2025 Southeastern Residency Conference

Title: Effect of Steroids on Post Cardiac Surgery Length of Stay 


Authors: Emily-Kate Carter, Krista Riche, and Jamie Wagner


Background: Steroids can be used for patients undergoing surgery to decrease inflammation that arises due to the trauma and stress of surgery, and they can be useful antiemetics in some patients. Additionally, steroids have been proposed to have many benefits in patients just having undergone surgery such as decreased length of stay, decreased pulmonary complications, decreased infection risk, and a decreased risk of post-cardiac surgery new onset atrial fibrillation (AFib). The benefit of steroids, specifically for post-operative AFib risk reduction, seems to be due to the decrease in C-reactive protein, white blood cell count, and inflammatory cytokines following steroid administration. However, using steroids is a known risk factor for hyperglycemia, and therefore increases insulin demand in post-operative patients. Studies show that post-operative hyperglycemia increases the risk of mortality in cardiac surgery patients with and without diabetes. The purpose of our study is to determine if administering steroids after cardiac surgery has an effect on patients’ length of stay.


Methods: This single-center, retrospective group pretest/posttest quasi-experiment included patients admitted to St. Dominic Jackson-Memorial Hospital from June 01, 2023 to December 31, 2023, when steroids were not given to patients post-surgery, and June 01, 2024 to December 31, 2024, when steroids began to be given, who were aged ≥18 years, undergoing major cardiac surgeries, including Coronary artery bypass graft (CABG), Aortic Valve Replacement (AVR), Mitral Valve Replacement (MVR), or Tricuspid Valve Replacement (TVR). Patients were excluded if an Impella device was utilized peri-operatively, if they were treated with antibiotics for known or suspected infection before surgery, or if they died within 48 hours of the surgery. The primary outcome is length of post cardiac surgery ICU stay in hours. Secondary outcomes include total length of post-cardiac surgery hospital stay in hours, prevalence of hyperglycemia within 72-hours post-operation, and prevalence of post-operative-infections within 30 days.


Results: A total of 100 patients were enrolled in this study, with 50 in the steroids group and 50 in the control group. Average length of stay in the ICU was similar in both groups at 88.28 ± 137.30 hours in the control group vs 92.04 ± 137.57 hours in the steroid group (p = 0.89). There was also no statistical difference in total hospital length of stay at 201.08 ± 189.09 hours for the control group vs 193.62 ± 130.84 hours for the steroid group (p= 0.82). The prevalence of hyperglycemia within 72 hours did not differ between the control group with 66% (n=33) and the steroids group with 68% (n=34). No post-operative deep sternal wound infections were observed in either group within 30 days. The only statistically significant finding was a lower rate of post-operative atrial fibrillation (AF) in the steroid group of 14% (n=7) compared to the control group with 48% (n=24) (p= <0.01).


Conclusions: Utilization of post-operative steroids did not impact ICU length of stay or total hospital length of stay. There was not a statistically significant difference in the prevalence of hyperglycemia or deep sternal wound infections between the groups. Post-operative AF occurrence was significantly lower in the steroid group compared to the control group.

Title: Evaluating CPP Impact to Ensure GDMT, Improve Heart Failure Patient Outcomes, and Reduce Readmissions


Authors: Allison D. Johnson; Kathy Davari; Mary K. Pounders


Background: The prevalence of heart failure (HF) is increasing annually with approximately 6.7 million American adults age 20 or older currently affected. The cost of HF in 2012 was estimated to be $30.7 billion. Previous studies have highlighted the role that clinical pharmacists can play in improving hospital readmission rates for patients with HF. The Atlanta VA Health Care System has a procedure in place for clinical pharmacist practitioners (CPP) to assess patients recently discharged from the hospital after a HF exacerbation. Patients are identified using a dashboard that lists any patient recently discharged with an exacerbation. This project aims to evaluate the efficacy of the Atlanta VA CPP interventions related to preventing readmissions for HF patients. A focus will be placed on interventions with Guideline Directed Medical Therapy (GDMT) agents.


Methods: This project is a retrospective quality improvement project comparing readmission rates and prescribing rates of GDMT agents of patients assessed by a CPP within 10 days of a HF exacerbation hospital discharge compared to patients without CPP assessment. For this project, a readmission is defined as a hospitalization within 30 days of initial discharge for a HF exacerbation. Patients that receive care from the Atlanta VA who have a diagnosis of HF during the year 2023 and the year 2024 were identified from the VA electronic health record. Fifty patients with a HF hospitalization in the year 2023 were randomly selected to evaluate their readmission rates and GDMT agents. Fifty patients with HF hospitalization in the year 2024 were randomly selected to evaluate their readmission rates and GDMT agents following CPP intervention. Data collection points will include, but are not limited to, age, gender, time of hospitalization, GDMT medications before and after hospitalization, GDMT agents after CPP assessment, patient readmission, primary care provider or clinic, and CPP who assessed the patient. Data will be recorded without patient identifiers and will be maintained confidentially. Upon review of the data, the impact of CPP’s assessment on patients with a hospitalization for HF exacerbation will be assessed.


Results: In progress


Conclusions: In progress

Authors' names: Katie Williams, Justin Joy, Stuart Pope, Ozlem Bilen, Matthew Gold, Byron Williams III
Background/Purpose: To evaluate the real-world incidence of left ventricular ejection fraction (LVEF) decline to <50% and identify predictors associated with reduced LVEF in patients receiving mavacamten for obstructive hypertrophic cardiomyopathy at an academic medical center.
Methodology: This is a single-center, retrospective chart review of adult patients diagnosed with obstructive hypertrophic cardiomyopathy, who have received mavacamten therapy for at least 3 weeks at the Emory Heart and Vascular Clinic from May 1, 2022, to September 30, 2024. Eligible patients must have a baseline left ventricular outflow tract gradient (LVOT) >30 mmHg and available echocardiogram data at both baseline and post-treatment initiation. Patients with incomplete medical records will be excluded. A univariate logistic regression analysis was performed to identify predictors associated with EF decline.
Results: A total of 54 patients met the inclusion criteria for the IRB-approved study. Among these, five patients (9.3%) discontinued mavacamten therapy[JJ4] . Three patients (5.6%) had an incidence of EF decline <50% during mavacamten therapy; two of them (66.7%) discontinued mavacamten. Patients that discontinued mavacamten had similar EF at baseline than those who continued mavacamten (51.2% vs. 63.6%; P=0.093). Similarly, patients that discontinued mavacamten had similar EF post mavacamten treatment than those who continued mavacamten (52.7% vs. 60.9%; P= 0.127). No factors were associated with EF decline were identified in the initial analysis.
Conclusions: The study revealed that the majority of patients did not have a EF decline <50% while on mavacamten for hypertrophic cardiomyopathy. Given the inconclusive findings, further exploratory analyses will be conducted to identify potential predictors of EF decline.
Presentation Objective: Identify key factors that may contribute to a decrease in ejection fraction in patients taking mavacamten for hypertrophic cardiomyopathy.

