PSHP 2026 Residency Conference

Purpose
 Evaluate the characteristics of patients started on intravenous heparin for a thrombotic indication that experienced PTT prolongation at Jefferson Einstein Philadelphia Hospital.
 
Methods
This study included patients at least 18 years old that received heparin for a thrombotic indication and had at least 48 hours of PTTs available in their chart. Prolonged PTT was defined by two or more PTT values greater than 112 seconds within 48 hours of heparin. If patients experienced a prolonged PTT, they were evaluated to determine if a bleeding event had occurred within 48 hours of heparin. Patients were excluded if they were pregnant at data collection. The primary endpoint was a multivariable analysis of characteristics that predisposed patients to prolonged PTTs, including hypertension, abnormal renal and/or liver function, previous stroke, history of bleed, baseline PTT 1.5 times the upper limit of normal, age, alcohol use disorder, body mass index, male sex, bolus on initiation, black race, and thrombolytic or anticoagulant use within 48 hours of heparin initiation. The secondary endpoint was the incidence of bleeding with prolonged PTT.
 
Results
Data was analyzed using GraphPad Prism 10.6.1. Out of 344 patients, 58 (16.9%) did not experience PTT prolongation. Baseline characteristics between both groups were similar. PTT 1.5 times the upper limit of normal (5.8, 95% CI [1.1-107], p=0.04) was the only variable associated with PTT prolongation. All other variables were considered statistically nonsignificant. Among the 286 patients (83.1%) that experienced PTT prolongation, 65 patients (22.7%) experienced a bleeding event within 48 hours of heparin initiation.
 
Conclusion/Summary
This study with 344 patients found that a baseline PTT 1.5 times the upper limit of normal is associated with PTT prolongation. Limitations include single-center, retrospective nature, and small sample size. Future steps include conducting a study using a nomogram with conservative heparin dosing in this cohort of patients with PTT prolongation at baseline and more frequent monitoring to prevent adverse outcomes.

Purpose: To compare the safety and efficacy of enoxaparin versus unfractionated heparin for venous thromboembolism prophylaxis in hospitalized patients with chronic liver disease by evaluating in-hospital bleeding and thromboembolic events.
Methods: This retrospective, single-center cohort study included adult patients (> 18 years) with a documented diagnosis of cirrhosis or chronic liver disease as identified by relevant ICD-10 codes from January 2020 to June 2025 that have received VTE prophylaxis with UFH or enoxaparin during hospitalization. The data collected includes baseline patient characteristics, admission diagnosis, prior to admission medications, important baseline laboratory values, MELD score, Child-Pugh score, VTE and bleed risk assessment tools, and VTE prophylaxis administered. The primary endpoint is the incidence of in-hospital bleeding events. Secondary endpoints include incidences of in-hospital International Society on Thrombosis and Haemostasis (ISTH) major and minor bleeding, in-hospital VTE events, drug discontinuations due to thrombocytopenia or anemia, and mortality. Data analysis was completed using descriptive statistics.
Results: A total of 82 patients were included (enoxaparin n=46; UFH n=36). Baseline demographics, laboratory values, and liver disease severity were similar, with median age 60 years and most patients classified as Child-Pugh C. All patients were high VTE risk by PADUA and IMPROVE scores. New bleeding events occurred in 8.6% with enoxaparin and 5.6% with UFH. Major bleeding occurred only with UFH (5.6%), while minor bleeding occurred only with enoxaparin (8.6%). VTE events were rare and comparable (2.2% vs 2.7%). Therapy discontinuation for non-bleeding events was more frequent with enoxaparin (32.6% vs 22.2%). In-hospital mortality was numerically lower with enoxaparin (6.5% vs 13.8%).
Conclusion: In hospitalized patients with cirrhosis requiring VTE prophylaxis, enoxaparin demonstrated similar efficacy to UFH in preventing thromboembolic events. Although bleeding occurred more often with enoxaparin, events were minor and did not require discontinuation of therapy, whereas fewer but more severe bleeding events were seen with UFH. These findings suggest that enoxaparin may be a safe alternative, though larger prospective studies are needed.

Purpose: Evaluate the impact of inpatient pharmacist interventions on SGLT2 inhibitor initiation in hospitalized heart failure patients and compare pre- and post-intervention rates, pharmacist involvement, barriers, and 30-day readmissions. 
 
Methods: This retrospective, pre- and post-quality improvement study included adult patients hospitalized with heart failure over two six-week periods. Data collected included demographics, heart failure classification, laboratory values, guideline-directed medical therapy (GDMT), pharmacist interventions, and 30-day readmissions. The intervention consisted of increased inpatient pharmacist involvement through chart review, documentation, medication recommendations, discharge counseling, and assistance with medication access. Statistical analyses included chi-square tests for categorical variables and t-tests for continuous variables.
 
Results: A total of 164 pre- and 170 post-intervention patients were included. Baseline demographics and clinical characteristics were similar between groups. Pharmacist interventions significantly increased from 7.3% pre-intervention to 21.3% post-intervention (p<0.001).
 
SGLT2 inhibitor use at discharge remained similar between groups (28.0% vs 27.2%, p=0.866), and initiation rates during hospitalization did not significantly change (12.2% vs 12.4%, p=0.949). Other GDMT utilization also showed no statistically significant differences.
However, 30-day readmission rates increased from 34.8% pre-intervention to 48.5% post-intervention (p=0.011). Barriers to SGLT2 inhibitor initiation were similar between groups (32.9% vs 30.8%).
 
Conclusion: Inpatient pharmacist involvement significantly improved documentation and intervention rates but did not result in increased SGLT2 inhibitor initiation. Despite enhanced pharmacist engagement, no reduction in 30-day readmissions was observed. These findings show persistent barriers to therapy initiation suggesting additional strategies beyond pharmacist intervention may be necessary to improve clinical outcomes in heart failure patients.
 
Authorship: 
Katherine Ghattas, PharmD; James Helms, PharmD, BCPS; Bonny Brownstein, PharmD, BCPS, BCPPS