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Background: High/intermediate‐risk pulmonary embolism (PE) confers increased risk of cardiovascular morbidity and mortality. International guidelines recommend the formation of a PE response team (PERT) for PE management because of the complexity of risk stratification and emerging treatment options. However, there are currently no available Australian data regarding outcomes of PE managed through a PERT. Aims: To analyse the clinical and outcome data of patients from an Australian centre with high/intermediate‐risk PE requiring PERT‐guided management. Methods: We performed a retrospective observational study of 75 consecutive patients with high/intermediate‐risk PE who had PERT involvement, between August 2018 and July 2021. We recorded clinical and interventional data at the time of PERT and assessed patient outcomes up to 30 days from PERT initiation. We used unpaired t tests to compare right to left ventricular (RV/LV) ratios by computed tomography criteria or transthoracic echocardiogram (TTE) at baseline and after interventions. Results: Data were available for 74 patients. Initial computed tomography pulmonary angiography RV/LV ratio was increased at 1.65 ± 0.5 and decreased to 1.30 ± 0.29 following PERT‐guided interventions (P < 0.001). TTE RV/LV ratio also decreased following PERT‐guided management (1.09 ± 0.19 vs 0.93 ± 0.17; P < 0.001). 20% of patients had any bleeding complication, but two‐thirds were mild, not requiring intervention. All‐cause mortality was 6.8%, and all occurred within the first 7 days of admission. Conclusion: The PERT model is feasible in a large Australian centre in managing complex and time‐critical PE. Our data demonstrate outcomes comparable with existing published international PERT data. However, successful implementation at other Australian institutions may require adequate centre‐specific resource availability and the presence of multispeciality input. [ABSTRACT FROM AUTHOR]

Background: Severe COVID‐19 causes acute inflammation, which is complicated by venous thromboembolism events (VTE). However, it is unclear if VTE risk has evolved over time since the COVID‐19 outbreak. Aims: To determine markers of thrombo‐inflammation and rates of symptomatic VTE in patients hospitalised for COVID‐19 in a metropolitan hospital in Sydney, Australia. Methods: A retrospective, single‐centre, cohort study was performed by reviewing electronic medical records of consecutive patients admitted to Royal Prince Alfred Hospital between March 2020 and September 2021. This period included three waves of COVID‐19 outbreaks in Australia with the ancestral, alpha and delta variants. Standard coagulation assays and inflammatory markers were recorded over 4 weeks. Results: A total of 205 patients were consecutively admitted during the study period. Activated partial thromboplastin time, neutrophil count and C‐reactive protein (CRP) were significantly increased in patients hospitalised in the intensive care unit (ICU) compared with non‐ICU patients. The use of anti‐inflammatory medication increased in 2021 compared with 2020. The mortality rate was 7.3% in our cohort. Ninety‐four per cent of patients received anticoagulation with 6.3% of patients developing VTE. Conclusion: We observed lower rates of VTE compared to the internationally reported rate for the same period. We conclude that in the setting of controlled hospital admission rate and standard anticoagulation guidelines, COVID‐19 resulted in similar thrombo‐inflammatory response and VTE rates over the first 1.5 years of the pandemic. [ABSTRACT FROM AUTHOR]

Cerebral amyloid angiopathy (CAA) is a disease with several clinical manifestations. It is characterised by amyloid‐beta deposition in cerebral blood vessels, making them prone to bleeding. The incidence of CAA increases with age and may be associated or co‐exist with intraparenchymal neurodegenerative proteinopathies, which makes it an increasingly relevant condition for adult physicians in all areas of medical practice. The vast majority of cases of CAA are sporadic with a small minority of familial cases. CAA is asymptomatic in many older adults but increases the risk of fatal intracerebral or subarachnoid haemorrhage. We review the existing literature on CAA and summarise the key findings. We specifically explore clinical challenges relevant to CAA, particularly in diagnosis, management of intracranial haemorrhage and management of concurrent medical conditions. [ABSTRACT FROM AUTHOR]

Background: Anticoagulants are recommended to prevent cardioembolic stroke in most patients with atrial fibrillation (AF). Management errors with anticoagulation and use of aspirin instead of anticoagulants have been documented worldwide, especially with vitamin K antagonists. Aims: To assess the rate of anticoagulant mismanagement errors in patients admitted with ischaemic stroke and the clinical correlates with stroke outcomes in the era of non‐vitamin K oral anticoagulants. Methods: We performed a retrospective analysis of patients admitted with ischaemic stroke and history of AF to a single‐centre tertiary hospital stroke unit in Melbourne, Australia, between January 2016 and June 2019. We assessed management errors as defined using European Heart Rhythm Association criteria with anticoagulation in the 2 weeks prior to the index stroke. Results: A total of 306 patients with AF and ischaemic stroke was included, of whom 196 (64%) had management errors. Patients with management errors were older (median age 84 vs 81 years; P = 0.002) and more often female (53% vs 38%; P = 0.02). Of those with management errors, 74 (37%) were not prescribed any anticoagulation despite increased stroke risk and absence of contraindications and 40 (20%) had anticoagulation inappropriately ceased. Mortality at 3 months was 32% in those with management errors, compared with 17% in the appropriately anticoagulated group (P = 0.005). Conclusions: Inappropriate management of anticoagulants is present in the majority of acute ischaemic stroke in the 2 weeks preceding the event and is linked to higher mortality. Improved anticoagulation practice has the potential to substantially reduce stroke rates in patients with AF. [ABSTRACT FROM AUTHOR]

