. Methods Canadian prescription volumes for warfarin, dabigatran, rivaroxaban, and apixaban from January 2008 to June 2014 were obtained from the Canadian Compuscript Audit of IMS Health Canada Inc and were analyzed by physician specialty at the national and provincial levels. Total prescriptions by indication were calculated based on data from the Canadian Disease and Therapeutic Index for all OAC indications and for each commonly prescribed dose of dabigatran (75, 110, and 150 mg), rivaroxaban (10, 15, and 20 mg), and apixaban (2.5 and 5 mg). Findings The overall number of OAC prescriptions in Canada has increased annually since 2008. With the availability of the NOACs, the proportion of total OAC prescriptions attributable to warfarin has steadily decreased, from 99% in 2010 to 67% by June 2014, and the absolute number of warfarin prescriptions has been decreasing since February 2011. The greatest decline in proportionate warfarin prescriptions was in Ontario. In general, the increase of NOAC prescriptions coincided with the introduction of provinces’ reimbursement of NOAC prescription costs. The proportion of total OAC prescriptions represented by the NOACs varied by specialty, with the greatest proportionate prescribing found among orthopedic surgeons, cardiologists, and neurologists. Implications Since their approval, the NOACs have represented a growing share of total OAC prescriptions in Canada. This trend is expected to continue because the NOACs are given preference over warfarin in guidelines on stroke prevention in patients with atrial fibrillation, because of growing physician experience, and due to the emergence of potential new indications. An understanding of the current prescribing patterns will help to encourage knowledge translation and possibly influence policy/reimbursement strategies.

Background: Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs). Objective: A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care. Methods: A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round. Results: All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities. Conclusions: A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

Background: Dabigatran, a direct thrombin inhibitor, is indicated for the prevention and treatment of venous thromboembolism and for stroke prophylaxis in atrial fibrillation. The manufacturer recommends that dabigatran etexilate be retained in the original packaging until administration. Currently, no information exists about the stability of dabigatran etexilate outside its original packaging. Objective: To evaluate the stability of dabigatran etexilate capsules over 120 days, with storage in the manufacturer’s original packaging, in unitdose packaging, and in community pharmacy blister packaging. Methods: Commercially available dabigatran etexilate capsules (110 mg) were stored at room temperature (25°C) in the manufacturer’s original blister pack, in unit-dose packaging, or in community pharmacy blister packs. Samples were collected from each container daily for the first 3 days, weekly up to 28 days, every other week until day 98, and at day 120. Suspensions were prepared, pH was evaluated, and samples were stored at –85°C until analysis. Each sample was analyzed in duplicate by a validated, stability-indicating high-performance liquid chromatography – ultraviolet detection method. The capsules were considered stable if they maintained at least 90% of the initial concentration. Results: Dabigatran etexilate capsules maintained 100.4% of the original concentration with 120 days of storage in the manufacturer’s original blister pack, 98.7% with storage in unit-dose packaging, and 98.0% with storage in community pharmacy blister packs. There were no notable changes in appearance, ease of suspension of the capsule content, or pH over the 120-day period. Conclusion: Dabigatran etexilate 110-mg capsules were stable for 120 days with storage at room temperature in 3 types of packaging widely used in hospital and community settings. RESUME Contexte : Le dabigatran, un inhibiteur direct de la thrombine, est approuve pour la prevention et le traitement des evenements thromboemboliques veineux et pour la prophylaxie de l’accident vasculaire cerebral en presence de fibrillation auriculaire. Le fabricant recommande que le dabigatran etexilate soit garde dans le conditionnement d’origine jusqu’a l’administration. Il n’existe aucune donnee sur la stabilite du dabigatran etexilate hors du conditionnement d’origine. Objectif : Evaluer la stabilite de capsules de dabigatran etexilate sur une periode de 120 jours lorsqu’elles sont entreposees dans : le conditionnement d’origine du fabricant, un conditionnement unitaire ou un pilulier de type plaquette alveolee prepare en pharmacie communautaire. Methodes : Des capsules de 110 mg de dabigatran etexilate, disponibles sur le marche, ont ete entreposees a temperature ambiante (25 °C) soit dans la plaquette alveolee d’origine du fabricant, soit dans un conditionnement unitaire, soit dans un pilulier de type plaquette alveolee prepare en pharmacie communautaire. Des echantillons ont ete preleves de chaque type d’emballage : quotidiennement pour les 3 premiers jours, hebdomadairement pour les 28 jours suivants, puis toutes les deux semaines jusqu’au jour 98, et au jour 120. Des suspensions ont ete preparees, le pH mesure et les echantillons entreposes a –85 °C jusqu’a l’analyse. Chaque echantillon a ete soumis a une double analyse a l’aide d’une epreuve validee mesurant la stabilite par chromatographie liquide haute performance avec detection ultraviolette. Les capsules etaient considerees comme stables si elles conservaient au moins 90 % de leur concentration initiale. Resultats : Au bout des 120 jours, les capsules de dabigatran etexilate ont conserve 100,4 % de leur concentration de depart lorsqu’entreposees dans les plaquettes alveolees d’origine du fabricant, 98,7 % lorsqu’entreposees dans un conditionnement unitaire et 98,0 % lorsqu’entreposees dans un pilulier de type plaquette alveolee prepare en pharmacie communautaire. Aucun changement notable de l’apparence, du pH et de la facilite de la mise en suspension du contenu de la capsule n’a ete observe pendant la periode de 120 jours. Conclusion : Les capsules de 110 mg de dabigatran etexilate sont demeurees stables pendant la periode de 120 jours d’entreposage a temperature ambiante dans trois types de conditionnement largement utilises dans les hopitaux et les pharmacies communautaires.

