Pharmacy News

Entries for October 2017

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infections: What Made the Cut?

By Kelly Kieffer, Pharm.D.; Amanda Martin, Pharm.D.; Kacie Smith, Pharm.D. and Steven Sohasky, Pharm.D. – pharmacy residents, Mercy Health Muskegon

Surgical site infections (SSIs) are the most common cause of hospital acquired infections (HAIs), accounting for approximately 31 percent of all HAIs.1 SSIs lead to increased antibiotic usage and healthcare costs, prolonged hospital stays and greater morbidity and mortality. One strategy to help reduce SSIs and their negative consequences is to use appropriate antimicrobial prophylaxis. The World Health Organization (WHO) and the American Society of Health-System Pharmacists (ASHP) SSI guidelines (published in 2016 and 2013, respectively) previously provided the most up-to-date recommendations on the prevention of SSIs. In May 2017, the Centers for Disease Control and Prevention (CDC) published an updated guideline on SSI prevention. The most recent CDC
recommendations on surgical antimicrobial prophylaxis will be reviewed in this article.

 

The first recommendation  made by the CDC is in regards to the use of topical antiseptic agents. The use of topical antiseptic agents is one measure utilized to prevent SSIs as an adjunct to intravenous (IV) antimicrobial prophylaxis. The CDC guideline recommends that patients shower or bathe with soap or an antiseptic agent at home the night prior to surgery (category 1B-strong recommendation).2 However, the CDC does not make further recommendations for the optimal timing or number of preoperative bath(s) due to inconclusive evidence from current randomized controlled trials. Intraoperatively, the CDC provides a category 1A-strong recommendation to prepare skin with an alcohol-based antiseptic agent, but there are currently no recommendations available to support reapplying antiseptic agents before closure of the surgical site.2

 

There is a consensus among all the guidelines that surgical antimicrobial prophylaxis should be administered preoperatively, if indicated, and that bactericidal concentration of antibiotics should be present in the vasculature and tissues at the time of incision.2-4 However, the use of postoperative antibiotics has historically been controversial. The updated CDC guideline now recommends that no additional systemic antimicrobials should be administered once the surgical incision is closed for clean and clean-contaminated procedures, even in the presence of a drain (1A recommendation).2 Procedures are considered clean or clean-contaminated if they are performed under a controlled environment without breaks in sterile technique and if there is no evidence of infection (i.e., purulent drainage). The CDC does not weigh-in on postoperative antibiotics in contaminated and dirty procedures, but the ASHP guideline recommends continuing postoperative antibiotics for a maximum duration of 24 hours unless an infection is currently present.3 Postoperative use of a topical antimicrobial agent at the surgical incision site is not recommended.

 

Similar to postoperative antibiotic prophylaxis, the use of antimicrobial prophylaxis for low-risk cesarean section procedures has also been questioned in the past. Prior to the 2017 guideline update, the CDC recommended antimicrobial prophylaxis to be given immediately after the umbilical cord was clamped in high-risk cesarean section procedures exclusively.5  However, the CDC now recommends the administration of IV antibiotics before incision in all cesarean section procedures, which is also supported by the ASHP guideline.2,3

 

Given the mix of evidence, no further recommendations regarding preoperative antimicrobial timing, weight-adjusted dosing or intraoperative re-dosing were provided by the CDC guideline. The ASHP guidelines offer a variety of recommendations on these topics, though. ASHP recommends administering preoperative doses within 60 minutes of incision, with the exception of some antibiotics that require administration over one to two hours (i.e., fluoroquinolones, vancomycin). Intraoperative re-dosing is also recommended per ASHP if the procedure exceeds two half-lives of the drug or if a significant amount of drug is presumed to be lost due to excessive blood loss.3  The CDC does not address decolonization with intranasal agents such as mupirocin; however, the ASHP guideline suggests that it may be beneficial for SSI prevention in addition to IV antimicrobial prophylaxis.3

 

Taking measures to prevent SSIs can greatly improve patient outcomes and decrease healthcare costs. The CDC has published updated guidelines that provide recommendations on preoperative and postoperative prophylaxis. The implementation of these guidelines can decrease the incidence of SSIs and their sequelae, as well as minimize the use of unnecessary antibiotics, especially the use of postoperative antibiotics. For more information, the CDC Guideline for the Prevention of Surgical Site Infections can be found at: http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725.