Title: Use of Guideline Directed Medical Therapy and Safety in Patients with Cardiogenic Shock


Authors: Thomas Thielbar, Kelly Dunton, Pujan Patel, Laila Handshaw


Background: Heart failure with reduced ejection fraction (HFrEF) clinical practice guidelines currently recommend the use of guideline directed medical therapy (GDMT) to improve survival, decrease hospitalizations, and improve symptoms in patients with HFrEF. Several studies have demonstrated that early initiation of GDMT during hospitalization, once hemodynamically stable, to be safe and clinically beneficial. This study aims to assess the current ordering practices and safety of GDMT in American Heart Association (AHA) stage D / New York Heart Association (NYHA) class IV heart failure (HF) patients hospitalized for acute decompensated heart failure (ADHF).

Methods: This single-site, retrospective, cohort study included patients age ≥18 years, hospitalized at AdventHealth Orlando, admitted with ADHF (defined as having signs and symptoms of congestion, actively receiving inotropes, and/or temporary mechanical circulatory support [MCS]), classified as AHA stage D / NYHA class IV HF, and underwent an advanced HF evaluation. Exclusion criteria include history of durable left-ventricular assist device (LVAD), type 1 diabetes, history of diabetic ketoacidosis (DKA) or euglycemic DKA, history of angioedema associated with GDMT, and pregnant women. The primary endpoint is percentage of patients on GDMT including angiotensin-converting enzyme inhibitor (ACEi) / angiotensin II receptor blocker (ARB) / angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker (BB), mineralocorticoid receptor antagonist (MRA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i) at three points including day of admission, 72 hours post inotrope or MCS initiation, and day of discharge (defined as hospital discharge, in-hospital mortality, left-ventricular assist device implant or heart transplant). Secondary safety endpoints include incidence of genitourinary infections, acute kidney injury or need for renal replacement therapy, hypotension, bradycardia, hyperkalemia, hypoglycemia, DKA, and angioedema assessed at admission, within 72 hours post inotrope or MCS initiation, and discharge. Additional secondary endpoints include number of patients on each individual medication and their doses from primary endpoint, MCS use, inotrope use and dose, vasopressor use, and VIS score at admission, within 72 hours post inotrope or MCS initiation, and discharge.  Exploratory safety endpoints include in-hospital mortality, hospital length of stay, ICU length of stay, implant of LVAD, heart transplant, and actively on heart transplant waitlist. Study endpoints were analyzed utilizing descriptive statistics. 

Results: A total of 129 encounters, encompassing 108 patients were screened for inclusion in which 27 encounters were excluded. The final study population included 102 encounters, encompassing 84 patients with a median age of 57 (IQR 48-65) years old, predominantly white (43.1%) males (72.5%) with past medical history significant for type 2 diabetes (52.9%), chronic kidney disease (52.9%), and arrhythmias (66.7%). The primary cause of HF was non-ischemic cardiomyopathy. Only 20.6% of patients were on all four GDMT medication classes prior to admission. SGLT2i and MRA were the most commonly prescribed GDMT at all three time points. Incidence of SGLT2i was 43.1%, 61.8%, and 78.1% at admission, 72 hours post inotrope or MCS initiation, and discharge respectively. Incidence of MRA was 49%, 80.4%, and 87.5% at admission, 72 hours post inotrope or MCS initiation, and discharge respectively. For secondary endpoints, administration of any GDMT did not increase incidence of any associated adverse effect.

Conclusion: We observed that in this patient population, SGLT2i and MRA were most commonly ordered and did not increase the incidence of any safety outcomes assessed. This study illustrates that it is safe to optimize GDMT in this patient population, however, further studies are needed to assess efficacy on a larger scale.

Title: Evaluation of Thrombophilia Testing in a VHA Healthcare Facility Before and After Implementation of a New Thrombophilia Testing Protocol
Authors: Katherine Medley, Jill Radford, Rebecca Worsham, Shouji Nagata
Background/Purpose: The James H Quillen VA Medical Center (JHQVAMC) does not currently have a standardized process for thrombophilia testing.  Testing for thrombophilia should be used to identify the cause of severe or fatal venous thromboembolism (VTE), aid in decision making on future VTE prevention, and direct family member testing.  Most risk classification guidelines for VTE recurrence do not consider thrombophilia test results.  There is a lack of evidence supporting the clinical benefit of routine testing among patients with VTE.  The accuracy and reliability of thrombophilia testing is dependent on the timing of the tests in association with the initial VTE presentation or the presence of an anticoagulant. Inaccurate testing can lead to false positive or false negative results.  These false results may contribute to patient harm through unnecessary prolonged duration of anticoagulation,  inaccurate diagnosis of thrombophilia, or providing false assurance related to the risk of recurrent VTE.  Studies have shown that thrombophilia testing increases the cost of VTE management without adding meaningful clinical value.  The purpose of this quality improvement project is to develop and implement a thrombophilia testing protocol to reduce unnecessary and inaccurate thrombophilia testing while promoting patient safety and cost savings at the JHQVAMC.
Methodology:  A standardized note template will be created and implemented across the JHQVAMC to guide providers in the appropriate testing for thrombophilia.  Data will be reviewed before and after implementation of the standardized ordering process.  All patients diagnosed with a VTE who had thrombophilia testing completed within the last 5 years will be identified.  Data will be sourced from the corporate data warehouse (CDW), computerized patient record system (CPRS), Joint Legacy View (JLV), and pharmacy benefit management (PBM) services direct oral anticoagulant (DOAC) dashboard.  These data will be evaluated to determine if testing and follow-up were appropriately completed.  Additional endpoints include costs, duration of anticoagulation, anticoagulant choice, and misdiagnosis rate.  Thrombophilia testing practices will be evaluated among inpatient, primary care, and specialty providers.
Results: In progress
Conclusions: In progress

Title: Use of Prophylactic Amiodarone for the Prevention of Atrial Fibrillation After Cardiac Surgery 


Authors: Savannah Salam, Sydney Davis, Michael Bitonti, Lisa Curran, Paul Weldner 