Background: The participation of pharmacists on cardiopulmonary resuscitation (CPR) teams has been associated with improvements in patient outcomes secondary to lower rates of adverse drug events and higher rates of compliance with guidelines for advanced cardiac life support (ACLS). The degree to which Canadian pharmacists participate on CPR teams and the services they provide have not previously been assessed. Objectives: To measure the frequency of pharmacists’ involvement on CPR teams in Canadian health care delivery organizations, to characterize the services provided by these pharmacists, to identify positive predictors of participation, and, for health care delivery organizations without pharmacists on CPR teams, to determine the reasons for the lack of involvement. Methods: An electronic survey was distributed to key informants in Canadian health care delivery organizations. The survey consisted of questions about characteristics of the health care delivery organizations, pharmacists’ participation and role on the CPR team, training, and barriers to implementation. The primary outcome was the percentage of health care delivery organizations with pharmacists participating on CPR teams in at least one centre within the organization. The secondary outcomes were pharmacists’ activities, training, and reasons for not participating on CPR teams. Results: Forty-three of 99 key informants responded to the survey. Twenty-nine respondents (67%) indicated that their organization had a CPR team, and 10 (23%) indicated participation by pharmacists on a CPR team. Roles reported to be performed by pharmacists during CPR events were provision of drug information, preparation and administration of medications, record- keeping, and chest compressions. Training for these pharmacists was variable: ACLS training for 4 (40%) of the 10 organizations with pharmacist participation, in-house training for 3 (30%), and no training for 2 (20%); one respondent (10%) did not report the level of training. Reasons for not having pharmacists on CPR teams included inconsistent coverage, lack of training, and staff shortages. Conclusions: This study characterized current pharmacist participation on CPR teams in Canadian health care delivery organizations. As evidence arises showing the impact of this practice on patient outcomes, pharmacist participation on CPR teams may become more common. RESUME Contexte : L’integration des pharmaciens aux equipes de reanimation cardio-respiratoire (RCR) a ete associee a une amelioration des resultats therapeutiques, qui est due a des taux plus faibles d’evenements indesi - rables lies aux medicaments et a un meilleur degre de conformite aux lignes directrices portant sur la technique specialisee de reanimation cardiorespiratoire. Or, aucune etude n’a encore analyse la mesure dans laquelle les pharmaciens canadiens participent aux equipes de RCR et l’eventail des services qu’ils fournissent en leur sein. Objectifs : Evaluer dans quelle mesure les pharmaciens participent aux equipes de RCR des organismes canadiens de prestation de soins de sante, decrire les services fournis par ces pharmaciens, identifier les facteurs predictifs de participation et, dans les organismes de prestation de soins de sante ou aucun pharmacien ne fait partie des equipes de RCR, determiner les raisons expliquant cette absence. Methodes : Un sondage electronique a ete donne aux informateurs cles des organismes canadiens de prestation de soins de sante. Le sondage contenait des questions portant sur les caracteristiques des organimes de prestation de soins de sante, la presence des pharmaciens au sein de l’equipe de RCR et le role qu’ils y jouent, leur formation en RCR et les obstacles s’opposant a leur participation. Le principal parametre d’evaluation etait le pourcentage d’organismes de prestation de soins de sante ou des pharmaciens faisaient partie d’equipes de RCR dans au moins l’un des centres de l’organisme. Les parametres d’evaluation secondaires comprenaient les activites et la formation des pharmaciens ainsi que les raisons expliquant leur absence des equipes de RCR. Resultats : En tout, 43 des 99 informateurs cles ont repondu au sondage. Vingt-neuf repondants (67 %) ont indique que leur organisme avait une equipe de RCR et 10 (23 %) ont souligne la participation de pharmaciens dans l’equipe. Selon les reponses, les pharmaciens jouaient differents roles pendant les episodes de RCR, notamment : fournir des renseignements sur des medicaments, preparer et administrer des medicaments, effectuer la tenue de dossiers et realiser des compressions thoraciques. La formation de ces pharmaciens etait inegale : 4 (40 %) des 10 organismes ou des pharmaciens participaient offraient une formation en technique specialisee de reanimation cardio-respiratoire, 3 (30 %) offraient une formation interne et 2 (20 %) n’offraient aucune formation; un repondant (10 %) n’a pas precise le niveau de formation. L’inegalite du service, le manque de formation et les penuries de personnel faisaient partie des raisons expliquant l’absence des pharmaciens des equipes de RCR. Conclusions : La presente etude a dresse le portrait actuel de la participation des pharmaciens dans les equipes de RCR des organismes canadiens de prestation de soins de sante. Au fur et a mesure qu’apparaitront des donnees illustrant l’effet de cette pratique sur les resultats therapeutiques, il est possible que la participation de pharmaciens dans les equipes de RCR devienne de plus en plus frequente.