 

References:

  1. National Healthcare Safety Network Patient Safety Component Manual Surgical Site Infection (SSI) Event. Center for Disease Control. Jan 2017. Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
  2. Berrios-Torres SI, Umscheid CA, Brazler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery. 5 May, 2017.
  3. Bratzler DW, Dellinger EP, Olsend KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70195-283
  4. Global Guidelines for the Prevention of Surgical Site Infection. World Health Organization. Nov 2016. Available from: http://www.who.int/gpsc/ssi-prevention-guidelines/en/
  5. Mangram AJ, Horan TC, Pearson ML, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 1999. AJIC. Apr 1999. Available from: https://www.sgna.org/Portals/0/Issues/PDF/Infection-Prevention/17_CDC%20Surgical%20Site%20infections.pdf
Posted in: Professional Practice
Capital Area Pharmacists Association Update

By Cathleen Edick, Pharm.D., CDE, pharmacy program coordinator, McLaren, Lansing and central regional representative

 

October tends to be one of the busiest months for the Capital Area Pharmacists Association (CAPA) given it is American Pharmacists Month. Through the use of banners and community outreach, CAPA tries to promote the important work that pharmacists do. During two weeks in October, watch for the “Know your Pharmacist, Know your Medicine” banners that will be hung on two different bridges in highly trafficked areas in the Lansing area. Last year, they were hung on the Pennsylvania River Trail Bridge and the Oakland Street Bridge. CAPA pharmacists will also reach out to the community on either Oct. 21 or 28 by providing blood pressure monitoring, medication information and pharmacy-related freebies at the Lansing City Market. Last year, the Saturday in October coincided well with a Halloween children’s event, bringing many opportunities to reach out to the local community. In addition to banners and community outreach, on Oct. 19 at 6:30 p.m. at the Michigan Pharmacists Association (MPA) headquarters, CAPA has a dinner and continuing education programming planned which should bring good entertainment. Eric Roath, Pharm.D., will host Pharmacy Feud as CAPA members battle it out with a different local pharmacy association. In addition to the CE and dinner on Oct. 19, CAPA will be presenting a $500 CAPA scholarships to two well deserving pharmacy students. Congratulations to Ferris State University pharmacy students Jacqueline Saunders (P4) and Patricia Whiting (P2) on receiving the scholarships!

 

Future opportunities to be involved with CAPA include:

  • Serving dinner at the Advent house in Lansing on Dec. 30
  • December law CE partnering with MPA in December at MPA headquarters
Posted in: Member News
Membership Committee Updates

By Gillian Leung, Pharm.D. candidate 2019, University of Michigan College of Pharmacy, Ann Arbor

Are you looking to advance your personal practice and profession? Do you sometimes feel laws are holding your work back? Or, are you looking for ways to give back to the profession? Being an active member of Michigan Society of Health-System Pharmacists (MSHP) and Michigan Pharmacists Association (MPA) is a great way to satisfy these needs and more. MSHP and MPA are the professional pharmacy organization in Michigan for Michigan pharmacists, residents, student pharmacists and pharmacy technicians. Being a member of the state pharmacy organization comes with a myriad of benefits.

By being part of MSHP and MPA, members receive free subscriptions to multiple MPA and MSHP newsletters and journals, numerous continuing education opportunities, countless events to network with fellow professionals, and affiliations with local and regional professional pharmacy organizations. As members, you can share your experience with friends and colleagues such that they receive the benefits as well. The MSHP/MPA Membership Committee has created the Member-Get-A-Member Program, which allows individuals who refer new members to receive monetary rewards to help with membership fees and professional needs.

Member-Get-A-Member Program

Recruit 1-2 Members and receive:

$25 per pharmacist

$10 per technician


Recruit 3-4 Members and receive (after the first two):

$50 per pharmacist

$14 per technician

 

Recruit 5 or more members and receive (after the first four):

$100 per pharmacist

$20 per technician

For every member you recruit during a month, you increase your chance to win a $50 Amazon gift card at the monthly drawing.

