Reimagining Anticoagulation Clinics in the Era of Direct Oral Anticoagulants
Geoffrey D Barnes1, Brahmajee K Nallamothu2, Anne E Sales2
1From the Frankel Cardiovascular Center, Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor (G.D.B., B.K.N., J.B.F.); and Department of Learning Health Science, University of Michigan Medical School and VA Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare Center, Ann Arbor, MI (A.E.S.). gbarnes@umich.edu.
Insights
Anticoagulation clinics are evolving to manage new oral anticoagulants and high-risk medications. These clinics are essential for drug selection, bleeding risk management, and patient adherence to improve cardiovascular care.
Area of Science:
- Cardiology
- Pharmacology
- Patient Safety
Background:
- Anticoagulation clinics traditionally managed warfarin therapy for atrial fibrillation, venous thromboembolism, and mechanical valves.
- The advent of direct oral anticoagulants (DOACs) has prompted reevaluation of the necessity of traditional anticoagulation clinics.
- A growing number of anticoagulant options necessitates an expanded role for specialized clinics.
Purpose of the Study:
- To redefine the role of anticoagulation clinics in the era of diverse oral anticoagulants.
- To outline key functions for reimagined clinics: drug selection, bleeding risk mitigation, and adherence monitoring.
- To explore repurposing these clinics as broader medication safety centers for high-risk cardiovascular drugs.
Main Methods:
- Literature review and expert opinion synthesis.
- Analysis of current challenges and proposed solutions for clinic expansion.
- Case examples of health systems implementing reimagined clinic models.
Main Results:
- Reimagined clinics can optimize drug selection among warfarin and DOACs.
- Enhanced monitoring and peri-procedural management can reduce bleeding risks.
- Focus on adherence and medication safety can improve outcomes for various cardiovascular conditions.
Conclusions:
- Anticoagulation clinics are vital for navigating complex oral anticoagulant choices.
- Expanding clinics to medication safety centers enhances care for high-risk cardiovascular medications.
- Successful implementation requires addressing specific health system challenges.
Abstract:
Anticoagulation clinics were initially developed to provide safe and effective care for warfarin-treated patients with atrial fibrillation, venous thromboembolism, and mechanical valve replacement. Traditionally, these patients required ongoing laboratory monitoring and warfarin dose adjustment by expert providers. With the introduction of direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban), many have questioned the need for anticoagulation clinic. However, we think that the growing number of oral anticoagulant choices creates an urgent need for expanding the traditional role of the anticoagulation clinic. We outline 3 key purposes that a reimagined anticoagulation clinic would serve: (1) to assist patients and clinicians with selecting the most appropriate drug and dose from a growing list of anticoagulant options (including warfarin), (2) to help patients minimize the risk of serious bleeding complications with careful long-term monitoring and peri-procedural management, and (3) to encourage ongoing adherence to these life-saving medications. We also describe how repurposing anticoagulation clinics as broader medication safety clinics would promote safe and effective care across a range of cardiovascular conditions for high-risk medications (eg, spironolactone, amiodarone). Finally, we highlight a few existing health systems that are overcoming key challenges to implementing a reimagined anticoagulation or medication safety clinic structure.
Related Concept Videos
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...
01:29Venous Thrombosis III: Interprofessional Care
01:30Anticoagulant Drugs: Low-Molecular-Weight Heparins
01:20Antiplatelet Drugs: Prostaglandin Synthesis, P2Y12 and Glycoprotein IIb/IIIa Inhibitors
Prostaglandin synthesis inhibitors, exemplified by the widely known aspirin, wield their power by irreversibly acetylating...
01:30Venous Thrombosis IV: Nursing Management
01:29Pulmonary Embolism II: Diagnostic Studies and Interprofessional Care