Objective: To improve the safety of anticoagulation initiation by increasing the proportion of patients reviewed by a pharmacist. Methods: An electronic intervention was developed to ensure all patients prescribed anticoagulation on discharge were reviewed by an ED pharmacist. Safe anticoagulation initiation was compared for patients seen and not seen. Results: The intervention increased the number of patients seen by an ED pharmacist. Pre-intervention (n = 238) 84.5% of patients were reviewed by a pharmacist. Postintervention (n = 253) 99.6% of patients were reviewed by a pharmacist. Of the 38 patients not reviewed by a pharmacist, 20 (52.6%) had safe anticoagulation initiation and in a sample of 40 patients reviewed by a pharmacist, all 40 (100%) had safe anticoagulation initiation (52.6% vs 100%, P < 0.001). Conclusion: The real-time electronic intervention improved the number of patients reviewed by a pharmacist. ED pharmacist reviewed patients were more likely to have safe anticoagulation initiation. [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolic (VTE) complications appear common in hospitalised COVID‐19 patients, particularly among critically ill patients in intensive care units. However, there is significant heterogeneity in the reported use of thromboprophylaxis. Aims: The primary objective was to determine rates of symptomatic VTE in hospitalised COVID‐19 patients. Secondary objectives were to assess adherence to an institutional risk‐adapted thromboprophylaxis guideline, and rates of bleeding complications. Methods: A retrospective, single‐centre, cohort study was performed in consecutive hospitalised COVID‐19 patients over a 6‐month period (March to August 2020). Enoxaparin was used as thromboprophylaxis in all patients without a contraindication, with dose adjusted according to disease severity, weight and renal function. Results: Among 86 hospitalised COVID‐19 patients, no VTE were identified. Eighty‐one (94%) patients received anticoagulation, with 90% adherence to institutional thromboprophylaxis guidelines. Four bleeding events occurred, with one clinically relevant non‐major bleeding event and three minor bleeding events. Conclusion: Low rates of VTE were identified in hospitalised COVID‐19 patients using a risk‐adapted thromboprophylaxis protocol. [ABSTRACT FROM AUTHOR]

In this clinical review we highlight aspects of the diagnosis and management of pulmonary embolism (PE) in pregnancy and post‐partum and how this may impact on antenatal and postnatal management. Investigation for PE in pregnancy is challenging and includes appropriate patient selection and knowledge of the risks and benefits of pulmonary imaging modalities. The complete Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post‐Partum comprehensively reviews all aspects of diagnosis, investigation and management and is accessible at https://www.somanz.org/guidelines.asp. It includes a summary of all recommendations and a guide to developing a management plan for birth in women on anticoagulation. [ABSTRACT FROM AUTHOR]

Objective: Prior studies have demonstrated that anticoagulation underutilisation for atrial fibrillation (AF) and elevated stroke risk is common. However, there is little data on factors associated with appropriate anticoagulation, particularly in Indigenous Australians who face a disproportionate burden of AF and stroke. We thus sought to determine factors associated with anticoagulation use in Australians with AF.Design: Administrative, clinical, prescriptive and laboratory data were linked and aggregated over a 12-year period.Setting: Single tertiary teaching hospital.Participants: 19,305 (98%) and 308 (2%) consecutive non-Indigenous and Indigenous Australians with AF identified from administrative databases.Main Outcome Measures: Associations of anticoagulation use according to ethnicity.Results: Significant independent predictors of anticoagulation use included hypertension (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.17-1.34; p<0.001), diabetes (OR 1.14, 95% CI 1.05-1.24; p=0.002), heart failure (OR 1.54 95% CI 1.43-1.66; p<0.001) and prior stroke or transient ischaemic attack (OR 2.07, 95% CI 1.84-2.33; p<0.001). In contrast, increasing age (OR 0.99, 95% CI 0.98-0.99; p<0.001), female gender (OR 0.88, 95% CI 0.82-0.93; p<0.001), and vascular disease (OR 0.72, 95% CI 0.64-0.80; p<0.001) were significant predictors of no anticoagulation. Hypertension was associated with less anticoagulation use in Indigenous compared to non-Indigenous Australians (p=0.02).Conclusions: Anticoagulation for AF was suboptimal in both Indigenous and non-Indigenous Australians. Older age, female gender, and comorbid vascular disease were found to be negatively associated with anticoagulation. Importantly, hypertension may also be under-recognised as a stroke risk factor in Indigenous Australians. Future efforts to encourage anticoagulation use in accordance with guideline recommendations is likely to reduce the burden of AF-related stroke in both Indigenous and non-Indigenous populations. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a growing epidemic. Current models of care delivery are inadequate in meeting the needs of the population with AF. Furthermore, quality of life is known to be poor in patients with AF and is associated with adverse patient outcomes. Objective: The aim of this study was to determine if nurse-led education and cardiovascular risk factor modification, undertaken using the principles of motivational interviewing, facilitated by an electronic decision support tool to ensure the appropriate use of oral anticoagulation (OAC), could improve health-related quality of life (HRQoL), guideline adherence to OAC, and cardiovascular risk factor profiles in individuals with AF. Methods: This was a multicenter, prospective, randomized controlled feasibility study of 72 individuals with AF. The intervention involved 1 face-to-face nurse-delivered education and risk factor management session with 4 follow-up telephone calls over a 3-month period to monitor progress. The primary outcome measure was HRQoL as assessed by the Short Form-12 survey. Results: A total of 72 participants were randomized, with 36 individuals in each arm completing follow-up.Mean age was 65 ± 11 years and 44%were women. At 3 months follow-up, no significant differences between groups were observed for the physical or mental component summary scores of the Short Form-12, nor any of the subscales. Appropriate use of OAC did not differ between groups at final follow-up. Conclusions: A brief nurse-delivered educational intervention did not significantly impact on HRQoL or risk factor status in individuals with AF. Further research should focus on interventions of greater intensity to improve outcomes in this population. Trial Registration: ACTRN12615000928516 [ABSTRACT FROM AUTHOR]

Background: Studies have shown that suboptimal anticoagulation quality, as measured by time in therapeutic range (TTR), affects a significant percentage of patients with atrial fibrillation (AF). However, TTR has not been previously characterised in Indigenous Australians who experience a greater burden of AF and stroke.Method: Indigenous and non-Indigenous Australians with AF on warfarin anticoagulation therapy were identified from a large tertiary referral centre between 1999 and 2012. Time in therapeutic range was calculated as a proportion of daily international normalised ratio (INR) values between 2 and 3 for non-valvular AF and 2.5 to 3.5 for valvular AF. INR values between tests were imputed using the Rosendaal technique. Linear regression models were employed to characterise predictors of TTR.Results: Five hundred and twelve (512) patients with AF on warfarin were included (88 Indigenous and 424 non-Indigenous). Despite younger age (51±13 vs 71±12 years, p<0.001), Indigenous Australians had greater valvular heart disease, diabetes, and alcohol excess compared to non-Indigenous Australians (p<0.05 for all). Time in therapeutic range was significantly lower in Indigenous compared to non-Indigenous Australians (40±29 vs 50±31%, p=0.006). Univariate predictors of poorer TTR included Indigenous ethnicity, younger age, diuretic use, and comorbidities, such as valvular heart disease, heart failure and chronic obstructive pulmonary disease (p<0.05 for all). Valvular heart disease remained a significant predictor of poorer TTR in multivariate analyses (p=0.004).Conclusion: Indigenous Australians experience particularly poor warfarin anticoagulation quality. Our data also suggest that many non-Indigenous Australians spend suboptimal time in therapeutic range. These findings reinforce the importance of monitoring warfarin anticoagulation quality to minimise stroke risk. [ABSTRACT FROM AUTHOR]