Objective: Discuss the potential benefit of routine oral amiodarone use for atrial fibrillation prophylaxis after cardiovascular surgery


Self Assessment Question: True or False: The use of oral amiodarone for atrial fibrillation prophylaxis should replace prophylactic beta blocker use in patients after cardiac surgery


Background: Amiodarone is a Vaughan-Williams Class III antiarrhythmic agent approved for the management of life-threatening ventricular arrhythmias but is commonly used for treatment of atrial fibrillation (Afib). Approximately 15-40% of patients develop postoperative Afib after cardiac surgery. The PAPABEAR trial found a significant reduction of postoperative Afib with oral amiodarone prophylaxis in patients undergoing nonemergent coronary artery bypass graft (CABG) and/or valve replacement/repair with or without beta blocker use. The 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guidelines added a level IIa recommendation for the use of short-term prophylactic beta blockers or amiodarone in patients undergoing cardiac surgery who are at high risk for developing postoperative Afib. Our institution recently began use of amiodarone prophylaxis in select patients at surgeon discretion. The purpose of this review is to evaluate the impact of oral amiodarone for Afib prophylaxis after cardiac surgery. 

Methods: This review was a single center, IRB reviewed, determined exempt, retrospective comparator evaluation conducted from July 1, 2024 to February 28, 2025. Adult patients who underwent CABG, valve replacement, or valve repair were included in this study. Patients were excluded if they had a history of Afib in the last 12 months, amiodarone use in the last 6 months, were on Vaughan- Williams Class I or III antiarrhythmic medications prior to procedure, required mechanical circulatory support, or if any ventricular or atrial arrhythmia was present before the procedure. Each patient was reviewed for demographic data, type of cardiac procedure, use of prophylactic amiodarone, development of Afib postoperatively, use of prophylactic beta blocker, and development of Afib or Aflutter within 30 days of hospital discharge. Included patients were stratified by use of prophylactic oral amiodarone. The prophylactic amiodarone standard order was 400 mg twice daily for five days. The length of amiodarone treatment and dose were adjusted based on clinical decision-making by the care team. The primary outcome was the incidence of postoperative Afib. Secondary outcomes include time to postoperative Afib, use of intravenous amiodarone, percentage of patients that discontinued prophylactic amiodarone, and readmission for atrial arrhythmias within 30 days of discharge from the index event.  

Results: Of the 126 patients screened, 80 patients were included in this study. There were 30 patients in the amiodarone prophylaxis group and 50 patients in the standard of care group. Baseline patient characteristics were balanced between groups apart from smoking history (16% in amiodarone group vs. 70% in standard of care), history of heart failure (14% vs. 36%), and index event including a valve procedure (70% vs. 32%). Notably all patients received prophylactic beta-blockers per standard practice at our facility. The primary outcome occurred in 23.3% of the amiodarone prophylaxis group vs. 42% in the standard of care group (OR 0.42, 95% CI 0.15-1.14, p=0.09). There were no significant differences in the average time to postoperative Afib (78.8 hrs vs. 70 hrs, p=0.13) and average length of hospital stay (172.1 hrs vs. 154.2 hrs, p=0.39). Rates of post-discharge atrial arrhythmias were 13.3% in amiodarone group vs. 4.0% in standard of care (p=0.13). In the amiodarone prophylaxis group, 3 patients discontinued amiodarone therapy, and 4 patients required a dose-reduction in amiodarone due to reported hypotension, heart block, and nausea.

Conclusions: The use of oral amiodarone prophylaxis may provide a strategy to reduce the incidence of atrial fibrillation after cardiac surgery. This intervention was well tolerated, though it would require further investigation to achieve statistical significance.

Title: Correlation of 4T, m4T, and LLL Scores with Positive Heparin-induced Platelet Antibodies and Serotonin Release Assays in Cardiac Surgery ICU Patients
 
Authors: Alese Photiadis, Michelle Dillon, Danielle McPherson
 
Objective: Evaluate the accuracy of diagnostic scoring tools used to predict heparin-induced thrombocytopenia (HIT) in cardiac surgery (CS) and mechanical circulatory support (MCS) patients.
 
Background/Purpose: HIT occurs in up to 5% of patients exposed to heparin. HIT is characterized by a significant fall in platelet count and a hypercoagulable state. Diagnostic scoring tools exist to risk stratify patients prior to ordering laboratory assays, which are limited by either low sensitivity or delayed turnaround times. CS and MCS patients receive large heparin doses and have other significant reasons for thrombocytopenia. This project aims to assess the accuracy of diagnostic scoring tools used to predict HIT in CS and MCS patients.
 
Methodology: This single center, retrospective study included adult CS and MCS patients with a positive heparin-induced platelet antibody result from August 1, 2022, to December 31, 2024. Patients were identified via reporting tools within the Epic Hyperspace platform. Patient demographic information was collected. Patients were allocated based on whether they underwent cardiac surgery only (CS Group), MCS only (MCS Group), or required a combination of CS and MCS (CS-MCS Group). Types of CS and MCS, platelet count, serotonin release assay (SRA) result, duration of heparin therapy, duration of cardiopulmonary bypass (CPB), presence of additional medications implicated in causing thrombocytopenia, time to initiation of bivalirudin, and presence of thrombus were also collected. The primary was the negative predictive values of each of the diagnostic scoring tools (4T, m4T, and LLL scores) in the CS, MCS, and CS-MCS groups. Patients were stratified into risk-categories based upon their score from each of the diagnostic scoring tools. The NPV was then calculated from the true and false negatives.
 
Results: One hundred fifty-eight patients were screened and 92 met inclusion with 28 in the CS Group, 44 in the MCS Group, and 20 in the CS-MCS Group. The most common reasons for exclusion were duplicate patient identifiers, veno-venous extracorporeal membrane oxygenation support, and labs drawn prior to surgery or MCS initiation. The negative predictive value (NPV) for the 4T score in the CS group was 100% for low-risk and 64% for intermediate risk patients. For the m4T score, the NPV was 90% and 80% for the low and intermediate risk groups, respectively. The NPV for the LLL score in the CS group was 100% and 74% for the low and high-risk categories. For low-risk patients in the MCS Group, the NPV of the 4T and m4T scores were 97% and 92%.  For intermediate risk patients, the NPV of the 4T and m4T scores was 80% and 89%. There were no patients in the MCS Group who were classified as high risk by either score. The NPV for the 4T score in the CS-MCS group was 82%, and 63% for the low and intermediate risk categories.  As for the m4T, the NPV in the CS-MCS group was 100%, and 80% for the low and intermediate risk categories. The NPV for the LLL score in the CS-MCS group was 67% and 60% for the low and high-risk categories.
 