As for existing members, be active to get the most benefits out of your membership. MSHP and MPA have continuing education sessions, training programs and conferences throughout the year. These occasions allow you to build connections with like-minded practitioners who can often understand the challenges you face in your career, learn from practitioners in different practice environments to broaden your horizon, become more involved in personal growth to excel in the profession and possibly get connected with job opportunities.

Standing Committee Opportunities

In addition to attending conferences and meetings, individuals who want to be more involved can join one of many standing committees and task forces in MSHP and MPA. Being part of these voluntary groups allows members to make a positive impact on the profession and foster relationships with other practitioners. You can find descriptions and contact information for each of the committees at www.MichiganPharmacists.org/committees and www.MichiganPharmacists.org/mshp/committees. Applications are accepted throughout the year on these webpages. Once appointed, each committee is assigned charges to accomplish over a one-year term from January to December. It is important to note that all members are eligible to join a standing committee. For example, the MSHP/MPA Membership Committee that I’m involved in consists of pharmacists, student pharmacists and pharmacy technicians.

It’s been a great year serving on the Membership Committee. I remember looking for additional involvement within MPA and stumbled on the committee page. I contacted the staff liaison, Mike Wolf, and received details on the responsibilities and workload. After careful consideration, I expressed my interest on the user-friendly online form, and then got notified at the end of November regarding my appointment. Joining the Membership Committee was one of the best decisions I have made professionally. It has helped me realized that I could also make contributions as a student pharmacist.

The Committee helps contribute to the success of the organization. It is mainly charged to increase membership and attendance at the MPA Annual Convention & Exposition, and organize the annual MSHP luncheon for student pharmacists. As a team of fifteen, we meet twice a year on MSHP Committee Days in January and May. Led by co-chairs, Annette Davis, CPhT, and Kali VanLangen, Pharm.D., BCPS, the team engages in discussions on the assigned charges and additional items regarding members’ benefits and recruitment tools. It is hard to describe how wonderful it has been being able to work with and learn from a diverse group of members.

This is just a glimpse of what a standing committee is like. Aside from receiving the general member benefits, I encourage you to look into the many standing committees before the appointment period starting in November. Current committee members must also submit a form to be reconsidered for reappointment. We look forward to seeing the new and returning faces at next year’s standing committees!

Posted in: Member News
USP <800>: Considerations for Implementation
By Vishnuprabha D. Vogel, Pharm.D., BCOP, BCPS, pharmacy department manager, Henry Ford Hospital, Detroit

Published reports of toxicity in healthcare personnel associated with occupational exposure to hazardous drugs was the driver to develop USP <800> 1-4 The foundation for <800> was based on existing guidance published by the National Institute for Occupational Safety and Health (NIOSH), American Society of Health-System Pharmacists (ASHP) and the Oncology Nursing Society (ONS).5 The overarching goal of USP <800> is to protect healthcare workers and the general public utilizing healthcare facilities where products deemed hazardous are prepared. The standards outlined in chapter <800> were planned to become federally enforceable on July 1, 2018, but recent updates have pushed enforcement to Dec. 1, 2019.6

Frequently the term hazardous is synonymous with chemotherapy. However, NIOSH has defined a hazardous drug (HD) as one that meets at least one of six specific characteristics (Table 1).2 The required manipulation of an agent in conjunction with meeting the definition of hazardous, primarily dictates the aspects of USP <800> that apply. Furthermore, USP <800> is not a standalone chapter and requires implementation in conjunction with <795> and <797>. 7-8

Table 1. NIOSH Criteria for Hazardous Drug Classification
Carcinogenicity
Teratogenicity or developmental toxicity
Reproductive toxicity in humans
Organ toxicity at low doses in humans or animals
Genotoxicity
New drugs that mimic existing hazardous drugs in structure or toxicity

Key expectations along with considerations for implementations are outlined below. 


USP <800> Expectation* Considerations
General Requirements 
Maintain standard operating procedures (SOPs) for safe handling of HDs for all situations in which HDs are used throughout the facility

SOPs require annual review

Minimize exposure to HDs
Complete tracer activities to identify gaps in SOPs

 

Complete a gap analysis.

