Background Anticoagulants are a leading cause of morbidity among hospitalized patients, with prescription errors commonly reported. Literature surrounding anticoagulation stewardship is scarce despite its documented effectiveness in the antimicrobial realm. Objective To determine the proportion of accepted recommendations on inappropriate anticoagulant prescriptions suggested by a multidisciplinary anticoagulation stewardship program (ASP). Methods We conducted a descriptive cohort study of hospitalized patients using therapeutic anticoagulation at a large Canadian tertiary care center between September 1, 2019, and February 28, 2020. A multidisciplinary ASP, composed of physicians and pharmacists, was implemented on June 1, 2019. Patient‐, anticoagulant‐, and admission‐related characteristics were collected. The primary outcome was the proportion of accepted ASP team recommendations by the prescribing team. Results A total of 381 patients were enrolled during the study period, resulting in 553 anticoagulant reviews (1.56 reviews/patient) by the ASP. The most common indications for anticoagulation were atrial fibrillation (n = 276, 72%) and venous thromboembolism (n = 84, 22%). Direct oral anticoagulants were most frequently prescribed (n = 253, 67%), followed by vitamin K antagonists (n = 88, 23%). Among the reviewed prescriptions, 355 of 553 (64%) generated a recommendation; 299 of 355 (84%) recommendations were accepted by the treating team. Dose adjustments were the leading category of recommendations (31%), followed by alerts regarding drug interactions (19%). Conclusion Inpatient anticoagulant prescriptions were optimized following recommendations by the ASP team. The most frequent types of prescription changes concerned dose adjustments and drug interactions. Further research is required to assess the effect of an ASP on clinical outcomes.

Introduction Coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), a virus strain that appeared in Wuhan China in December 2019, that has since spread to become pandemic. An increased risk of venous and arterial thromboembolism has been consistently reported in critically ill patients with COVID-19 in several countries. The mechanism is thought to be multifactorial, largely mediated by the interplay between inflammation and the coagulation system, or thromboinflammation. We aim to report the risk of thrombosis in a Canadian patient population admitted to the intensive care unit (ICU) with COVID-19. Method We conducted a retrospective cohort study of all consecutive patients with COVID-19 admitted to the ICU between March 1st, 2020 and May 10th, 2020 at the Jewish General Hospital (JGH) in Montreal, Canada. The JGH is a tertiary care centre in Montreal, the epicenter of the COVID-19 pandemic in Canada, and the JGH was the first designated hospitalization centre in Montreal for COVID-19 patients. Patients were followed from date of ICU admission to the earliest of the following: objectively confirmed venous or arterial thrombosis; discharge from hospital; death; or study end date (May 24th, 2020). We determined risk of venous (pulmonary embolism (PE) and deep vein thrombosis (DVT)) and arterial (myocardial infarction, cerebrovascular accident, arterial limb ischemia, and mesenteric ischemia) thrombotic events. Results During the study period, a total of 90 patients admitted to the ICU with COVID-19 were included. The median age was 66 years (standard deviation (SD) 13.8), and 41.1% of patients were female. The median body mass index was 30 kg/m2(SD 5.1), and 64% of patients were mechanically ventilated and 10.1% received continuous renal replacement therapy. The median duration of follow-up was 17.1 days (SD 13.4). In all, 98.9% of patients were prescribed anticoagulation, among whom 78.2% were on a prophylaxis dose, 15.0% intermediate dose, and 6.9% therapeutic dose. In all, 11 (12.2%) patients developed a thrombotic complication among whom 9 patients had objectively diagnosed pulmonary embolism (PE) and 2 patients had an arterial thromboembolism. Both arterial events were cerebrovascular accidents. All PE episodes involved segmental arteries. One PE was incidental, and 3 patients had a concomitant diagnosis of DVT. Overall, death was observed in 16.7% of cohort patients and 12.2% of patients were still admitted to hospital at study end date. Conclusion In this first Canadian study of critically ill patients with COVID-19, we found a 12.2% risk of thrombotic complications despite almost 100% use of anticoagulation primarily with standard prophylaxis dosing. This risk is considerably lower than most reported estimates to date from critical care COVID-19 cohorts in Europe, China and the United States. Our results fuel the ongoing discussion of optimal dose of anticoagulation in these patients. Disclosures No relevant conflicts of interest to declare.

Background Polypharmacy is associated with higher rates of adverse drug events and unplanned hospital visits in medical patients. Little is known about polypharmacy in frail older adults undergoing transcatheter (TAVR) or surgical (SAVR) aortic valve replacement. Purpose To determine the prevalence and prognostic implications of polypharmacy and potentially inappropriate medications (PIM) following TAVR or SAVR. Methods A post hoc analysis of the McGill Frailty Registry was conducted. Patients 70 years of age or older who were discharged alive after TAVR or SAVR at two university hospitals were included. Discharge prescriptions were codified and analyzed using the MedSafer electronic tool that has been validated to flag drug interactions and PIMs considering patient-specific comorbidities. Associations with the primary outcome of 30-day all-cause readmission were examined by logistic regression after adjusting for age, sex, Charlson Comorbidity Index, and procedure type. Results The cohort consisted of 495 patients (52% TAVR, 21% isolated SAVR, 27% combined SAVR). The mean age was 80.1±5.5 years with 52% females. The mean number of medications was 10.2±3.7 with 90% having 5 or more medications. A total of 55 patients were readmitted within 30 days. While the total number of medications was not predictive, three specific PIMs were found to be harmful and one PIM was found to be protective for readmission: clopidogrel with warfarin or heparin (OR 3.99; 95% CI 1.47, 10.82), diltiazem with heart failure (OR 3.16; 95% CI 1.04, 36.41), doxazosin or terazosin with hypertension (OR 6.21; 95% CI 0.99, 38.88), and any proton pump inhibitor (OR 0.47; 95% CI 0.26, 0.86). Of note, the combination of clopidogrel with direct oral anticoagulants was not found to be harmful for readmission. Conclusion The prevalence of polypharmacy is elevated in older patients undergoing TAVR or SAVR. Specific PIMs, but not total number of medications prescribed, were found to be associated with potentially preventable readmissions. FUNDunding Acknowledgement Type of funding sources: None.