Background: Therapeutic anticoagulation may be required during pregnancy to treat venous thromboembolism (VTE), for patients considered at high risk of thrombosis and for the management of mechanical heart valves (MHVs). Prescribing of therapeutic anticoagulation during the postnatal peripartum period is complicated by managing the risk of postpartum haemorrhage. Currently, there are no standardised protocols for the use of therapeutic heparin in this setting and no randomised control trials have been undertaken to evaluate best practice. Aim: Using survey techniques, this study aimed to establish current practice in Australia and New Zealand regarding the use of therapeutic anticoagulation during the postnatal peripartum period. Methods: The survey consisted of 36 questions and was made available using the electronic Internet platform Survey Monkey. Results: For patients at low risk of rethrombosis, 91% and 78% of respondents would use low molecular weight heparin (LMWH) after standard vaginal delivery (SVD) and after caesarean section (CS), respectively, with the remaining respondents choosing to use unfractionated heparin (UFH). For patients at high risk of rethrombosis, 56% and 51% of respondents would use LMWH after SVD and CS, respectively, with the remaining respondents choosing to use UFH. For patients with MHVs, 29% and 26% of respondents would use LMWH after SVD and CS, respectively, with the remaining respondents choosing to use UFH. Conclusion: Although this study included a relatively small cohort of respondents, the results do indicate trends among therapeutic anticoagulation in the postnatal peripartum period. Research regarding the most efficacious anticoagulation management would help clinicians develop evidence‐based protocols to guide best practice. [ABSTRACT FROM AUTHOR]

Background: Cardioembolism (CE) contributes to a large proportion of ischaemic stroke. Aims: To evaluate the demographic and clinical profile of CE stroke in Western Sydney. Methods: A retrospective analysis of ischaemic stroke patients presenting to Westmead Hospital (January–October 2016) was performed. Strokes were classified by TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria into different categories. Clinical and demographic data were collected on all stroke patients, and differences between CE and other stroke causes were identified. Results: Two hundred and twenty‐eight consecutive patients (70.9 years; 53% male) were identified. By TOAST criteria, 21 (9%) had large‐artery atherosclerosis, 94 (41%) CE, 10 (5%) small‐vessel disease, 2 (1%) other aetiology and 101 (44%) undetermined aetiology. A significant proportion of CE stroke patients had cardiovascular risk factors including hypertension (66%), hypercholesterolaemia (50%), diabetes (26%) and ischaemic heart disease (28%). The majority (81%) of patients with CE had atrial flutter/flutter. CE stroke, compared with other types of stroke, was more common in females (56 vs 41%, P = 0.022) and patients with CE stroke were more likely to have previous cerebral ischaemia (34 vs 21%, P = 0.026), suggesting increased recurrence in this group. Of the patients with atrial flutter/flutter (n = 56), the majority (87%) had a high CHA2DS2‐VASC score (≥2); however, a significant proportion (55.4%) were not on anticoagulation. Conclusions: Cardioembolic stroke remains a significant burden in Western Sydney, and it is likely that a significant proportion may be preventable, as evidenced by the substantial presence of modifiable cardiovascular risk factors, and inadequate anticoagulation of patients with atrial arrhythmias. [ABSTRACT FROM AUTHOR]

Background: There is a need to improve cardiovascular nurses' knowledge and practices related to stroke prevention, atrial fibrillation and anticoagulation therapy. Aims: The aim of this study was to evaluate the efficacy of EVICOAG – a novel mHealth, smartphone-based, spaced-learning intervention on nurses' knowledge of atrial fibrillation and anticoagulation. Methods: Nurses employed in four clinical specialties (neuroscience, stroke, rehabilitation, cardiology) across three hospitals were invited to participate. In this quasi-experimental study, 12 case-based atrial fibrillation and anticoagulation learning scenarios (hosted by an mHealth platform) were delivered to participants' smartphones over a 6-week period (July–December 2016) using a spaced timing algorithm. Electronic surveys to assess awareness and knowledge were administered pre (T1) and post (T2) intervention. Results: From 74 participants recruited to T1, 40 completed T2. There was a 54% mean improvement in knowledge levels post-intervention. The largest improvement was achieved in domains related to medication interaction and stroke and bleeding risk assessment. Post-intervention, those who completed T2 were significantly more likely to use CHA2DS2-VASc (2.5% vs. 37.5%) and HAS-BLED (2.5% vs. 35%) tools to assess stroke and bleeding risk, respectively (P<0.01). Conclusion: The EVICOAG intervention improved nurses' knowledge of atrial fibrillation and anticoagulation, and influenced their uptake and use of stroke and bleeding risk assessment tools in clinical practice. Future research should focus on whether a similar intervention might improve patient-centred outcomes such as patients' knowledge of their condition and therapies, medication adherence, time in the therapeutic range and quality of life. [ABSTRACT FROM AUTHOR]

Background: Patient education is a key component of management in the anticoagulated patient. Aim: The aim of this study was to establish whether reiteration of warfarin education in the outpatient setting affects patients' knowledge of warfarin and anticoagulation control. Methods: The study was a randomised prospective trial. Participants newly commenced on warfarin at The Royal Melbourne Hospital were randomised to either standard inpatient education (n = 19) or to receive an additional comprehensive warfarin education session (n = 21). The primary outcome was warfarin knowledge as assessed by the Oral Anticoagulation Knowledge (OAK) test. Secondary outcomes were time in therapeutic range (TTR) and complications. The duration of follow‐up was 6 weeks. Results: There were no significant differences between the intervention and control groups in OAK test scores (16.3/20 vs 14.4/20, respectively; p = 0.07), TTR (56.9% vs 59.3%, respectively; p = 0.09) or in the incidence of complications. Conclusion: Within the limitations of a single‐centre, underpowered study, we did not detect any significant additional benefit to patient knowledge from further outpatient warfarin education. Current standard inpatient education at our centre compared favourably with other such designed interventions outlined in previous studies. Nevertheless, it is possible that certain subsets of the population may benefit from additional education, such as those with mild cognitive impairment and those from non‐English‐speaking backgrounds; however, a much greater sample size would be required to study these groups. [ABSTRACT FROM AUTHOR]

