The American journal of medicine
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Randomized Controlled Trial Multicenter Study
Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.
More than 1.6 million Americans currently reside in nursing homes. As many as 12% of them receive long-term anticoagulant therapy with warfarin. Prior research has demonstrated compelling evidence of safety problems with warfarin therapy in this setting, often associated with suboptimal communication between nursing home staff and prescribing physicians. ⋯ Facilitated telephone communication between nurses and physicians using the SBAR approach modestly improves the quality of warfarin management for nursing home residents.
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Social isolation is associated with progression of cardiovascular disease, with the most socially isolated patients being at increased risk. Increased left ventricular mass is a predictor of cardiovascular morbidity and mortality. It is not yet clear whether social isolation is a determinant of increased left ventricular mass. ⋯ In this urban tri-ethnic cohort, social isolation was prevalent and associated with indices of low socioeconomic status. Hispanics who were socially isolated had a greater risk for increased left ventricular mass.
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There is increasing recognition of the value of oral anticoagulation for stroke prevention in atrial fibrillation, as well as the availability of new oral anticoagulants that overcome the limitations of warfarin, implying that even more atrial fibrillation patients will be using oral anticoagulation, with the role of aspirin being less defined. Thus, we need a paradigm shift so that stroke risk assessment can be simplified in the identification of those patients who are truly at low risk (ie, CHA(2)DS(2)-VASc [Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] score=0) who could be treated with no antithrombotic therapy, and all others (ie, CHA(2)DS(2)-VASc score ≥1), would be considered for oral anticoagulation. A simple bleeding risk assessment can clearly help guide office management here. The new HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile International Normalized Ratio, Elderly, Drugs/alcohol concomitantly) bleeding risk schema has been proposed as a simple, easy calculation to assess bleeding risk in atrial fibrillation patients, whereby a score of ≥3 indicates "high risk" and some caution and regular review of the patient is needed, following the initiation of antithrombotic therapy, whether with oral anticoagulation or antiplatelet therapy.