Dr David Hill (Host): Hello and welcome to Expert Insights with the Carle Foundation Hospital. I'm Dr. David Hill, and today joining me we have Dr. Robert Healy, associate Chief Medical Officer for quality, safety, and experience, And also Dr. Karen Wiarda, a non-invasive cardiologist. They're here to talk to us today about anticoagulation, which can be lifesaving in a variety of heart conditions. So, Dr. Healy and Wiarda, first of all, can you talk to us about what anticoagulation means? What is this thing we're talking about?

Dr Karen Wiarda: So anticoagulation, anticoagulants are blood thinners that reduce the risk of stroke. By reducing the risk of stroke, blood thinners can also increase the risk of bleed. So anticoagulants are blood thinners that reduce the risk of clotting specifically.

Dr David Hill (Host): So that sounds like one of those tools that is super powerful, but you have to use it in the right way. Am I right?

Dr Karen Wiarda: Exactly.

Dr David Hill (Host): Fantastic. Can you name some examples of semantic coagulants that people might be on, whether they're aware of it or not?

Dr Karen Wiarda: The most common is the oldest anticoagulation, which we're sort of moving away from is Warfarin or Comanin. And that anticoagulation requires regular blood monitoring and keeping the range within typically two to three for atrial fibrillation. Then there's what we call now Doex. and these are oral anticoagulants. And the typical ones we use are Zeralto and Eliquis. And those are dosed according to, renal function for Zeralto and for Eliquis. It is dosed according to age, renal function, and body mass. So that dose varies from 15 milligrams a day to 20 milligrams a an also and from Eliquis from 2.5 milligrams twice a day to five milligrams twice a day.

Dr David Hill (Host): When might we want to use anticoagulants? You said that they've reduced the risk of stroke. How do you know somebody is at risk for having that kind of stroke?

Dr Karen Wiarda: So when we look at atrial fibrillation, when we look at the risk of stroke, we look at something called a Chad's Vasc score. And if you calculate high enough on a Chad's vasc score, it is recommended that you go on oral anticoagulation. So Chad's vasc score to break it down is looking at a history of congestive heart failure. History of hypertension, your age, whether or not you're 65 or 75. For those three, including age of 65, that would be one score. Each age of 75 is two points. Diabetes is one point and whether or not you've had a risk of strokes or blood clots or mini strokes in the past, that would be two points. Then the VASC is whether or not you have either peripheral artery disease or coronary artery disease, and you would get another point.

So if you are greater than two CHAD'S Vasc score, then it is recommended that you go on Anticoagulation. If your score is simply because of age and female, then it would be a score of greater than three It would be recommended that you go on anticoagulation. When we look at risk of strokes, we also look at the risk of bleed, and that is something called a HAS blood score. And when you calculate the HAS blood score, it's a point of discussion to look at whether or not your bleeding score is also elevated to increase your risk of bleed, and then that's when you have a conversation. And we'll get into, some of the options available, like a watchman procedure.

Dr David Hill (Host): Right. I wanna back up a little bit. I know that a lot of strokes are caused by blood clots and that's why you would want to anticoagulate do blood clots cause all strokes?

Dr Karen Wiarda: Blood clots do not cause all strokes. You can also have, plaques that can rupture, that can cause a stroke. Another cause of a stroke would be from a blood pressure that is too high, which is actually a intracranial hemorrhage, which I think some people term a stroke. That works by blood vessels that have actually, bled into your brain that have bursted from elevated blood pressures or other causes that would cause bleeding in the brain, like aneurysms and things like that.

Dr David Hill (Host): So say my doctor identifies me as having these scores in such a way that it would keep me from having a stroke to be on an anticoagulant medication, and it would not significantly increase my risk of having bleeding. How do I start these medicines and what do I have to do to make sure that I'm using them right?

Dr Robert Healy: As a primary care doctor, I can address that. Cause I think normally we're the ones in the majority of cases that would talk to someone who we've just diagnosed with atrial fibrillation. Of course we consult, closely with our cardiology colleagues. But if you have atrial fibrillation, as been has been stated, you're at an increased risk for a stroke, and these powerful medications can help reduce that risk. We also know that, as Dr. Wiarda said, there's side effects from the medication, so it's a powerful tool used in the right circumstances, and that would mean that your scores are correct, that you are at risk for a stroke and your bleeding complication risk is low enough to put up with that slight chance of bleeding.