Background: Remote monitoring (RM) can facilitate early detection of subclinical and symptomatic atrial fibrillation (AF), providing an opportunity to evaluate the need for stroke prevention therapies. We aimed to characterize the burden of RM AF alerts and its impact on anticoagulation of patients with device-detected AF., Methods: Consecutive patients with a cardiac implantable electronic device, at least one AF episode, undergoing RM were included and assigned an estimated minimum CHA 2 DS 2 -VASc score based on age and device type. RM was provided via automated software system, providing rapid alert processing by device specialists and systematic, recurrent prompts for anticoagulation., Results: From 7651 individual, 389,188 AF episodes were identified, 3120 (40.8%) permanent pacemakers, 2260 (29.5%) implantable loop recorders (ILRs), 987 (12.9%) implantable cardioverter defibrillators, 968 (12.7%) cardiac resynchronization therapy (CRT) defibrillators, and 316 (4.1%) CRT pacemakers. ILRs transmitted 48.8% of all AF episodes. At twelve-months, 3404 (44.5%) AF < 6 min, 1367 (17.9%) 6 min-6 h, 1206 (15.8%) 6-24 h, and 1674 (21.9%) ≥ 24 h. A minimum CHA 2 DS 2 -VASc score of 2 was assigned to 1704 (63.1%) of the patients with an AF episode of ≥ 6 h, 531 (31.2%) who were not anticoagulated at 12-months, and 1031 (61.6%) patients with an AF episode duration of ≥ 24 h, 290 (28.1%) were not anticoagulated., Conclusions: Despite being intensively managed via RM software system incorporating cues for anticoagulation, a substantial proportion of patients with increased stroke risk remained unanticoagulated after a device-detected AF episode of significant duration. These data highlight the need for improved clinical response pathways and an integrated care approach to RM., Trial Registration: Australian New Zealand Clinical Trial Registry: ACTRN12620001232921., (© 2023. Crown.)

Background: Warfarin remains a widely used anticoagulant but application in the remote context is not well documented. This study aimed to assess in more detail whether warfarin is being utilised effectively in Australia's most isolated and remote areas.Methods: Retrospective cohort analysis of 2013 captured international normalised ratio (INR) results from people engaged in long term warfarin usage within a number of remote Northern Australian communities. Assessment of monitoring, effectiveness of dosing and complication rates was undertaken.Results: A cohort of 167 patients was established. On average, warfarin was utilised within therapeutic range 52% of the time. Monitoring frequency averaged 16 days. Major bleeding and thrombo-embolism occurred at rates of 5.8 and 4.1 per 100 patient years respectively.Conclusions: Therapeutic utilisation of warfarin in this setting is close to accepted rates but has room for improvement. Monitoring was acceptable and complication rates were not disproportionately high. This study indicates that warfarin is being used with reasonable safety and efficacy in remote regions, but further research is needed. [ABSTRACT FROM AUTHOR]

Aims & Objectives The purpose of this study was to elucidate the barriers and enablers to adherence to anticoagulation in individuals with chronic heart failure ( CHF) with concomitant atrial fibrillation ( AF) from the perspective of patients and providers. Background CHF and AF commonly coexist and are associated with increased stroke risk and mortality. Oral anticoagulation significantly reduces stroke risk and improves outcomes. Yet, in approximately 30% of cases, anticoagulation is not commenced for a variety of reasons. Design Qualitative study using narrative inquiry. Methods Data from face-to-face individual interviews with patients and information retrieved from healthcare file note review documented the clinician perspective. This study is a synthesis of the two data sources, obtained during patient clinical assessments as part of the Atrial Fibrillation And Stroke Thromboprophylaxis in hEart failuRe ( AFASTER) Study. Results Patient choice and preference were important factors in anticoagulation decisions, including treatment burden, unfavourable or intolerable side effects and patient refusal. Financial barriers included cost of travel, medication cost and reimbursement. Psychological factors included psychiatric illness, cognitive impairment and depression. Social barriers included homelessness and the absence of a caregiver or lack of caregiver assistance. Clinician reticence included fear of falls, frailty, age, fear of bleeding and the challenges of multimorbidity. Facilitators to successful prescription and adherence were caregiver support, reminders and routine, self-testing and the use of technology. Conclusions Many barriers remain to high-risk individuals being prescribed anticoagulation for stroke prevention. There are a number of enabling factors that facilitate prescription and optimise treatment adherence. Nurses should challenge these treatment barriers and seek enabling factors to optimise therapy. Relevance to clinical practice Nurses can help patients and caregivers to understand complex anticoagulant risk-benefit information, and act as a patient advocate when making complex stroke prevention decisions. [ABSTRACT FROM AUTHOR]

Background: Coronary embolism is a relatively rare but important non-atherosclerotic cause of acute coronary syndrome, mainly caused by atrial fibrillation and mechanical heart valve thrombosis due to subtherapeutic anticoagulation. There have been increasing reports of bioprosthetic valve thrombosis (BPVT), but thromboembolic events are rare and mainly affect the cerebrovascular system. Coronary embolism is an extremely rare complication of BPVT., Case Presentation: A 64-year-old male presented with non-ST-Elevation myocardial infarction (NSTEMI) to an Australian regional health service. Three years ago, he had undergone Bentall procedure with bioprosthetic aortic valve replacement for severe aortic regurgitation and significant aortic root dilatation. Diagnostic coronary angiography revealed embolic occlusion of first diagonal branch in the absence of underlying atherosclerosis. Prior to NSTEMI presentation, the patient was clinically asymptomatic apart from the progressive increase in transaortic mean pressure gradient on transthoracic echocardiography which was first detected seven months after surgical aortic valve replacement. Transoesophageal echocardiography showed restrictions of the aortic leaflet opening but no evidence of mass or vegetation. After eight weeks of warfarin therapy, the raised aortic valve gradient returned to normal. Lifelong warfarin was prescribed, and patient remained clinically well at 39-month follow-up., Conclusion: We experienced a case of coronary embolism in a patient with probable BPVT. Reversible bioprosthetic valve hemodynamic deterioration after anticoagulation strongly supports the diagnosis in the absence of histopathology. Early moderate-to-severe hemodynamic valve deterioration warrants further investigations, including cardiac computed tomography and sequential echocardiography, to investigate for probable BPVT and consideration of timely anticoagulation initiation to prevent thromboembolic events., (© 2023. Crown.)