Background: Hypertension is a leading risk factor for death and disability in Canada. Pharmacists can help to improve the treatment and control of hypertension through collaboration with physicians and patients to improve pharmacotherapy. Objective: To review appropriate pharmacotherapy for hypertension, as outlined in the recommendations of the Canadian Hypertension Education Program. Methods: The recommendations of the Canadian Hypertension Education Program were reviewed with a view to identifying gaps in the recommendations as they apply to pharmacy practice. For some of these gaps, it was determined that pharmacists could provide further care to patients with hypertension, and opportunities for pharmacist involvement are suggested here. Results: Initial pharmacotherapy for uncomplicated hypertension includes thiazide-type diuretics, beta-blockers for patients under 60 years of age, angiotensin-converting enzyme (ACE) inhibitors, long-acting calcium channel blockers, and angiotensin receptor blockers. For additive hypotensive action in two-drug combinations, either a diuretic or a calcium channel blocker should be combined with a beta-blocker, ACE inhibitor, or angiotensin receptor blocker. Other combinations are less effective or unproven. Areas where pharmacists must become more actively involved in the management of patients with hypertension include provision of balanced information about benefits and side effects, identification of secondary druginduced causes of hypertension or drug interactions, and suggestion of adjustments to medication dosage for patients with renal dysfunction. Conclusions: There are specific and unique roles for pharmacists in the management of hypertension. Pharmacists can play a greater role in improving the pharmacological management of hypertensive patients, aided in part by regular updates to the recommendations of the Canadian Hypertension Education Program.