Conclusion: In this study, the m4T score had the highest NPV for those undergoing cardiac surgery procedures; however, for low risk stratified patients, all three tests were reliable in ruling out HIT. In the mechanical circulatory support group, both the 4T or m4T score had high NPVs. The m4T was more reliable in the joint cardiac surgery and mechanical circulatory support group.

Presentation Objective: Evaluate the accuracy of diagnostic scoring tools used to predict heparin-induced thrombocytopenia (HIT) in cardiac surgery (CS) and mechanical circulatory support (MCS) patients

Self-Assessment Question: Based on this study, which diagnostic scoring tool(s) is the best in CS, MCS, and CS + MCS patients to rule out HIT?
A. 4T score
B. m4T score
C. LLL score
D. All the above

Safety outcomes with cangrelor versus eptifibatide in patients undergoing periprocedural bridging
Angkear Khorn, Matt Bibb, Kelley Baxter
Ascension Saint Thomas Hospital West, TN


Objective: Evaluate the safety of cangrelor versus eptifibatide for periprocedural IV bridging in cardiac surgery patients focusing on bleeding risk categorized by the  Global Use of Strategies to Open Occluded Arteries (GUSTO) criteria


Self Assessment question: Does the choice of IV bridging agent (cangrelor or eptifibatide) impact bleeding risk in patients undergoing periprocedural cardiac procedures?


Background/purpose:  Periprocedural bridging with intravenous (IV) antiplatelet agents is essential for patients undergoing cardiac surgery to prevent thrombotic events while minimizing bleeding risks. Cangrelor and eptifibatide are commonly used IV bridging agents, but limited data directly compare their safety profiles. This study evaluates the bleeding risk associated with both agents using the GUSTO criteria and assesses secondary outcomes, including transfusion requirements, hospital length of stay, and cost. 


Methodology: This study was a single-center retrospective chart review conducted at Ascension Saint Thomas Hospital West (ASTHW) to evaluate the safety outcomes of cangrelor versus eptifibatide in patients undergoing periprocedural bridging for cardiac procedures. The study included patients who received eptifibatide between July 22, 2018, and July 21, 2021, and those who received cangrelor between July 22, 2021, and July 21, 2024. Patients were included if they required intravenous bridging with either agent for a planned cardiac procedure. Exclusion criteria included patients with a documented allergy to either agent, those receiving the medication for indications other than cardiac bridging, pregnant individuals, and incarcerated patients. The primary outcome assessed was the incidence of bleeding events classified using the GUSTO criteria, while secondary outcomes included transfusion requirements, post-bridge length of stay, bridging duration, and cost analysis.


Results: A total of 268 patients were screened, with 66 meeting the inclusion criteria (31 in the eptifibatide group and 35 in the cangrelor group). Baseline characteristics were similar between groups, with a slightly higher proportion of male patients in the cangrelor group (78%) compared to the eptifibatide group (69%), but no significant differences in age, renal function, comorbidities, or types of cardiac procedures. There was no significant difference in bleeding events between the two groups as assessed by the GUSTO criteria. Secondary outcomes showed that transfusion requirements were higher in the eptifibatide group (42%) compared to the cangrelor group (20%), though this difference did not reach statistical significance (p = 0.053). The median post-bridge hospital length of stay was similar between groups, with cangrelor patients staying a median of 4 days (IQR 5-12) and eptifibatide patients staying 2 days (IQR 1-6, p = 0.884). Bridging duration was also comparable, with a median of 3 days (IQR 2-4) for cangrelor and 2 days (IQR 1-2) for eptifibatide (p = 0.180). However, cost analysis revealed a significant difference, with cangrelor being substantially more expensive per patient (median $3,797, IQR $1,145-$5,727) compared to eptifibatide ($1,847, IQR $938-$2,345, p = 0.0043). 


Conclusions: In this study, we observed that cangrelor and eptifibatide had no significant difference in bleeding outcomes for periprocedural cardiac bridging. Both agents showed similar bridging durations and hospital stays, though cangrelor was significantly more expensive. While eptifibatide had a trend toward higher transfusion requirements, it was not statistically significant. Cost considerations should guide agent selection and further prospective studies are needed to validate these findings.

Title: Use of SGLT2 Inhibitors in Heart Failure Patients Requiring Renal Replacement Therapy 
Authors: Meggie Gilkey, PharmD, Lindsay Reulbach, PharmD, BCPS, Jessica Howington, PharmD, Andi Ray, PharmD, BCCP
Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors, initially studied for type 2 diabetes, were found to reduce heart failure (HF) hospitalizations and cardiovascular death in both heart failure (HF) with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) populations. Additionally, they slow renal disease progression by 35–50%. As SGLT2 inhibitors become central to guideline-directed medical therapy (GDMT), their role in patients with concurrent HF and chronic kidney disease (CKD) has drawn attention. Concerns remain regarding use in severe CKD, especially among those on renal replacement therapy (RRT). To address this gap, we conducted a study evaluating the real-world safety and efficacy of SGLT2 inhibitors in HF patients requiring RRT.
Methods: A single-center, retrospective, observational, cohort study was conducted at Prisma Health Greenville Memorial Hospital. Patients 18 years or older admitted for HF who received an SGLT2 inhibitor and required RRT between October 1, 2023, and June 30, 2024, were included. Patients were monitored for outcomes over six months post-index hospitalization. HF-related admissions were identified using emergency department (ED) diagnoses, and RRT status was determined via nephrologist progress notes. Exclusion criteria included type 1 diabetes, pregnancy, non-HF SGLT2 inhibitor use, recent RRT initiation, RRT nonadherence, or malignancy. The primary outcome was SGLT2 inhibitor related adverse events. The secondary outcome assessed HF-related ED visits or hospitalizations.
Results: A total of 725 patients were screened and 7 were included. All patients received empagliflozin during their hospitalization. RRT was split between hemodialysis (57.1%) and peritoneal dialysis (42.8%). One patient (14.3%) experienced an SGLT2 inhibitor related adverse event, resulting in an ED visit 16 days post-index hospitalization. The adverse event was a urogenital infection in a patient with a known history of frequent urinary tract infections. No episodes of diabetic ketoacidosis, hypoglycemia, or hypotension were observed. No hospitalizations occurred due to SGLT2 inhibitor-related adverse events. Two HF-related hospitalizations occurred during the 6-month follow-up. One patient (14.3%) died during the study period, although the death was not related to SGLT2 inhibitor therapy or HF exacerbation.
 Conclusion: This real-world, observational study provides preliminary insight into the safety and efficacy of SGLT2 inhibitors in HF patients requiring RRT. Although limited by a small sample size, the findings suggest that SGLT2 inhibitors may be well tolerated, with minimal adverse events and potential benefit in reducing HF-related hospitalizations. However, due to the observational nature and limited scope of the study, no definitive conclusions can be drawn. Larger, controlled studies are needed to better understand the role of SGLT2 inhibitors in this high-risk population and to inform clinical decision-making with greater confidence.