The management of stroke risk in patients with non-valvular atrial fibrillation has changed over the past few years. This change has occurred due to the introduction of novel oral anticoagulants (NOACs) such as apixaban, rivaroxaban and dabigatran for the management of non-valvular atrial fibrillation. These agents have shown comparable stroke risk reduction to warfarin in large international multicentre trials [1-3]. This has changed the clinical practice of many treating physicians since their introduction from 2011 to 2013. The purpose of this review was to highlight the now mainstream use of NOAC administration in preference to warfarin, by comparing the trends in the number of prescriptions filled since all three forms of oral anti-coagulant became available in 2013. These agents are being increasingly prescribed due to their ease of use compared to warfarin, which not only requires ongoing monitoring due to narrow therapeutic range but also has many drug and food interactions. Since November 2015, NOACs have become the mainstream choice for anticoagulation in atrial fibrillation likely given their ease of use compared to warfarin. The use of each anticoagulant remains divergent with the use of warfarin continuing to decrease. [ABSTRACT FROM AUTHOR]

Background Patient education delivered through pharmacist counselling is important in promoting the safe and effective use of anticoagulants. Aim To evaluate the extent to which patients retain information after counselling from a clinical pharmacist about the anticoagulant warfarin; to perform a brief analysis of the cost-analysis of warfarin counselling; and to investigate relationships between case-specific characteristics and patient outcomes. Method A total of 22 patients was recruited. Eligibility criteria included age ≥18 years, new initiation of warfarin in hospital, intact cognition and an expectation of self-administration of warfarin after discharge. Key elements of knowledge were assessed immediately after counselling and 6 weeks after counselling. The duration of each counselling session was recorded as a surrogate for costs involved, and case-specific characteristics were documented. Results Participants demonstrated an ability to recall an average (mean ± standard deviation) of 79.9 ± 14.6% of key information elements immediately after counselling, significantly higher than was observed 6 weeks after counselling (71.0 ± 11.7%; p = 0.02). The percentage of participants achieving an 'acceptable' score for knowledge was 68.2%, both immediately after counselling and 6 weeks later. No significant relationships between specific case characteristics and patient outcomes, duration of counselling or overall warfarin knowledge retention scores 6 weeks after counselling were demonstrable. Conclusion These findings imply that more emphasis should be placed on educating patients on the critical information elements for warfarin counselling. Further research is required to explore potential relationships between case-specific characteristics and patient outcomes, as well as the costs associated with the counselling process. [ABSTRACT FROM AUTHOR]

What is known and objective Ischaemic heart disease ( IHD) is a major cause of death in developed countries. Patients with IHD are at greater risk of subsequent myocardial infarction ( MI). International studies suggest that guideline recommended therapies proven to reduce this risk are underutilised. The objectives of this study were to review the use of guideline-recommended medications for the secondary prevention of IHD in Australians and identify patient characteristics influencing use of these medications. Methods The medication regimens of community dwelling Australians with documented IHD who received a Home Medicines Review ( HMR) between January 2010 and September 2012 were extracted from a pharmacist decision support software database and retrospectively reviewed. Each patient's use of antithrombotics; angiotensin converting enzyme inhibitors ( ACEIs) or angiotensin receptor blockers ( ARBs); statins; and β-blockers ( BBs) or non-dihydropyridine calcium channel blockers ( CCBs) was evaluated in conjunction with documented contraindications. Guideline concordance in all four categories was classified as 'Optimal Medical Therapy' ( OMT). Univariate and multivariate analyses identified patient characteristics influencing OMT use. Results and discussion Of the 5396 patient medication regimens reviewed, 24·3% demonstrated OMT. Guideline concordance was observed in 91·6%, 75·6%, 74·8%, and 42·4% of patients for antithrombotics, statins, ACEI/ ARBs, and BB/ CCBs, respectively. The independent predictors of not receiving OMT were age 75 years or over (adjusted odds ratio [ AOR] 0·76; 95% confidence interval [ CI] 0·67-0·87), asthma ( AOR 0·69; 95% CI 0·57-0·84), and depression or anxiety ( AOR 0·84; 95% CI 0·71-0·99). Diabetes ( AOR 1·20; 95% CI 1·04-1·38), hypertension ( AOR 1·56; 95% CI 1·36-1·79) and a high Charlson Comorbidity Index score ( AOR 1·37; 95% CI 1·15-1·64) independently predicted receipt of OMT. What is new and conclusion Only one quarter of community dwelling Australian patients with IHD receive antithrombotics, ACEI/ ARBs, BB/ CCBs and statins. The potential consequences of these evidence-to-practice gaps are exacerbated by Australia's increasing prevalence of IHD. Healthcare professionals must work to ensure that recommended therapies are prescribed and adhered to long-term, especially in the elderly and patients with asthma and mental health problems, to reduce IHD-related mortality and morbidity and the consequent healthcare and financial impact. [ABSTRACT FROM AUTHOR]

Background: SARS-CoV-2 infection is associated with a significant risk of hospitalisation, death, and prolonged impact on quality of life. Evaluation of new treatment options and optimising therapeutic management of people hospitalised with SARS-CoV-2 infection remains essential, but rapid changes in pandemic conditions and potential therapies have limited the utility of traditional approaches to randomised controlled trials., Methods: ASCOT ADAPT is an international, investigator-initiated, adaptive platform, randomised controlled trial of therapeutics for non-critically ill patients hospitalised with COVID-19. The study design is open label and pragmatic. Potential participants are hospitalised adults with PCR confirmed, symptomatic, SARS-CoV-2 infection, within 14 days of symptom onset. Domains include antiviral, antibody and anticoagulant interventions, with a composite primary outcome of 28-day mortality or progression to intensive-care level respiratory or haemodynamic support. Initial interventions include intravenous nafamostat and variable dose anticoagulation. A range of secondary endpoints, and substudies for specific domains and interventions are outlined., Discussion: This paper presents the trial protocol and management structure, including international governance, remote site monitoring and biobanking activities and provides commentary on ethical and pragmatic considerations in establishing the ASCOT ADAPT trial under pandemic conditions., Trial Registration: Australian and New Zealand Clinical Trials Registry (ACTRN12620000445976) and ClinicalTrials.gov (NCT04483960)., (© 2022. The Author(s).)