And what we've done in the quality world here at Carle is taking a look at this very important treatment. That we wanna make sure that those that should be treated do have the opportunity to get the medication. And those that are too high of a risk to be treated, aren't treated because they could have a bleeding episode either in their brain or in their GI tract. That could be very, very deadly. So what we did was, we looked in our electronic medical record, we looked at everyone who had a diagnosis of atrial fibrillation, all adults and were they on one of the anticoagulants that Dr. Wiarda Talked about earlier?

And we found that there were gaps. We looked at a couple practices just to get an idea and found that about probably 20 or 30% of those time patients who on paper look like should have anticoagulation weren't done anticoagulation.

Dr David Hill (Host): So say you've started a patient on anticoagulants, I know back in the day used to be really frequent blood testing. We might check somebody daily for their INR or PT and is that still something that we do or is it not quite so many sticks these days?

Dr Robert Healy: So one of the benefits of the newer medications that Dr. Viarda talked about is there doesn't need to be the monitoring of a blood test so often. So you're right with Coumadin or Warfarin. In the beginning, we would check frequently and at least once a month for as long as you're on that medication. And frequently we found that even though we had the best of intentions and patients had the best of intentions, Diet changes would affect the number, or it seemingly kind of randomly would change. And the patient wasn't in the optimal state of anticoagulation for a good chunk of time. With the newer medications, we could be assured that they are in the right area of anticoagulation without even checking blood tests.

Dr David Hill (Host): Fantastic. If I'm on the new medicines, can I finally eat grapefruit? I know that was an issue with warfarin.

Dr Karen Wiarda: That is certainly less than an issue. And I will when you say good chunk of the time, it was definitely a good chunk of the time because it's about 60% of the time, that 60 to 70% of the time that people were appropriately in coagulated on warfarin, which is a pretty significant gap. Whereas with these medications, when you take them, you're protected. And so The The beauty of it, there's far less interactions with drug interactions and with food interactions, and so you don't have to worry as much about alcohol. Things like grapefruit. Grapefruit is a bigger issue for statins, but you don't have to worry about some of those foods the way that you do, with warfarin.

Dr David Hill (Host): That's fantastic. Now, Dr. Healy, you did an investigation recently through Carle that looked at people who might benefit from being on anticoagulants, but for some reason they were not. What did you learn and what kinds of changes do you hope to see in the future as a result of that?

Dr Robert Healy: So interestingly, with the anticoagulants, can be lifesavers and decrease your risk for stroke. There are also complications, and we know that not everybody who has atrial fibrillation should automatically be put on one of these medications. deserves a talk between your, physician or provider and you, and looking at your individual risks. But in general, we would expect. more than 80 out of a hundred people that have atrial fibrillation should be on anticoagulate medication. And when we looked at it in our system, it was down about 60 out of a hundred patients in some practices, and we wondered why that was.

So what we did was we looked into the charts of some of these practices and found that a lot of those people were appropriately not on anticoagulation, meaning they had atrial fibrillation, but their risk was so high for bleeding and other complications, that the decision was made with their provider not to use this medication and accept the risk of a stroke because that was lower than the complication rate. We also found that there were some people that either hadn't seen their doctor in a while or they were seen for something else, and even though they also had atrial fibrillation, the anticoagulation wasn't addressed at that last visit. So that's what prompted us to do this study and to do a kind of a quality improvement project.

Dr David Hill (Host): So what did you find helped in terms of improving this quality?

Dr Robert Healy: What we found helped was if someone had atrial fibrillation in their diagnosis when they saw their primary care doctor or their cardiology specialist, we would let that provider know at that visit. It's something called a best practice advisory or a popup. Which can be annoying because we have, frankly a lot of popups because there's so many things that we wanna document in the chart and so many things that we wanna get right. But we felt in this case, this was important enough that we wanted to add a new popup. So if I were to see someone in my practice for a visit, for a upper respiratory infection or an ankle injury, and they also happen to have atrial fibrillation. Behind the scenes, the computer would look and see was that personnel, one of these anticoagulant medications?