Title: Assessment of Intravenous Sotalol Loading Usage in a Veterans Affairs Medical Center


Authors: Justin Barnett, Rebecca Holt, and Cynthia Pohland


Background: Atrial fibrillation (AF) affects up to six million Americans, with approximately 15% of those being veterans. AF can be managed pharmacologically with rate control or rhythm control strategies. Sotalol is a non-selective beta-blocker with potent potassium channel blocking properties and can be used for pharmacological rhythm control.  Sotalol is typically initiated in a health care facility capable of creatine clearance calculation, continuous electrocardiographic monitoring, and cardiac resuscitation to ensure safety during the loading phase. Loading with oral sotalol tablets requires at least 3 days in an appropriate health care facility; however, loading with sotalol intravenous (IV) solution can be achieved in 1 day. The purpose of this quality assurance project is to assess the effects of IV versus oral sotalol loading on hospital length of stay in the James H. Quillen VA Medical Center (JHQVAMC) and to assess the facility’s initiation of sotalol in accordance with monitoring recommendations to identify areas for improvement in the medication use process. 


Methods: This project will identify patients who were initiated on sotalol in the JHQVAMC. Hospital length of stay will be determined as the time from sotalol initiation until the time of discharge. Serum electrolytes (potassium and magnesium), serum creatinine, creatinine clearance, heart rate, QTc interval, and heart rhythm will also be assessed at baseline, during sotalol loading, and after sotalol loading prior to hospital discharge. These electrocardiogram and electrolyte parameters will be evaluated for appropriateness as recommended by manufacturer package labeling, guideline recommendations, and expert opinion for sotalol monitoring. 


Results: In progress


Conclusion: In progress

TITLE: Impact of Prior Beta-Blocker Use on Antihypertensive Escalation in Acute Ischemic Stroke 
 
AUTHORS: Shivani Patel PharmD, Kirbie Wells PharmD
 
OBJECTIVE: To identify the impact of home beta blocker use and its effect on labetalol for achieving blood pressure targets prior to administration of tissue plasminogen activator (tPA) in acute ischemic stroke patients at a rural community hospital. 
 
SELF ASSESSMENT QUESTION: What is the primary clinical concern when managing blood pressure in acute ischemic stroke (AIS) patients who are on beta-blocker therapy at home prior to alteplase (tPA) administration? 
A) Increased risk of hemorrhagic transformation due to excessive blood pressure lowering. 
B) Potential need for escalation to alternative antihypertensive agents after labetalol. 
C) Decreased efficacy of thrombolytic therapy due to beta-blocker-induced vasoconstriction. 
D) Higher likelihood of spontaneous blood pressure normalization without intervention. 
 
BACKGROUND: Stroke is a leading cause of mortality and disability in the U.S., with the highest burden in the Southeastern "stroke belt," where rural areas like Southwest Georgia face barriers to specialized care. In acute ischemic stroke (AIS), timely blood pressure control is crucial before alteplase (tPA) administration to reduce the risk of hemorrhagic transformation. The AHA/ASA recommends lowering systolic BP to <185 mmHg and diastolic BP to <110 mmHg using labetalol, hydralazine, or nicardipine, without specifying a preferred agent. However, prior beta-blocker use may reduce labetalol’s effectiveness due to beta-adrenergic receptor downregulation, necessitating escalation to other agents. This study evaluates whether outpatient beta-blocker use influences the need for additional antihypertensive therapy in AIS patients, potentially guiding personalized stroke management strategies.

METHODOLOGY: This study was a retrospective chart review which included adult patients diagnosed with acute ischemic stroke who had an initial SBP >185 mmHg or DBP >110 mmHg and received labetalol for blood pressure control prior to tPA administration treated at Phoebe Putney Memorial Hospital (PPMH) from January 2019 to December 2023. Patients were excluded if they were pregnant or transferred from another healthcare institution.  
 
RESULTS: A total of 199 patients were included: 65 with prior beta-blocker (BB) use and 134 without. The prior BB group was slightly younger (62 vs. 64.8 years) and heavier (96.6 vs. 83.2 kg). Stroke severity was similar between groups, with the prior BB group having a slightly higher percentage of severe strokes (15.4% vs. 12.7%). More patients with prior BB use required additional antihypertensives (37.5% vs. 19%). The interquartile range for door-to-needle time was 30.5–69 minutes, and for blood pressure control, 19.4–58.3 minutes. Severe hypotension occurred in 4.6% of the prior BB group and 9.7% of the no BB group. Intracerebral bleeding occurred in 6.2% of the prior BB group and 3.7% of the no BB group.
 
CONCLUSIONS: Patients on prior beta-blockers were more likely to require escalation to nicardipine or hydralazine for blood pressure control before Alteplase administration. These findings suggest that prior beta-blocker use may reduce the effectiveness of labetalol, necessitating a more individualized approach to antihypertensive management. Future studies should explore whether alternative first-line strategies could improve blood pressure control efficiency and minimize complications, particularly in resource-limited settings.

Evaluation of VTE Prophylaxis in Trauma Patients at a Large Community Hospital
Authors: Sarah Skaggs Gatewood and Jerry Robinson
Objectives:

1. Identify current recommendations for proper VTE prophylaxis in trauma patients.
2. Explain the implementation of guideline directed VTE prophylaxis management.
3. Compare VTE event rates before and after implementation.