Objective: To identify the facilitators of and barriers to the implementation of Community Pharmacists-Led Anticoagulation Management Services (CPAMS)., Data Sources: MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL Register of Controlled Trials were searched from inception until August 20, 2021., Study Selection and Data Extraction: All abstracts proceeded to full-text review, which was completed by 2 reviewers. Data extraction was completed by a single reviewer and verified. Analysis was completed using best-fit framework synthesis., Data Synthesis: A total of 17 articles reporting on CPAMS from 6 jurisdictions were included: 2 Canadian provincial programs (Nova Scotia, Alberta), a national program (New Zealand), and 3 cities in the United Kingdom (Whittington and Brighton and Hove) and Australia (Sydney). Facilitators of CPAMS included convenience for patients, accessibility for patients, professional satisfaction for pharmacists, increased efficiency in anticoagulation management, improved outcomes, enhanced collaboration, and scalability. Barriers included perceived poor quality of care by patients, resistance by general practitioners, organizational limits, capping of the number of eligible patients, and cost., Relevance to Patient Care and Clinical Practice: The barriers and facilitators identified in this review will inform health policy makers on the implementation and improvement of CPAMS for patients and health care practitioners., Conclusion and Relevance: CPAMS has been implemented in 6 jurisdictions across 4 countries, with reported benefits and challenges. The programs were structurally similar in most jurisdictions, with minor variations in implementation. New anticoagulation management programs should consider adapting existing frameworks to local needs.

What's known on the subject? and What does the study add? Urologists are increasingly involved in the management of patients taking oral anticoagulation ( OA) who present with haematuria. It is accepted practice that haematuria in the presence of concurrent anticoagulation requires a full diagnostic evaluation, as it is frequently precipitated by a significant pathological lesion. However, there is limited data on the impact of anticoagulation on the initial inpatient management of these patients. Much of the current evidence is either based around perioperative management of elective patients or, for emergency presentations, is focused on bleeding associated with high morbidity and mortality, such as in the neurosurgical population. In the present study, about half of all admissions with haematuria were for patients on some form of OA. The use of OA strongly predicted for the need for admission for bladder irrigation, regardless of the type of agent or combination of agents used. The use of dual antiplatelet therapy had the strongest association with the need for bladder irrigation, probably due to the well-described synergistic effect between aspirin and clopidogrel. The results of the present study emphasise the importance of early intervention in the management of patients on OA presenting with haematuria. Objective To examine the effect of oral anticoagulation ( OA) on the prevalence and inpatient management of haematuria in a contemporary Australian patient cohort., Patients and methods Patients across all inpatient units who had diagnosis-related group ( DRG) coding for haematuria were identified from April 2010 to September 2011., A retrospective chart review was performed to identify the type of anticoagulation (if any), requirement for bladder irrigation or blood transfusion, length of stay ( LOS) and cause of haematuria., Patients for whom the anticoagulation status was uncertain were excluded from analysis., Statistical significance was determined by Pearson's chi-square tests and Student's t-tests., Results In all, 335 admissions with DRG coding for haematuria were identified from hospital records, of which 268 admissions had clear documentation of anticoagulation. There were 118 emergency admissions and 150 elective admissions for day case cystoscopy. The mean age of the patients was 66 years and the male:female ratio was 5:1. In all, 123 admissions were for patients on some form of anticoagulation (46%)., Patients were on anticoagulation in 53% of the 118 emergency admissions for gross haematuria. These comprised patients on aspirin (28%), clopidogrel (4%), warfarin (10%), combined aspirin and warfarin (1%) and combined aspirin and clopidogrel (10%)., The use of OA was a significant predictor of the need for intervention among the 118 emergency admissions (86% vs 62%, P = 0.003)., In particular, dual antiplatelet therapy in the form of aspirin and clopidogrel was associated with an increased requirement for bladder irrigation (92%) when compared with patients on other forms of anticoagulation (84%) or none at all (62%, P = 0.01)., The mean LOS for patients admitted to hospital with haematuria was 5.6 days. Patients on warfarin had a statistically significant longer LOS than the other groups (13.7 vs 4.5 days, P < 0.001). A cause for haematuria was identified in 120 of the 234 patients (51%). Of these, the most common was benign prostatic hyperplasia (21%), followed by bladder urothelial carcinoma (17%)., Conclusion In our cohort of patients, about half of all admissions with haematuria were for patients on some form of OA., OA use increased the need for intervention, especially for patients on dual antiplatelet therapy. [ABSTRACT FROM AUTHOR]

