Prevention of CI-AKI must remain a clinical priority. Intraprocedural preventive measures should include a priori calculation of the MACD and contrast volume to eGFR ratio to limit contrast volume. Other measures may include the adoption of the transradial approach, the use of automated contrast injectors and small catheters to limit contrast volume, the use of low-osmolar contrast agents, and if necessary the use of staged procedures. We call for the system-wide implementation of evidence-based care bundles to prevent CI-AKI.

We report an interesting case of warfarin resistance and subtherapeutic international normalized ratio (INR) in the setting of chronic smokeless tobacco use. A 33-year-old white male with a mechanical mitral valve failed to achieve therapeutic INR despite being on warfarin doses of up to 30 mg by mouth daily. The patient admits to chewing tobacco daily for the past 16 years. While evaluating potential causes of subtherapeutic INR, nonadherence, drug interactions, genetic polymorphisms, and dietary factors were considered. Subtherapeutic INR may be due to increased exposure to vitamin K from chewing tobacco. Tobacco is rich in vitamin K, and its chronic use may have caused the failure to attain a therapeutic INR. To our knowledge, there is only one other case of warfarin resistance resulting from smokeless tobacco described in published literature.

Heparin-induced thrombocytopaenia (HIT) is a serious complication of heparin therapy. Evidence-based guidelines recommend the use of the 4Ts scoring system to calculate pretest probability of HIT. However, this scoring system is often underused, and inappropriate testing can lead to increased morbidity, medical costs and length of hospital stay. We identified that inappropriate testing for HIT was common at our institution and implemented structured multicomponent educational interventions to evaluate the impact of education on the appropriateness of HIT testing. The educational interventions led to a significantly increased rate of appropriateness of HIT testing (69% vs 35%; p=0.001). In addition, the 4Ts score documentation rate significantly improved following the intervention (52% vs 17%; p=0.001). The rates of discontinuation of heparin products and initiation of alternative anticoagulation increased, although not statistically significantly. Educational interventions can improve compliance with evidence-based guidelines on appropriateness of testing for HIT.