Background/Purpose: In 2022, the American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma published a clinical protocol with updated recommendations for inpatient venous thromboembolism (VTE) prophylaxis after trauma.  The dosing of enoxaparin for VTE prophylaxis in trauma patients at Huntsville Hospital did not match these recommendations. Trauma patients are at an increased risk of VTE, including deep vein thrombosis and pulmonary embolism. Pharmacologic and mechanical VTE prophylaxes are often necessary to decrease the risk of thromboembolic events after a trauma occurs. This project seeks to explore previous institution-specific dosing based on age, renal function, and other factors, compared to updated dosing to match 2022 recommendations.
Methods: This single-center, pre-post implementation, quasi-experimental study evaluated adult patients 18 years of age or older admitted to Huntsville Hospital under the care of trauma services from January 1st, 2024, to January 31st, 2025. Data was collected from the electronic health record (EHR) and analyzed using descriptive statistics. The following pre-intervention and post-intervention data were collected: patient demographics, hospital length of stay, renal function, VTE prophylaxis dosing, lab monitoring, and risk factors. Patients were excluded if they had a length of stay less than 72 hours, did not receive any mechanical VTE prophylaxis, or if they transferred to a long-term facility. A classification of patients was made based on current VTE prophylaxis guidelines after the trauma algorithm published by the American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma1. The primary endpoint was appropriate compliance with the 2022 algorithm for VTE prophylaxis post-trauma. Efficacy was assessed via anti-Xa monitoring, targeting a range of 0.2-0.4 units/mL, with 10 mg dosing adjustments for levels outside this range.  Secondary endpoints included composite rates of deep vein thrombosis and pulmonary embolism, patient length of stay, days on VTE prophylaxis, and adverse drug events (ADEs) related to enoxaparin administration. Hospital-specific data and current policies were reviewed to identify areas of improvement, which included adherence to practice guidelines for VTE prophylaxis in trauma patients. Post-intervention data included the same metrics as listed for the pre-implementation data set. An ongoing quality review was performed in the post-intervention phase to identify potential changes and ensure compliance.
Results: A total of 160 patients (mean age, 50 years) were studied, 80 in the pre-implementation group and 80 in the post-implementation group, with similar baseline characteristics, risk scores, overall length of stay, and days on VTE prophylaxis between groups. Adherence to guidelines was noted to be overall 44% in the pre-implementation group and 84% in the post-implementation group for all patients included. No anti-Xa levels were checked in the pre-implementation phase. In the post-implementation phase, target range anti-Xa levels were achieved in 53 out of 80 patients (87%), with 43 patients (70%) having their first level within the target range. The incidence of VTE events was similar between groups but lower in the post-implementation phase, with only 9% of patients experiencing VTE events versus 13% in the pre-implementation phase.
Conclusion: The implemented order set and ongoing feedback integration lead to successful protocol implementation. Overall compliance with the 2022 published algorithm for post-trauma venous thromboembolism prophylaxis was achieved in 84% of patients. Anti-Xa monitoring post implementation occurred in 87% of patients versus zero prior to implementation. VTE events were less in the post implementation phase as well. An ongoing review will be continued to evaluate ordering options as well as opportunities to optimize monitoring and adherence.
Self-Assessment Question:
What is the primary purpose of anti-Xa monitoring in patients?

1. To assess renal function
2. To evaluate anticoagulant effect of current dosing strategy for effectiveness and safety
3. To monitor for potential allergic reactions
4. To check for the development of deep vein thrombosis (DVT)

IMPACT OF A MULTIDISCIPLINARY TEAM IN THE MANAGEMENT OF SUBJECTS WITH HEART FAILURE
Nicole DeLalla, Athena Colon, Richard Lane, Reginald Leandre, Tracey Dobbs
AdventHealth Apopka – AdventHealth Apopka, Florida, FL
Background: In 2024, nearly seven million individuals in the United States were diagnosed with heart failure.1,2 The resulting healthcare-related expenditure for treatment of this disease state has been calculated at over $3 million.1,2 In order to improve clinical outcomes, studies have shown that guideline-directed medical therapy (GDMT) can increase survival rates by 6.3 years. Additionally, GDMT has the potential to alleviate financial burden as a single heart failure-related hospitalization can cost about $15,000. 3,4 A study by Fallon and colleagues found that taking an interdisciplinary approach to heart failure management resulted in a 6% decrease in 30-day recurrent admissions in this patient population.5 However, there are limited studies focusing on how inpatient interventions affect rehospitalizations.
Methods: This was a single-center, retrospective chart review conducted at AdventHealth Apopka between July 1st, 2024 to December 31st, 2024. Included subjects were 18 years of age or older with a diagnosis of heart failure with reduced ejection fraction (HFrEF), defined as ejection fraction (EF) less than 40%. The exclusion criteria were subjects with an EF of 40% or greater, a history of a heart transplant, or planned heart transplant at the time of index visit. The primary objective was to assess the impact of a multidisciplinary heart failure management team on 30-day readmission rates. Secondary objectives included 30-day cardiovascular-related readmission, 30-day all-cause mortality, dose optimization defined as dose titration of GDMT medications or addition of at least one GDMT medication drug class, and inpatient length of stay (LOS). In addition, safety outcomes evaluated were incidence of acute kidney injury (AKI), hypotension, bradycardia, and hyperkalemia. 
Results: A total of 904 subjects were reviewed. Among those patients 146 subjects were included while 758 subjects were excluded. Baseline characteristics showed mainly white/Caucasian males with an average age was 67 years old. The 30-day readmission rates among the included patients were 33%. The 30-day cardiovascular readmission rate was 14%, and the 30-day all-cause mortality rate was 7%. Beta blockers had the highest incidence of dose titration at 17 %. The highest incidence of GDMT initiation was both beta blocks and diuretics with 27%. The average LOS was about 4.92 days.
Conclusion: In conclusion, this study saw a readmission rate of 33% after a multidisciplinary heart failure management team. When compared to national readmission rate of 25%, there is an eight percent difference in readmission rates to this study.6 This would suggest that there are areas of opportunities to further development of this heart management team.
 
References
HF stats 2024: Heart Failure Epidemiology and ... Accessed February 25, 2025. https://onlinejcf.com/article/S1071-9164(24)00232-X/fulltext.

• Centers for Disease Control and Prevention. Heart Failure. CDC. https://www.cdc.gov/heart-disease/about/heart-failure.html. Published October 14, 2022. Accessed September 11th, 2024
• Martin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association [published correction appears in Circulation. 2024 May 7;149(19):e1164. doi: 10.1161/CIR.0000000000001247]. Circulation. 2024;149(8):e347-e913. doi:10.1161/CIR.0000000000001209   
• Weiss AJ, Jiang HJ. Overview of Clinical Conditions With Frequent and Costly Hospital Readmissions by Payer, 2018. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); July 20, 2021.
• Fallon JM, Anderson K, McElhaney E, Lewis DA, Williams JB. Pharmacy-led optimization of transitions of care in patients with heart failure. J Am Coll Clin Pharm. 2024;7(6):778-786. doi:10.1002/jac5.1982. 

