Congestive heart failure (CHF) is a pervasive and insidious disease that affects almost 5 million, mostly elderly, Americans. Significant therapeutic advances in the management of heart failure (HF) have resulted in striking decrements in mortality rates, but hospitalization use is ever increasing, now at over 1 million hospitalizations per year with a cost of > $15 billion--a cost that is largely borne by Medicare and Medicaid. One of the most historically challenging factors facing case managers who work with the CHF population is how to minimize treatment costs while enhancing clinical outcomes for those with this highly prevalent and clinically challenging chronic disease. To date the typical treatment of acute decompensation has been based in the hospital and woefully inadequate in promoting any long-term medical stability.

By understanding barriers, providing education, and advocating appropriate treatment, case managers play an essential role in the prevention and treatment of thromboembolic disorders. Yet, thromboembolic events such as stroke and deep-vein thrombosis still result in substantial morbidity and mortality despite the availability of effective prophylactic anticoagulation therapy. Although oral warfarin, because of its established efficacy, remains the mainstay in the prevention and treatment of thromboembolic disorders associated with atrial fibrillation, a common antecedent, it is fraught with enduring impediments that hinder effectiveness, safety, and use. With a narrow therapeutic widow, optimal treatment relies on maintaining a tight international normalized ratio (INR) range, usually between 2.0 and 3.0. Lacking intensive anticoagulation clinic monitoring, patients are often outside the therapeutic range, compromising efficacy or safety. Furthermore, the need for frequent and demanding INR monitoring, a slow onset of action, and an elevated risk for drug-drug and food-drug interactions conspire to undermine the use of warfarin, especially in high-risk groups, such as the elderly. Unquestionably, well-tolerated, convenient, and effective alternatives to oral warfarin are needed to improve the management of patients in need of anticoagulation therapy. Several new oral anticoagulants are in development, but only one, ximelagatran, has completed Phase-III development and awaits Food and Drug Administration (FDA) approval. An oral direct thrombin inhibitor, ximelagatran, appears to offer a profile quite different from warfarin: a wide therapeutic window that obviates routine drug-level monitoring and twice-daily oral administration with minimal drug interactions; however, transient liver enzyme elevations remain an unresolved issue. As case managers typically work with those who present with clinical or psychosocial challenges, or both, this treatment approach may provide an alternative that would enhance patient outcomes.