 

Identify and implement technology that can limit staff exposure to HDs (i.e., camera technology allowing hands-off pharmacist verification of compounding)  
Maintain list of HDs
  • Include all items on NIOSH list and the entity handles
  • Review list every 12 months
  • All new agents must be reviewed against entity’s list
  • Any drugs entering market after most recent NIOSH list should be evaluated for meeting the NIOSH definition of a HD; if there is insufficient information to make a decision, consider the agent hazardous
  • USP <800> permits an entity to complete an annual risk assessment to identify if alternate containment strategies may be utilized
Engage an individual familiar with inpatient and ambulatory administration of HDs (i.e., hematology/oncology or infusion experience)

Designated individual to work closely with entity’s compounding supervisor to ensure compliance
All personnel handling HDs are responsible for understanding practice requirements All pharmacy staff potentially exposed to an HD should complete annual basic education and competency

All pharmacy staff to annually complete a hazardous drug handling affidavit stating they understand the risks associated with HDs and it is the employee’s responsibility to inform management if there is a change in health status requiring exception from HD handling (i.e., pregnancy, breastfeeding or trying to conceive)

Pharmacy staff preparing sterile HDs or manipulating solid dosage forms to complete detailed education and competency
Facilities and Engineering Controls
Clear signage at entrance of HD handling areas Utilize standardized signage throughout entity

Have signage available in case a spill occurs
HDs removed from external shipping container in area that is neutral or negative pressure relative to surrounding areas Designate a secluded deboxing area for removal of HDs from external shipping
HDs requiring manipulation (i.e., sterile compounding) must be stored in externally vented, negative pressure room with at least 12 air changes per hour (ACPH) Store within the hazardous drug buffer room or segregated compounding area
Refrigerated antineoplastic HD be stored in dedicated fridge in externally vented, negative pressure room with at least 12 air changes per hour (ACPH) Store within the hazardous drug buffer room or segregated compounding area
Refrigerated antineoplastic HD be stored in dedicated fridge in externally vented, negative pressure room with at least 12 air changes per hour (ACPH) Store within the hazardous drug buffer room or segregated compounding area
Compounding activities to occur within a primary engineering control (PEC; i.e., biological safety cabinet) located within secondary engineering control (SEC)

SEC requirements
  • SEC needs to be externally vented through high-efficiency particulate air (HEPA) filtrations
  • Located in dedicated space
  • Negative pressure 0.01 – 0.03 inches of water column relative to adjacent areas
  • Minimum 12 ACPH for SCA
  • Minimum 30 ACPH for clean room
ALL USP <795> and <797> need to be met

Develop physically separate and dedicated work space for HD related compounding activities.

NOTE: <800> does allow for non-HD products to be prepared in PEC/SEC dedicated to HD compounding; however, these products then must follow HD SOPs due to the possibility of contamination. From a patient and nursing perspective, seeing a non-HD product labeled as HD incites concern.

Complete a gap analysis at each location within an entity that prepares sterile HDs (i.e., ambulatory infusion centers)

Most entities should have minimal non-sterile HD compounding. For occasional nonsterile HD compounding, <800> allows use of PEC utilized for sterile compounding, but it needs to be decontaminated prior to reinitiating sterile HD compounding
Containment Supplemental Engineering Control (i.e., closed system transfer device [CSTD])
CSTD must be used for administration Entity should perform assessment of currently available CSTD systems periodically; validate each system against the recommendations provided by International Society of Oncology Pharmacy
CSTD should be used for preparation Practitioners and the National Institute for Occupational Safety and Health to make the best decision for an institution

Utilization of CSTD during compounding decreases exposure to compounding personnel and may improve surface sampling results
Environmental Quality and Control
Semi-annual surface sampling to include:
  • Interior of PEC
  • Pass-through chambers
  • Work surface in SEC
  • Area adjacent to PEC (i.e., floor, dispensing area)
  • Area immediately outside SEC
Entity to develop policy on specific location and timing of surface sampling (i.e., immediately after decontamination), timing of repeat sampling after positive result, etc.
Personal Protective Equipment (PPE)
PPE required for receipt, storage, transporting, compounding, cleaning, administration, spill management, waste disposal

Entity needs to identify and obtain PPE that meets industry standards
Entity needs to create a multidisciplinary policy addressing PPE requirements

Indication for respiratory protection needs to be evaluated by entity
Deactivating, Decontaminating, Cleaning and Disinfecting
All areas where HDs are handled must be deactivated, decontaminated, cleaned and disinfected Engage the entity’s environmental service to ensure appropriate products are selected and staff are properly educated

Policies should specifically outline which products are utilizing at various stages

Detailed spill policy should include actions based on specific quantity of spill

* Please note this summary is tended for use in conjunction with USP <800>. 