Abstract: Background: Despite the proven effectiveness of antiplatelet and anticoagulation treatment for atrial fibrillation (AF), their use has been suboptimal in practice, particularly in rural areas of Australia. Objective: The aim of this study was to describe medication use in the management of AF in elderly hospitalized patients with comorbid congestive heart failure (CHF). Methods: The hospital records of patients with a diagnosis of AF and CHF were reviewed in a rural Australian medical center. All the patients were hospitalized because of significant systolic ventricular dysfunction. The collected data included age, sex, weight, presenting symptoms of AF, and principle diagnosis on admission; medical history; and history of smoking and alcohol consumption. Electrocardiogram before hospital discharge was also retrieved from patient''s medical records and was analyzed by the investigators. Cardiovascular and noncardiovascular drugs administered during the hospital stay and at discharge were also documented. Comparison of antiarrhythmic and anticoagulant drugs was made between patients who had AF while hospitalized and those who had a history of AF but were in sinus rhythm while hospitalized. When patients had ≥2 moderate risk factors (eg, age ≥75 years, hypertension, CHF, left ventricular ejection fraction ≤35%, diabetes mellitus) or ≥1 high risk factor (eg, previous stroke, transient ischemic attack or embolism, mitral valve stenosis, or prosthetic heart valve), they were defined as being eligible for anticoagulation treatment. Results: One hundred forty patients (74 men, 66 women; mean [SD] age, 77.1 [6.9] years; all were white) had a diagnosis of AF and were selected for the study. Of these, 92 patients (65.7%) (47 women, 45 men; mean [SD] age, 77.4 [9–2] years) had continuous AF and 48 patients (34.3%) (29 men, 19 women; mean [SD] age, 76.3 [12.4] years) had a history of AF but were in sinus rhythm at admission and discharge. The most commonly used antiarrhythmic drug was digoxin, which was prescribed significantly more frequently in the AF group than in the history of AF group (50 (54.3%] vs 14 [29.2%]; P < 0.01). Amiodarone was prescribed significantly less frequently in the continuous AF group than in the group with a history of AF (7 [7.6%] vs 19 [39−6%]; P < 0.01). There was no significant between-group difference in the use of β-blockers (26 [28.3%] vs 19 [39−6%]), verapamil/diltiazem (9 [9–8%] vs 3 [6.3%]), or Sotalol (2 [2.2%] vs 4 [8.3%]). The mean (SD) resting heart rate for the 140 study patients was 91 (27) bpm. The mean resting heart rate for the patients with AF was significantly higher at admission than at discharge (97 [28] vs 79 [19] bpm; P < 0.01). Of the 110 patients who were eligible for anticoagulation treatment, 64 (58.2%) were prescribed warfarin at discharge. Eligible patients not receiving oral warfarin were significantly older than those who did receive warfarin (79−7 [9−0] vs 75.8 [9.0] years; P = 0.02). Conclusions: In these elderly hospitalized Australian patients with AF and CHF, digoxin, β-blockers, and amiodarone were the most commonly used antiarrhythmic drugs. Anticoagulation treatment was prescribed in ~60% of these patients. [Copyright &y& Elsevier]

The aim of this project was to assess whether rural pharmacist involvement in the management of patients receiving warfarin has the potential to lead to safer and more effective anticoagulation, and is valued and welcomed by patients and their general practitioners (GPs). A convenience sample of rural pharmacists was trained in the use of the CoaguChek S International Normalized Ratio (INR) monitor and then conducted pharmacy-based testing for approximately 3 months. Two types of testing were performed in the pharmacy: (i) comparison testing was defined as pharmacy-based tests taken within 4 h of conventional laboratory testing or (ii) additional testing, which was a pharmacy-based test with no direct comparison laboratory test taken. Pharmacists, GPs and patients completed anonymous satisfaction surveys after the completion of the pharmacy-based testing. Pharmacists from 16 rural pharmacies were trained to use the CoaguChek S monitor. During the trial period, 518 INR tests were performed in the pharmacies on 137 different patients. A total of 120 tests were evaluated against results from laboratory testing. The pharmacy-based INR values were significantly correlated with the laboratory INR values (mean of 2·32 ± 0·77 and 2·32 ± 0·59 respectively; r = 0·88, P < 0·0001). A total of 398 additional pharmacy-based tests were conducted in the pharmacy and 8·5% of the additional tests resulted in a subsequent dosage change. The monitoring was well received by pharmacists, GPs and patients. The results of the trial were very positive. The CoaguChek S monitor in pharmacy-based testing performed accurately compared with conventional laboratory testing. Further research needs to be conducted on the impact of community pharmacy-conducted INR monitoring on patient care and outcomes. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are a common problem and corrective surgery is recommended within 24 h. However, most peri-operative direct oral anticoagulant (DOAC) guidelines suggest a washout period of 48 h before major surgery. There are limited data on utility of drug levels., Aim: To investigate the effect of DOAC therapy on time to surgery and patient outcomes, and to explore the impact of different pre-operative protocols on surgical delay., Methods: A multi-centre, retrospective analysis of all adult patients that presented with acute hip fracture at three tertiary hospitals in Perth, Western Australia, was performed. Data were collated from the West Australian hip fracture registry and electronic records. Time to theatre, DOAC levels, bleeding and transfusion rates were compared between sites., Results: Of 1240 hip fracture patients, 146 (11.9%) were on anticoagulation, with more patients taking a DOAC than warfarin. The time to surgery was significantly longer for those on a DOAC compared with those on warfarin (P = 0.003). There was no difference in bleeding, transfusion requirement or 30-day mortality in patients taking a DOAC compared to those on warfarin. Fifty-eight (70.7%) patients had a DOAC level prior to surgery. Of 25 patients who had a level performed within 12 h of presentation, 13 (52%) had a result of ≤50 ng/mL. Outcomes were similar between sites., Conclusion: People on DOAC treatment had a significant delay before corrective surgery compared with those on warfarin. The frequent finding of early DOAC levels <50 ng/mL suggests this delay may be unnecessary in a significant proportion of patients., (© 2020 Royal Australasian College of Physicians.)

In pediatric LT, anticoagulants and antiplatelet agents are regularly used to reduce the risk of vascular thrombosis. As evidence for optimal strategy is lacking, local practices vary greatly. The present survey aimed to compile an international overview of anticoagulation and antiplatelet strategies in pediatric LT. An online survey was sent to 98 pediatric LT centers in North and South America, Europe, Asia, and Australia. Twenty‐four centers answered the survey. 20/24 (83%) use some sort of anticoagulation and antiplatelet therapy, yielding 20 different strategies. Perioperative vascular problems, size of the hepatic artery, and patient weight were the most frequent determinants of changes in anticoagulant and antiplatelet strategy. Early HAT rates were reported to be 5% or less in 79% of responding centers. Anticoagulation and antiplatelet strategies were not significantly associated with early HAT rates (P = 0.63), or with the number of pediatric LTs performed per year and center (P = 0.92). Internationally, there is a wide variety in anticoagulation and antiplatelet strategies after pediatric LT. Efforts must be made to design a prospective multicentric trial to identify the optimal antithrombotic strategy. [ABSTRACT FROM AUTHOR]