Payam Dehghani,1 Varun Chopra,1 Ali Bell,2 Sheila Kelly,1 Lori Zulyniak,2 Jeff Booker,1 Rodney Zimmermann,1 William Semchuk,2 Asim N Cheema,3 Andrea J Lavoie1 1Prairie Vascular Research Network, University of Saskatchewan, Regina, SK, 2Regina Qu’Appelle Health Region, Regina, SK, 3St Michael’s Hospital, University ofToronto, Toronto, ON, Canada Background: As ticagrelor enters into clinical use for acute coronary syndrome, it is ­important to understand patient/physician behavior in terms of appropriate use, adherence, and event rates. Methods: The Saskatchewan Registry is a prospective, observational, multicenter cohort study that identifies consecutive patients started on ticagrelor. We aimed to evaluate both on- and off-label use, identify characteristics of patients who prematurely stop ticagrelor, and describe patient/physician behavior contributing to inappropriate stoppage of this medication. Results: From April 2012to September 2013, 227patients were initiated on ticagrelor, with a mean age of 62.2±12.1years. The participants were 66% men and had a mean follow up of 157.4±111.7days. Seventy-four patients (32.4%) had off-label indications. Forty-seven patients (20.7%) prematurely stopped ticagrelor and were more likely to be older, women, nonwhite, present with shock, and complain of dyspnea. Twenty-six of the 47patients stopped ticagrelor inappropriately because of patient nonadherence (18patients) and physician advice (eight patients). A composite outcome event of death from vascular causes, myocardial infarction, or stroke occurred in 8.8% of the entire cohort and was more likely to occur in those older then 65years, those presenting with cardiogenic shock, and those who prematurely stopped ticagrelor. Conclusion: In this real-world registry of patients started on ticagrelor, a third have off-label indications and a fifth prematurely stop the medication. Premature discontinuation was an independent predictor of major life-threatening bleeding and increased composite event rate of death from vascular causes, myocardial infarction, or stroke. Keywords: ticagrelor, acute coronary syndrome, registry, adherence, compliance, antiplatelets

Recent studies on the effectiveness of patient information tools and methods confirm that what patients want and what they get are sometimes widely at odds. As the paternalistic notion of “compliance” is evolving into the patient-centred concept of “adherence,” new data and guidelines may help us to address our patients' wants and needs for medication information. This in turn supports patients in their own health and medication management.

Dabigatran etexilate is a substrate of the P-glycoprotein (adenosine triphosphate-binding cassette subfamily B member 1) transport system and is subject to interactions with medications that induce or inhibit this system. The clinical relevance of the interaction between dabigatran and phenytoin has not been well described. We report a case of left atrial thrombus in a patient receiving concomitant dabigatran etexilate and phenytoin, which is a P-glycoprotein inducer. This case illustrates the potential clinical significance of the interactions of medications that affect P-glycoprotein and dabigatran.