References

1.      Sessink PJ, Bos RP. Drugs hazardous to healthcare workers. Evaluation of methods for monitoring occupational exposure to cytostatic drugs. Drug Saf. 1999;20(4):347-59.

2.      Venitt S, Crofton-Sleigh C, Hunt J, Speechley V, Briggs K. Monitoring exposure of nursing and pharmacy personnel to cytotoxic drugs: urinary mutation assays and urinary platinum as markers of absorption. Lancet 1984;1(8368):74-7.

3.      Valanis B, Vollmer WM, Steele P. Occupational exposure to antineoplastic agents: self-reported miscarriages and stillbirths among nurses and pharmacists. J Occup Environ Med. 1999;41(8):632-638.

4.      McDiarmid MA, Oliver MS, Roth TS, Rogers B, Escalante C. Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs. J Occup Environ Med. 2010;52(10):1028-1034.

5.      NIOSH [2016]. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings, 2016. By Connor TH, MacKenzie BA, DeBord DG, Trout DB, O’Callaghan JP. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupa­tional Safety and Health, DHHS (NIOSH) Publication Number 2016-161 (Supersedes 2014-138).

6.      United States Pharmacopeial Convention, Inc. <800> Hazardous Drug Handling In Healthcare Settings. United States Pharmacopeia 39- National Formulary 34. Rockville, MD: US Pharmacopeial Convention, Inc. 2016.

7.      United States Pharmacopeial Convention, Inc. <797> Pharmaceutical Compounding – Sterile Preparations. United States Pharmacopeia 39- National Formulary 34. Rockville, MD: US Pharmacopeial Convention, Inc. 2016.

8.      United States Pharmacopeial Convention, Inc. <795> Pharmaceutical Compounding – Nonsterile Preparations. United States Pharmacopeia 39- National Formulary 34. Rockville, MD: US Pharmacopeial Convention, Inc. 2016.

9.      Kienle PC. Improving Safe Handling Practices for Hazardous Drugs: Completing an Risk Assessment. Joint Commission Resources 2016;75-102.

10.  National Institute for Occupational Safety and Health Alert. Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Healthcare Settings. Atlanta, GA: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No 2004–165; 2004

11.  NymanH., JorgensonJ., SlawsonM. Workplace contamination with antineoplastic agents in a new cancer hospital using a closed-system drug transfer device. Hosp Pharm. 2007; 42(3): 219225


 

Posted in: Professional Practice
Triple Therapy or Triple Threat?
By Hope Broxterman, Pharm.D., clinical pharmacist, Munson Medical Center, Traverse City

Long-term anticoagulation is needed for patients who have mechanical heart valves and often needed in the millions of patients diagnosed with atrial fibrillation. Whether patients are on warfarin or a direct oral anticoagulant (DOAC), a patient’s risk of bleeding is relatively low when taken by itself or in combination with low dose aspirin. However, of the patients diagnosed with atrial fibrillation, 20-30 percent will experience a heart attack requiring percutaneous coronary intervention (PCI) with stenting which will increase the risk of bleeding due to the addition of guideline based therapy to prevent stent thrombosis. Standard therapy for these patients include aspirin, a P2Y12 inhibitor, and an anticoagulant (which is a defined as triple therapy). While clinicians have varying thoughts in regards to length of certain agents included in triple therapy, the risk of bleeding remains high regardless, thus leading to the dilemma of weighing the risk vs. benefit of initiating triple therapy.