Background: Idarucizumab is a specific antidote for the direct thrombin inhibitor oral anticoagulant dabigatran etexilate. It has been used with increasing frequency in Australia since it was granted Therapeutic Goods Administration approval in October 2016., Aims: To assess idarucizumab usage, effect on coagulation parameters and clinical outcomes in patients who received idarucizumab in Western Sydney Local Health District (WSLHD)., Methods: A retrospective audit was conducted of all patients who received idarucizumab in WSLHD between September 2015 and December 2017., Results: Of the 23 patients who received idarucizumab, 17 (74%) had bleeding, and 6 (26%) required urgent surgery/procedure. Thrombin time (TT) or activated partial thromboplastin time (APTT, when TT not available) remained prolonged at 24 h post-idarucizumab infusion in 10 of 20 (50%) patients. Renal impairment at admission was associated with prolonged TT/APTT at 24 h (P = 0.02). Of the six (26%) patients who died during hospital admission, five had raised TT/APTT at 24 h (P = 0.05). Two deaths were due to continued bleeding despite idarucizumab. Only 17% of patients received prohaemostatic treatments, and none received plasma derivatives. Despite assay availability, dabigatran drug level was only measured in eight patients., Conclusion: Idarucizumab helped achieve haemostasis in 15 bleeding patients and allowed 6 patients to undergo urgent surgery. Half the patients had prolonged TT/APTT at 24 h post-idarucizumab, which was more likely to occur in patients with impaired renal function., (© 2018 Royal Australasian College of Physicians.)

Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) has recently been recommended as first-line over heparin. Evidence suggests that RCA prolongs filter life and may reduce bleeding risk, but there is little research on the benefits to dialysis dose delivery or cost, or the effectiveness of transitioning to RCA first-line. The aim of the present study was to assess the effect on dialysis delivery, cost and safety when transitioning from systemic heparin to RCA for first-line anticoagulation for CRRT. A single-center, retrospective observational study was conducted from 2006 to 2012, during which a transition from heparin to a simplified RCA protocol occurred. Demographic and dialysis data, pathology results and costs were obtained. Data were analyzed for both heparin and RCA, and for before and after the transition. 166 patients had 992 dialysis days (heparin 334 vs. RCA 658); demographics were well matched; RCA used less filters per day (P = 0.03), had more days when prescribed dialysis was achieved (85% vs. 60%, P < 0.001), and less filter "down-time" per day (2.4 vs. 6.1 h, P = 0.02). RCA was estimated to cost AU$487 per day, compared to heparin at $479 per day. When the data were analyzed, comparing before and after the transition, these results remained statistically significant. There was no statistical difference in clinical safety events. Transition to first-line RCA was safe, provided more time on filter and consumed less filter circuits using a simple and user friendly protocol. The adjusted cost difference appears negligible., (© 2016 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Background: Atrial fibrillation (AF) is a leading cause of preventable stroke in Australia. Given that anticoagulation therapy can significantly reduce this stroke risk, we sought to characterise anticoagulation use in Indigenous and non-Indigenous Australians with AF., Methods: Administrative, clinical and prescription data from patients with AF were linked. Anticoagulation use was characterised according to guideline-recommended risk scores and Indigenous status., Results: 19,613 individuals with AF were studied. Despite a greater prevalence of other risk factors, Indigenous Australians were significantly younger than their non-Indigenous counterparts (p<0.001) and thus had lower CHADS₂- (1.19±0.32 vs 1.99±0.47, p<0.001) and CHA₂DS₂VASc-scores (1.47 ± 0.03 vs 2.82 ± 0.08, p<0.001). Correspondingly, the percentage of Indigenous Australians with CHADS₂ ≥ 2 (39.6% vs 44.1%, p<0.001) and CHA₂DS₂VASc-scores ≥ 2 (62.9% vs 78.8%, p<0.001) was also lower. Indigenous Australians, however, had greater rates of under- and over-anticoagulation. Overall, 72.1% and 68.9% of Indigenous and non-Indigenous Australians with CHADS₂ scores ≥2, and 76.3% and 71.3% with CHA₂DS₂VASc scores ≥2, were under-anticoagulated. Similarly, 27.4% and 24.1% of Indigenous and non-Indigenous Australians with CHADS₂ scores=0, and 24.0% and 16.7% with CHA₂DS₂VASc-scores=0, were over-anticoagulated. In multivariate analyses, Indigenous Australians were more likely to receive under- or over-anticoagulation according to CHADS₂- or CHA₂DS₂VASc-score (p=0.045 and p<0.001 respectively)., Conclusion: Anticoagulation for AF is frequently not prescribed in accordance with guideline recommendations. Under-anticoagulation in those at high stroke risk, and over-anticoagulation in those at low risk, is common and more likely in Indigenous patients with AF. Improving adherence to guideline recommendations for anticoagulation in AF may reduce both ischaemic and haemorrhagic strokes in Indigenous and non-Indigenous Australians., (Crown Copyright © 2015. Published by Elsevier Ireland Ltd. All rights reserved.)

Introduction: Atrial fibrillation (AF) is a common arrhythmia and a risk factor for stroke and other, adverse events. Internationally there have been recent advancements in the therapies available for, stroke prevention in AF. Nurses will care for individuals with AF across a variety of primary and acute, care settings and should be familiar with evidence based therapies., Aim: This paper provides a review of the epidemiology of AF and stroke, stroke and bleeding risk, assessment tools and evidence based treatments for the prevention of stroke in AF including the use of, novel anti-thrombin agents., Method: A review of key databases was conducted from 2002 to 2012 using the key search terms 'atrial, fibrillation' 'anticoagulation' 'risk assessment' and 'clinical management'. The following electronic, databases were searched: CINAHL, Medline, Scopus, the Cochrane Library and Google Scholar., Reference lists were manually hand searched. Key clinical guidelines from National Institute for, Clinical Excellence (NICE, UK), American Heart Association (AHA, USA), American College of Cardiology, (ACC, USA) and the European Society of Cardiology (ESC) and key government policy documents were, also included. Articles were included in the review if they addressed nursing management with a focus, on Australia., Results: Many treatment options exist for AF. Best practice guidelines make a variety of, recommendations which include cardioversion, ablation, pulmonary vein isolation, pharmacological, agents for rate or rhythm control approaches, and antithrombotic therapy (including anticoagulation, and antiplatelet therapy). Treatment should be patient centred and individualised based upon, persistency of the rhythm, causal nature, risk and co-morbid conditions., Conclusion: AF is a common and burdensome condition where treatment is complex and not without, risk. Nurses will encounter individuals with AF across a variety of primary and acute care areas, understanding the risk of AF and appropriate therapies is important across all care settings. Treatment, must be individually tailored to the needs of the patient and balanced with the best available evidence., (Copyright © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)