Background: Many patients with atrial fibrillation who are at moderate to high risk of stroke do not receive anticoagulation with vitamin K antagonists (VKAs) in accordance with recommendations. Objective: To determine (1) why Canadian patients with atrial fibrillation who are potentially eligible for VKA do not receive this therapy, (2) why Canadian primary care physicians discontinue VKA therapy, and (3) why VKA therapy is perceived as difficult to manage. Methods: The study involved a chart review of 3 cohorts of patients with nonvalvular atrial fibrillation at moderate to high risk of stroke: patients who had never received VKA treatment (VKA-naive), those whose treatment had been discontinued, and those whose VKA treatment was considered difficult to manage. Results: Charts for 187 patients (mean age 78.4 years, standard deviation 8.9 years) treated at 39 primary care sites were reviewed (62 treatment-naive, 42 with therapy discontinued, and 83 whose therapy was considered difficult to manage). Atrial fibrillation was paroxysmal in 82 (44%) of the patients, persistent in 47 patients (25%), and permanent in 58 (31%). One patient in each of the 3 cohorts had experienced a stroke during the 6 months before study participation. Bleeding events were more frequent among patients who had discontinued VKA therapy than in the other 2 groups. Among those whose therapy was discontinued and those whose therapy was difficult to manage, the mean time in the therapeutic range was 46.3% and 56.4%, respectively. The most common reason for not initiating VKA therapy in treatment-naive patients was the transient nature of atrial fibrillation (25/62 [40%]). The most common reason for discontinuation of VKA therapy was a bleeding event (10/42 [24%]). The presence of a concomitant chronic disease was the most common reason that a patient’s therapy was considered difficult to manage (46/83 [55%]). Conclusions: VKA therapy was not initiated or was discontinued for various reasons. Multiple comorbid conditions made management of VKA therapy more difficult. These findings reflect the challenges that primary care physicians experience in managing the care of patients with atrial fibrillation. RESUME Contexte : De nombreux patients atteints d’une fibrillation auriculaire (FA) et presentant un risque d’accident vasculaire cerebral (AVC) modere ou eleve ne recoivent pas d’anticoagulotherapie par un antagoniste de la vitamine K, conformement aux recommandations. Objectif : Determiner 1) pourquoi les patients canadiens atteints d’une FA et qui sont des candidats potentiels a l’anticoagulotherapie par un antagoniste de la vitamine K ne recoivent pas ce traitement, 2) pourquoi les medecins canadiens de soins primaires interrompent l’anticoagulotherapie par un antagoniste de la vitamine K, et 3) pourquoi la prise en charge d’un tel traitement est consideree comme difficile. Methodes: Cette etude comportait une analyse des dossiers medicaux des patients de trois cohortes atteints d’une FA non valvulaire et consideres comme presentant un risque modere ou eleve d’AVC : patients qui n’avaient jamais recu d’anticoagulotherapie par un antagoniste de la vitamine K, patients chez qui ce traitement avait ete interrompu et patients chez qui la prise en charge de ce traitement etait consideree comme difficile. Resultats : Les dossiers medicaux de 187 patients (âge moyen de 78,4 ans, ecart-type de 8,9 ans) traites dans 39 etablissements de soins primaires ont ete analyses (62 : jamais traites, 42 : traitement interrompu et 83 : prise en charge consideree comme difficile). On a repertorie 82 (44 %) cas de FA paroxystique, 47 (25 %) cas de FA persistante et 58 (31 %) cas de FA permanente. Un patient dans chacune des trois cohortes a eu un AVC durant les six mois precedant sa participation a cette etude. Les saignements etaient plus frequents parmi les patients chez qui on avait interrompu le traitement par l’antagoniste de la vitamine K que chez ceux des deux autres groupes. Parmi les patients chez qui le traitement avait ete interrompu ou sa prise en charge etait consideree comme difficile, le temps moyen dans l’ecart therapeutique etait respectivement de 46,3 % et de 56,4 %. La raison la plus souvent evoquee pour ne pas instaurer le traitement par un antagoniste de la vitamine K chez les patients n’ayant jamais recu un tel traitement etait la nature passagere de la FA (25/62 [40 %]). La raison la plus souvent evoquee pour interrompre ce traitement etait les saignements (10/42 [24%]). La presence d’une comorbidite chronique etait la raison la plus souvent evoquee pour expliquer la prise en charge difficile de ce traitement (46/83 [55 %]). Conclusions : L’anticoagulotherapie par un antagoniste de la vitamine K n’etait pas instauree ou etait interrompue pour diverses raisons. La presence de multiples comorbidites rendait sa prise en charge plus difficile. Ces resultats refletent les difficultes des medecins de soins primaires dans la prise en charge des patients atteints de fibrillation auriculaire.