Foroutan F, Rayner DG, Ross HJ, et al. Global comparison of readmission rates for patients with heart failure. Journal of the American College of Cardiology. 2023;82(5):430-444. doi:10.1016/j.jacc.2023.05.040

Title: Safety Outcomes of Tirofiban Weight Based Dosing Strategy in Overweight Patients
Authors: Merrie Barnett-Brock, Audrey Johnson, Sofiya Paciotti
Background: Tirofiban is a GIIb/GIIIa receptor antagonist therapy used for the treatment of myocardial revascularization in non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). Tirofiban dosing is weight based utilizing actual body weight. There is a hole in the literature regarding studies with information regarding safety outcomes in patients >85kg, including obese patients. Specifically, the previous literature lacks any information regarding safety outcomes in obese patients. Current studies show incidence of bleeding ranging from 0.4% to 5%. This is a major gap in the literature that this study hopes to resolve. 
Methods: This IRB-approved, retrospective, single-center cohort study included patients from a 711-bed academic medical center in Savannah, Georgia. Adult patients treated with tirofiban for cardiac conditions at Memorial Health University Medical Center between January 1, 2015 and September 27, 2024 were utilized as the cohort. Other inclusion criteria included receipt of tirofiban ≥1 hour and patients dosed on actual body weight with renal dose adjustment using a creatinine clearance calculation with actual body weight. Patients were excluded if they were a protected population or if the patients were discharged <48 hours from when infusion started. The aim of this study was to assess the safety outcomes of patients with a weight ≥85 kg with a primary outcome of major bleeding defined by the ISTH criteria and secondary outcomes of minor bleeding, mortality, and rescue agents utilized. These outcomes were further assessed amongst subgroups based on BMI, renal function, and weight. The BMI subgroups included 3 categories, category one being BMI <30 kg/ m², category two being BMI 30-40 kg/m², and category three being BMI >40 kg/m². The weight subgroups included three categories, category one being 85-119.9 kg, category two being 120-149.9 kg, and category three being ≥150 kg. 
Results: Of the 304 patients screened, 47 were included in the final analysis. The majority of patients were white males and no patients were found to have renal dysfunction. The median weight observed in the patient population was 98 kg and the median BMI was 30.7 kg/m². We observed a 29.7% incidence of major of bleeding. For the subgroups defined by BMI, major bleeding was found to be 44.4% in the category 1 patients, 17.3% in the category 2 patients, and 33.3% in the category 3 patients. Major bleeding occurred specifically in the weight subgroups with 30.9% of the category 1 patients, 25% of the category 2 patients, and 0% in category 3 patients. Secondary outcomes in the overall cohort included mortality in 2.1% of the population, minor bleeding in 12.7%, and 2.1% of the patients utilized a rescue agent.
Conclusions: This retrospective study provides descriptive information regarding major bleeding occurrences in patients weighing ≥85 kg where both BMI and weight subgroups were observed. We observed 29.7% of the patient population experienced major bleeding. These findings demonstrate that further research with adequately powered studies are needed to show the incidence of major bleeding amongst higher weight patients receiving tirofiban. 
Disclosures: "This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities."
Best contact point for follow up of interested participants: merrie.barnettbrock@hcahealthcare.com

Title: Evaluation of a heparin calculator best practice alert (BPA) implementation at a multi-hospital health system 
Authors: Brittaney-Ann Simpson, Kirsten DiPiro, Ambra Hannah, Jerri Jenkins  
Objective: Describe the use of a heparin infusion calculator dose mismatch Best Practice Alert (BPA) within a health system  
Self Assessment Question:
Background: The electronic heparin calculator has demonstrated benefits in reducing medication errors by minimizing manual calculations in the hospital setting. At Wellstar Health System, heparin infusion initiation and maintenance follow a nurse-driven protocol.  This study evaluated the effectiveness of the heparin infusion calculator dose mismatch Best Practice Alert (BPA) in improving adherence to the heparin calculator and its impact on correct dosing and therapeutic efficacy.  
Methods: A multicenter retrospective chart review was conducted analyzing adult patients who received a heparin infusion 90 days before BPA implementation (May 24, 2023 to August 22, 2023) and 90 days after (October 1, 2023 to December 30, 2023).  Patients were included if they exceeded the maximum starting dose requiring a weight-based heparin infusion adjustment (weight >83.3 kg on low/neuro dose heparin and >125 kg on high dose heparin). Patients were excluded if the heparin infusion was initiated in a procedural area, ordered outside of the heparin order sets, restarted after interruption, or continued on Xa monitoring after receiving a direct oral anticoagulant within 72 hours of heparin initiation. Additionally, patients were excluded from therapeutic efficacy calculations and safety measures if the heparin infusion was less than 24 hours. The primary outcome was to evaluate the impact of the BPA on adherence to heparin calculator weight-based dosing on initiation of a heparin infusion. The secondary outcome evaluated the time to therapeutic heparin levels while safety outcomes assessed major and minor bleeding events. 
Results: A total of 212 patients were included in each study arm. Between both study groups, the majority of patients received low-dose heparin (82%), with acute coronary syndromes being the most common indication (41.7%). The BPA was triggered 33 times in the post-implementation cohort, with an acceptance rate of 84.8% (28 cases). Incorrect initial heparin rates were significantly lower in the post-BPA group at 2.5% (n=5) compared to 6.8% (n=13) in the pre-BPA group (P=0.008). For secondary outcomes, the mean time to achieve the second therapeutic level was similar between groups (27 hours; P=0.53). There was no statistically significant difference in major and minor bleeding events (P=1.0 and P=0.49, respectively).
Conclusions: Implementation of the heparin calculator BPA was associated with improved compliance with starting the correct infusion rate for patients that exceeded the max rate based on weight.  No correlation was observed between heparin calculator compliance and the time to therapeutic levels or bleeding events. Further studies are needed to assess the BPA’s impact on heparin infusion rate adjustments over time.

Title: Injectable Glucagon-Like Peptide-1 Receptor Agonists and Cardiovascular Outcomes in Patients Without Diabetes in Outpatient Cardiology Clinics
 
Authors: Kristina Benbow, Madison Burke, Lauren Schultz, Marina Carter, Deborah Hurley, Benjamin Tabor
 
Background: Glucagon-Like Peptide-1 (GLP-1) receptor agonists have emerged as clinically significant treatment options for type 2 diabetes, obesity, and cardiovascular (CV) risk reduction. To date, Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes (SELECT Trial) is the only trial to comprise of non-diabetic patients with preexisting CV disease defined as myocardial infarction, stroke, or symptomatic peripheral artery disease. In this trial, semaglutide was superior to placebo in reducing a CV composite of death from CV causes, nonfatal myocardial infarction, and nonfatal stroke. This study explores an expansion of the inclusion criteria used in the SELECT Trial, using a large outpatient cardiology population. 
 