And if not, they would let me know. Your patient has atrial fibrillation. They're not on anticoagulant. Basically the question would be, why not ? And what we found is that for some people the answer was, oh, I didn't even think about that. I thought someone else had dealt with it. Or, I thought we had talked about it before. So in other words, you prompted that provider to talk to the patient, right? Then it your records showing me that you have atrial fibrillation, your at high risk for stroke. Let's talk about anticoagulation. What also could happen was that the provider had already talked about this with the patient. The patient comes in for their ankle injury.

The computer says, Hey, this person has atrial fibrillation. They're not on anticoagulation. And I would say that's correct because we've already talked about it and I'd be able to press a button saying, To the system, essentially. Here's why they're not on anticoagulant medications. it's appropriate that they're not on. And here's why. And importantly we were able to share that information then in our electronic record system with the next doctor that saw that patient. Or if they went to the emergency room and the emergency room wondered, why aren't they on anticoagulation? They would be able to find out because the doctor had written why they weren't on anticoagulation.

Dr David Hill (Host): It saves everybody a lot of time and hassle. That sounds a really great system you've got there.

Dr Robert Healy: Yeah, and especially I think the wins I think are, well first of all, just aligning why someone is or isn't on the medication, but it's especially those people who, the doctor wants to talk about it. They know it's important, but because there's being seen for something else, another reason, they thought someone else talked about it, they didn't even realize they weren't on that important medication. So with those patients, it's really a big win cause we're then putting 'em on the right medication and decreasing their risk for a stroke. And that's so important.

Dr David Hill (Host): That is one lifesaving popup right there. I'm glad we have that. Before we go? Are there any last takeaways that either of you would like to leave our listeners with today regarding anticoagulation?

Dr Robert Healy: I'd like to add one more thing, which is that in this study we did, or in this improvement project, we asked the provider, why aren't they on anticoagulation? And what we found out is that for the most part, if they weren't, they weren't supposed to be, but sometimes our providers would say they aren't on anticoagulation because their fall risk is too high or because their age and we're worried about their falling. And some of these things show us that there's opportunities for us to learn as a group. The real reasons why you should or shouldn't be on anticoagulation, and I think Dr. Wiarda Can add to that with some ideas about what really is a contraindication versus what's maybe conventional wisdom, but not so true anymore.

Dr Karen Wiarda: So realistically, the number one true contraindication is patient refusal. if they've had a history of bleeding, like GI bleeding, that doesn't always mean that they can't be retry to see whether or not, can tolerate it now since they might have actually had something cauterized something where they can now tolerate it. If they've had nose bleeds. Same issue. I've seen patients come off for nose bleeds and if they are at risk for falls, you know, a history of falls is very different than a risk of falls. And so to not anticoagulate someone really puts them at risk for a stroke. And I what's nice now is we have something called a watchman. And so if someone has had an intracranial hemorrhage, for example, that isn't necessarily a contraindication unless that isn't stable or neurosurgery has deemed that they cannot have anticoagulation.

If they have these risks of falls or they're concerned about a risk of a bleed, we actually have a watchmen procedure now that we can place a little umbrella over the left atrial appendage to actually stop the clots from being released on the highest risk area for having a blood clot in left atrium, which is called the left atrial appendage. And so that opens up opportunities where maybe someone, could not be on anticoagulation and maybe we would've kept retrying, but then with this device available, if they have a future risk of bleed or at a high risk of bleed or an occupation or lifestyle where anticoagulation is not in ideal or they're not compliant with interactions, or there are way too many drug interactions. Then they can actually have this watchman device placed through the interventional or structural, heart program at Carle. And they can have that placed and then they only need short term aspirin implants, or aspirin amorin for 45 days. And so that is an option now where that kind of takes away that risk of bleeding and gives us another opportunity.

Dr David Hill (Host): That is a really impressive innovation. Dr. Karen Wiarda and Dr. Robert Haley, thank you so much for joining us today.

Dr Karen Wiarda: Thank

Dr Robert Healy: you.

All right. Thank..

Dr David Hill (Host): this has been expert insights with Carle Foundation Hospital. If you have questions about anticoagulation, atrial fibrillation, or anything else regarding your health, start@carl.org.