Background: Many patients who experience a venous thromboembolic event have cancer, and thrombosis is much more prevalent in patients with cancer than in those without it. Thrombosis is the second most common cause of death in cancer patients and cancer is associated with a high rate of recurrence of venous thromboembolism (VTE), bleeding, requirement for long-term anticoagulation and poorer quality of life. Methods: A literature review was conducted to identify guidelines and evidence pertaining to anticoagulation prophylaxis and treatment for patients with cancer, with the goal of identifying opportunities for pharmacists to advocate for and become more involved in the care of this population. Results: Many clinical trials and several guidelines providing guidance to clinicians in the treatment and prevention of VTE in patients with cancer were identified. Current clinical evidence and guidelines suggest that cancer patients receiving care in hospital with no contraindications should receive VTE prophylaxis with unfractionated heparin (UFH), a low-molecular-weight heparin (LMWH) or fondaparinux. Patients who require surgery for their cancer should receive prophylaxis with UFH, LMWH or fondaparinux. Cancer patients who have experienced a VTE event should receive prolonged anticoagulant therapy with LMWH (at least 3 months to 6 months). No routine prophylaxis is required for the majority of ambulatory patients with cancer who have not experienced a VTE event. Most publicly funded drug plans in Canada have developed criteria for funding of LMWH therapy for patients with cancer. Conclusions: Evidence suggests that LMWH for 3 to 6 months is the preferred strategy for most cancer patients who have experienced a thromboembolic event and for hospital inpatients, but this is often not implemented in practice. Concerns about adherence with injectable therapy should not prevent use of these agents. Pharmacists should assess cancer patients for their risk of VTE and should advocate for optimal VTE pharmacotherapy as appropriate. If LMWH is the preferred agent, on the basis of the evidence, the pharmacist should educate the patients appropriately and work with the prescriber to ensure best care. Can Pharm J

Background—The use of evidence-based medications in patients with heart failure has increased over the past 10 years. We aimed to determine whether adherence to these medications has also increased during this time.Methods and Results—A retrospective cohort was created using administrative databases from the province of Saskatchewan, Canada. Subjects discharged alive from their first hospitalization for heart failure between 1994 and 2003 were eligible. Those filling a prescription for a β-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) within 6 months of discharge were followed for 1 year after the initial prescription. Of 8805 eligible patients, 67% of BB users (941/1414) and 74% of ACEI/ARB users (4441/5991) exhibited optimal adherence at 1 year (defined as ≥80% adherence calculated from pharmacy refill records). When grouped by year of initial heart failure hospitalization, the proportion of optimally adherent patients improved from 54% to 75% with BB and from 67% to 80% with ACEI/ARBs between 1994/1995 and 2002/2003 (Pfor trend Conclusions—One-year adherence to BB and ACEI/ARB is improving over time in patients discharged after first heart failure hospitalization. Patients taking multiple cardiac medications were not any less likely to exhibit optimal adherence than patients taking only 1 medication.

Background: In Canada, there is a dose cap for weight-based treatment with low-molecular-weight (LMW) heparins. Objective: To review whether capping of LMW heparin doses is warranted for patients with obesity. Methods: English-language publications concerning the use of LMW heparin in Canada were reviewed, and the literature regarding use of these drugs at treatment doses in patients with obesity was assessed. Results: Five pharmacokinetic or pharmacodynamic studies meeting the inclusion criteria were identified. The evidence in those studies pointed toward no excess accumulation of LMW heparin in patients with obesity. In addition, 5 trials involving patients with acute coronary syndromes and 6 trials involving patients with venous thromboembolism and other indications were identified, but only 7 of these 11 trials included sufficient information for review. Subgroup analysis of patients with acute coronary syndrome whose LMW heparin dose was not capped showed no increased risk of bleeding for obese patients treated with enoxaparin. For patients with venous thromboembolism and other indications, the best evidence was for dalteparin, with anti-Xa levels used as a surrogate end point. In this setting, excess accumulation did not occur when there was no dose cap. Discussion: There is little literature dedicated to the dosing of LMW heparin for obese patients. In particular, there are few data for those with body weight above 150 kg. Despite the limitations of these studies, there appears to be little justification for capping the doses of these drugs. On the basis of the available literature, it is suggested that treatment doses of LMW heparin be based on body weight up to 150 kg. RESUME Contexte : Au Canada un plafond est fixe a la dose pour les traitements par l’heparine de faible poids moleculaire (HFPM) fondees sur le poids ont ete etablies. Objectif : Evaluer si les doses limites d’HFPM sont justifiees chez les patients obeses. Methodes : Des publications de langue anglaise sur l’emploi d’HFPM au Canada ont ete examinees et la litterature sur l’emploi d’HFPM a des doses therapeutiques chez les patients obeses a ete evaluee. Resultats : Cinq etudes de pharmacocinetique ou de pharmacodynamie satisfaisant aux criteres d’inclusion ont ete recensees. Les donnees dans ces etudes portent a croire qu’il n’y a pas d’accumulation excessive de ces medicaments chez cette population de patients. En outre, cinq etudes menees sur le traitement de patients atteints de syndromes coronariens aigus et six autres sur le traitement de patients souffrant de thromboembolie veineuse et pour d’autres indications ont ete identifiees, mais seulement sept de ces onze etudes comportaient suffisamment d’information pour etre analysees. L’analyse de sous-groupes de patients atteints de syndrome coronarien aigu dont la dose d’HFPM ne respectait pas le plafond fixe n’a montre aucune augmentation du risque de saignement chez les patients obeses traites par l’enoxaparine. Chez les patients souffrant de thromboembolie veineuse et pour d’autres indications, les donnees les plus probantes etaient pour la dalteparine, avec les taux de facteur anti-Xa utilises comme critere de substitution. Dans ce contexte, aucune accumulation excessive n’est survenue en l’absence d’un plafonnement de la dose. Conclusions : Il existe peu de documentation portant sur la posologie de l’HFPM chez les patients obeses. On dispose de particulierement peu de donnees pour les patients ayant un poids corporel superieur a 150 kg. Malgre les limites de ces etudes, le plafonnement des doses de l’HFPM semble peut justifie. La litterature disponible porte a croire que les doses therapeutiques d’HFPM peuvent etre fondees sur le poids corporel jusqu’a une taille de 150 kg.