Methods: This retrospective cohort study includes adult patients prescribed injectable GLP-1 receptor agonists followed by Prisma Health Cardiology between January 2022 and April 2023. Data was collected through April 2024. Patients were assigned to the control group if they never filled the medication with all other patients considered the intervention group. The primary outcome is a composite of death from cardiovascular causes, nonfatal myocardial infarction, and nonfatal stroke. Secondary outcomes include total change in patient health variables (body weight, blood pressure, cholesterol, hemoglobin A1c), hospitalization or urgent medical visit for heart failure, and death from any cause. Descriptive statistics, stratified analyses (control vs intervention group), and multivariable logistic regression will be used to summarize the data and to evaluate the association of GLP-1 use and risk of death and other non-fatal cardiovascular outcomes.
 
Results: 123 patients without diabetes were prescribed a GLP-1 receptor agonist, 83 received the medication (intervention) and 40 did not (control). The primary endpoint did not differ between study arms, with no occurrences of death from CV cause or nonfatal stroke in either group. There was a nonsignificant trend in the control group for nonfatal MI (n=2 control, n=0 intervention; p=0.104). There were no occurrences of death from any cause and hospitalization or urgent medical visit for heart failure between groups. Secondary outcomes reflected a statistically significant reduction for intervention group in body weight (-1.0 kg control, -8.4 kg intervention; p<0.001), BMI (-0.2 kg/m2 control, -3.2 kg/m2 intervention; p<0.001), LDL (+1.4 mg/dL control, -34.1 mg/dL intervention; p<0.001), systolic blood pressure (+1.4 mmHg control; -7.9 mmHg intervention; p<0.001), and diastolic blood pressure (+1.2 mmHg control; -5.4 mmHg intervention; p=0.003). There was no difference in change in A1c between arms (0.0 ± 0.9 control, 0.0 ± 0.3 intervention; p=0.374).

Conclusions: Although unable to find a statistically significant difference in the composite primary endpoint, secondary cardiovascular outcomes favored the use of GLP-1 receptor agonists in patients without diabetes. There was a statistically significant lowering of known cardiovascular risk factors, including body weight, LDL, and blood pressure. Limitations of this study include a small study size which does not allow for true evaluation of primary endpoint, inclusion of patients irrespective of adherence to the GLP-1 receptor agonist or changes to background medications, and lack of available laboratory data points for many patients (notably, A1c and LDL). Unlike the SELECT Trial which looked exclusively at patients with a past medical history of MI, stroke, or symptomatic peripheral artery disease, this study was able to find CV benefit in a population both without CV history and in patients with coronary artery disease, all who were baseline close to having controlled/goal labs and vitals. Ultimately, this data helps advocate for insurance approval of GLP-1 receptor agonist in patients without diabetes secondary to their CV benefit.

EVALUATION OF PROTAMINE DOSING STRATEGIES FOLLOWING CARDIOPULMONARY BYPASS
Justine Bur, Amanda Sowder, Hetal Patel
AdventHealth Orlando-Orlando, FL


OBJECTIVE: Compare the impact of low, medium, or high protamine dosing on bleeding outcomes following cardiopulmonary bypass assisted cardiac surgery.


BACKGROUND: Protamine is used to reverse the anticoagulant effects of heparin after cardiopulmonary bypass (CPB). Improper dosing of protamine may lead to increased postoperative bleeding. Although it is paramount to have an appropriate protamine-to-heparin dosing ratio, evidence remains weak on guiding optimal dosing and inconsistencies exist between guidelines. At our institution, protamine dosing is routinely based off the initial heparin bolus. To our knowledge, no studies have compared protamine-to-heparin dosing ratios in otherwise healthy patients undergoing initial, elective CPB-assisted cardiac surgery. 


METHODS: A single centered, retrospective analysis was performed at a major tertiary referral hospital. Healthy adults aged 18 to 75 years old who underwent CPB-assisted coronary artery bypass graft or valve repair or replacement, with or without concomitant left atrial appendage ligation, MAZE, or myectomy were included. Exclusion criteria included chronic kidney disease or dialysis, liver dysfunction, hematologic disorders, pregnancy, or cancer. Patients were also excluded if they received non-packed red blood cell products in the operating room (OR). Primary endpoints included 24-hour chest tube output and 24-hour postoperative allogeneic transfusion requirements. Secondary endpoints included reintubation within 24 hours and operative re-exploration within 24 hours due to postoperative bleeding. All endpoints were measured after disposition from OR to the intensive care unit. Outcomes were evaluated based on low (<1:1), medium (1:1), and high (>1:1) protamine-to-heparin dosing ratios based on initial heparin and protamine boluses administered.


RESULTS: Seventy of the 267 patients screened between February 2023 and January 2025 were included in the analysis. Patients were median age 60 years, median BMI of 28.6 kg/m2 and 42 (60%) were male. At baseline, median pre-operative labs included: hemoglobin 13.6 g/dL, hematocrit 40.3%, platelets 240,000/μL, ACT 107 seconds, INR 1.0 and aPTT 29.6 seconds. Mitral valve replacement, 37 (53%), and repair, 15 (21%), were the most common cardiac surgeries. Median bypass time was 82 minutes. Median heparin and protamine boluses administered were 36,000 units and 320 mg, respectively. Protamine-to-heparin dosing ratios were characterized as follows: 32 (46%) patients comprised low, 28 (40%) comprised medium, and 10 (14%) comprised high. Twenty-four-hour chest tube output for low, medium, and high dose groups totaled 468, 530, and 850 mL, respectively (p=0.136). Of the 36% of patients who received transfusions, median total volume of transfusions for low, medium, and high dose groups were 506, 349, and 473 mL, respectively (p=0.936). No patients were reintubated due to postoperative bleeding within 24 hours and one patient in the high dose group returned to the OR for re-exploration for postoperative bleeding. Lastly, the median time to extubation of low, medium, and high dose groups was 226, 188, and 351 minutes, respectively (p=0.052).


CONCLUSION: This is the first study evaluating association of protamine-to-heparin dosing ratios with bleeding outcomes in otherwise healthy patients undergoing initial, elective CPB-assisted cardiac surgery. Despite the small sample size, there was a trend in increased post-operative 24-hour chest tube output as the protamine-to-heparin ratio increased. Although time to extubation did not statistically differ between groups, the greater time to extubation experienced by the high dose protamine group presents a clinically interesting finding for further exploration.