Three studies have compared standard triple therapy (warfarin, aspirin, P2Y12 inhibitor) to alternative combination therapies. The first of these trials is the WOEST (What is the Optimal antiplatElet and anticoagulant therapy in patients with oral anticoagulation and coronary StenTing) study published in 2013.1This trial enrolled 573 patients, of whom 279 were randomized to double therapy (clopidogrel plus an oral anticoagulant) and 284 randomized to triple therapy (clopidogrel, aspirin, plus an anticoagulant). At one year of follow-up (the duration of the trial) the primary outcome of any bleeding episode in the double therapy group occurred in 54 (19.4 percent) patients and 126 (44.4 percent) patients in the triple therapy group (p <0.0001). The combined secondary endpoint (death, myocardial infarction, stroke, target-vessel revascularization, and stent thrombosis) was found to be similar (p <0.025). Thus the rate of thrombotic and thromboembolic events did not differ in patients who did or did not take aspirin.


The PIONEER AF-PCI (Open-Label, Randomized, Controlled, Multi-center Study Exploring Two Treatment Strategies of Rivaroxaban and a Dose-adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects with Atrial Fibrillation who Undergo Percutaneous Coronary Intervention) trial was published in 2016 and compared three treatment regimens.2 A total of 2,124 patients were enrolled in the trial and 709 were assigned to group one (low-dose rivaroxaban [15mg daily] plus a P2Y12 inhibitor for 12 months), 709 patients to group two (very-low-dose rivaroxaban [2.5mg twice daily] plus a P2Y12 inhibitor plus aspirin) and 706 patients to group three (standard therapy with dose adjusted vitamin K antagonist [once daily] plus a P2Y12 inhibitor plus aspirin). The primary endpoint of clinically significant bleeding occurred in 16.8 percent of patients in group one, 18.0 percent in group two and 26.7 percent in group three (p<0.001). A major adverse cardiovascular event (death from cardiovascular causes, myocardial infarction, or stroke) among the three treatment groups was similar (p<0.05). 

The most recent trial studying triple therapy, RE-DUAL PCI (Randomized Evaluation of Dual Antithrombotic Therapy with Dabigatran versus Triple Therapy with Warfarin in Patients with Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) was published August 2017.3 Two thousand seven hundred and twenty five patients enrolled in the study with 981 of them receiving dual therapy with dabigatran 110mg plus a P2Y12 inhibitor (group one), 763 patients received dabigatran 150mg plus a P2Y12 inhibitor (group two) and 981 patients assigned to standard triple therapy (warfarin, aspirin and a P2Y12 inhibitor, group three). The primary endpoint of first major or clinically relevant non-major bleeding events occurred in 15.4 percent of group one, 20.2 percent in group two and 26.9 percent in group three (p<0.001). The incidence of the secondary endpoint of thromboembolic events (myocardial infarction, stroke, or systemic embolization) occurred 13.7 percent in both group one and two and 13.4 percent in group three (p<0.001).

Three studies have now been conducted in comparing warfarin, rivaroxaban and now dabigatran in combination with a P2Y12 inhibitor with or without aspirin. Each study was able to show that the proposed therapy regimens in comparison to standard triple therapy, patients experienced significantly less bleeding without any increase in thromboembolic events. As with all clinical dilemmas, the risk vs. benefit of triple therapy will need to be addressed. Decreasing time of or eliminating certain agents included in triple therapy, adding gastric protective agents such as a proton pump inhibitor, or breaking the mold of standard triple therapy to include a DOAC in place of warfarin are all viable options to keep in our toolbox to ensure we keep our patients safe and continuing to gear up for provider status. 


References: 
1. Dewilde W, Berg JT. Design and rationale of the WOEST trail: What is the Optimal antiplatelet and anticoagulant therapy in patients with oral anticoagulation and coronary StenTing (WOEST). Am Heart J. 2009;158(5):713-8. 
2. Gibson CM, Mehran R, Bode C, et al. An open-label, randomized, controlled, multicenter study exploring two treatment strategies of rivaroxaban and a dose-adjusted oral vitamin K antagonist treatment strategy in subjects with atrial fibrillation who undergo percutaneous coronary intervention (PIONEER AF-PCI). Am Heart J. 2015;169(4):472-8.
3. Cannon CP, Bhatt DL, Oldgren J, et al. Dual Antithrombotic Therapy with Dabigaran after PCI in Atrial Fibrillation. N Engl J Med. 2017. DOI: 10.1056/NEJMoa1708454. 

Posted in: Professional Practice
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