Background: Despite the availability of proven therapies, outcomes in patients with heart failure (HF) remain poor. In this 2-stage, multicenter trial, we evaluated the effect of a disease management program on clinical and economic outcomes in patients with HF. MethodsandResults: In Stage 1, a pharmacist or nurse assessed each patient and made recommendations to the physician to add or adjust angiotensin-converting enzyme (ACE) inhibitors and other HF medications. Before discharge (Stage 2), patients were randomized to a patient support program (PSP) (education about HF, self-monitoring, adherence aids, newsletters, telephone hotline, and follow-up at 2 weeks, then monthly for 6 months after discharge) or usual care. In Stage 1 (766 patients) ACE inhibitor use increased from 58% on admission to 83% at discharge (P .0001), and the daily dose (in enalapril equivalents) increased from 11.3 8.8 mg to 14.5 8.8 mg (P .0001). In Stage 2 (276 patients) there was no difference in ACE inhibitor adherence, but a reduction in cardiovascular-related emergency room visits (49 versus 20, P .030), hospitalization days (812 versus 341, P .003), and cost of care ($CDN 2,531 less per patient) in favor of the PSP. Conclusion: Simple interventions can improve ACE inhibitor use and patient outcomes.

Despite clear evidence for the efficacy of lowering cholesterol levels, there is a deficiency in its real-world application. There is a need to explore alternative strategies to address this important public health problem. This study aimed to determine the effect of a program of community pharmacist intervention on the process of cholesterol risk management in patients at high risk for cardiovascular events.A randomized controlled trial conducted in 54 community pharmacies (1998-2000) included patients at high risk for cardiovascular events (with atherosclerotic disease or diabetes mellitus with another risk factor). Patients randomized to pharmacist intervention received education and a brochure on risk factors, point-of-care cholesterol measurement, referral to their physician, and regular follow-up for 16 weeks. Pharmacists faxed a simple form to the primary care physician identifying risk factors and any suggestions. Usual care patients received the same brochure and general advice only, with minimal follow-up. The primary end point was a composite of performance of a fasting cholesterol panel by the physician or addition or increase in dose of cholesterol-lowering medication.The external monitoring committee recommended early study termination owing to benefit. Of the 675 patients enrolled, approximately 40% were women, and the average age was 64 years. The primary end point was reached in 57% of intervention patients vs 31% in usual care (odds ratio, 3.0; 95% confidence interval, 2.2-4.1; P.001).A community-based intervention program improved the process of cholesterol management in high-risk patients. This program demonstrates the value of community pharmacists working in collaboration with patients and physicians.