2026 Southeastern Residency Conference

Optimization of Guideline-Directed Medical Therapy in Veterans Hospitalized with an Acute Heart Failure Exacerbation
Benjamin Brewer, Mary Martin McGill
Birmingham VA Health Care System-Birmingham, AL
Background/Purpose: Recent guidance for treatment of heart failure with reduced ejection fraction (HFrEF) states that patients with HFrEF should have guideline-directed medical therapy (GDMT) initiated and then titrated to maximum dose as quickly as possible . Previous studies have shown inpatient titration of GDMT is safe. The purpose of this study is to evaluate the difference in 30-day readmission rate in patients with HFrEF hospitalized with an acute heart failure exacerbation in patients who have GDMT optimized in order to obtain current real world data GDMT usage and evaluate how GDMT utilization at discharge effects patient outcomes.
Methodology: This will be a retrospective observational chart review conducted by reviewing medical records of patients hospitalized with an acute heart failure exacerbation between 3/15/2025 and 9/24/2025. Inclusion criteria will include admission for heart failure exacerbation and documented ejection fraction (EF) < 40%. Exclusion criteria will include patients discharge to palliative care or patients undergoing dialysis. Patients with more than two admissions will only have the first readmission counted. Readmissions were not counted if for non-HFrEF indication. GDMT is considered an angiotensin converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNi), HF-specific beta blocker (BB), mineralocorticoid receptor antagonist (MRA) and sodium glucose cotransporter 2 inhibitor (SGLT2i) at maximum tolerated doses. Medication reconciliation on admission will be compared to the discharge medication list given to the patient. Patients will be grouped by whether GDMT medication was titrated or if therapy was not escalated.
Results: There were 140 patients reviewed and 65 met inclusion criteria. Of those 65 patients included in the study 32 had GDMT titrated at discharge and 33 did not have GDMT titrated at discharge.  Nine (28%) patients in the optimized group were readmitted within 30-days and 6 (18%) patients were readmitted from the non GDMT optimized group (Relative Risk: 1.40; p-value: 0.40). Patient population is underpowered for statistical significance, but increased readmission rates could indicate clinical significance. Of the patient’s who had GDMT titrated,  the most  commonly titrated medication group was SGLT2i. They were optimized in 14 (44.8%) patients, next were BB and ACEi/ARB/ARNi which was each optimized in 13 patients (40.6%), and the least commonly optimized group was MRAs. They were optimized in 7 (21.9%) of patients. In patients who had GDMT titrated 17 (53.1%) also had loop diuretics add or titrated on discharge compare to 13 (39%) in those who did not have GDMT titrated. The pharmacy cardiology clinic provided quicker post discharge follow-up at an average of five days post discharge and met with 52.3% within 30 days of discharge, compared to cardiology clinic (11 days; 18% of patients), and primary care (7 days; 10.8% of patients). Forty-three of the patients received follow-up from a cardiology pharmacist, cardiology, or primary care and of those patients 4 (9.3%) were readmitted compared to those who did not receive follow-up with 30 days 12out of 22 (54.5%) were readmitted.
Conclusions: There were a few limitations that limit the applicability of these results to the overall population. The study had a small sample size evaluated over a short time period, there are many confounding variables, and data was only collected form a single facility. Follow-ups are limited by failure to reach patient, readmission, and possible lack of established care within BVAHCS. From this data medication titration at discharge was not associated with an increase of 30-day readmission. However, the opportunity to further titrate GDMT upon discharge does exist, specifically in MRAs.
Presentation Objective: Evaluate 30-day readmission rates of HFrEF admissions who have GDMT titrated at discharge in the Birmingham VA Health Care System (BVAHCS).
Self-Assessment: Which of the following is not a first line option for optimizing GDMT?

Authors:
Austin Seawright, Natalie Giddens, Marci Swanson, Alexis Pruitt

Purpose:
Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors have demonstrated significant cardiovascular benefits in patients with heart failure, regardless of diabetes status. Despite strong guideline recommendations, prescribing rates remain suboptimal at the Carl Vinson VA Medical Center. This quality improvement project aims to optimize the use of SGLT2 inhibitors in Veterans with heart failure by identifying eligible patients, initiating therapy when appropriate, and improving adherence to guideline-directed medical therapy.

Methods:
This quality improvement project increased SGLT2 inhibitor initiation among eligible Veterans, improving prescribing rates across heart failure phenotypes. Adverse reaction and discontinuation rates were low and consistent with those reported in clinical trials. Pharmacist‑led outreach and structured follow‑up supported expanded access to guideline‑directed therapy, with opportunities for future enhancement through automated alerts and dashboard optimization. Exclusion criteria included: active prescription for an SGLT2 inhibitor, documented severe allergy to an SGLT2 inhibitor, type 1 diabetes mellitus, history of diabetic ketoacidosis, genitourinary infections, eGFR <20 mL/min/1.73m², age ≥90 years, or deceased status. Chart review was conducted to verify eligibility, evaluate contraindications, and identify potential clinical considerations influencing initiation. Eligible Veterans or their providers were contacted via a multimodal approach to provide education regarding benefits and assess interest in therapy. Those agreeable were referred to a pharmacist‑led clinic for further evaluation and potential initiation of empagliflozin, the VA formulary‑preferred agent. Baseline laboratory values, renal function, blood pressure, and medication history were reviewed prior to initiation. Follow‑up included monitoring for tolerability, adverse reactions, adherence, and continued appropriateness of therapy.

Results:
Of 396 Veterans identified, 339 met inclusion criteria. A total of 83 Veterans (24.5%) initiated an SGLT2 inhibitor following outreach and clinical evaluation. The most common reasons for non‑initiation included urinary incontinence (30.5%), predominantly outside care (12.5%), and inability to reach patients (10.2%). Seven adverse drug reactions were reported, most commonly dizziness or renal function decline, with only two events leading to discontinuation. Seven Veterans discontinued therapy. Five discontinuations were attributed to ADRs, while two Veterans self‑discontinued due to concerns regarding polypharmacy. Initiation rates increased across heart failure classifications.

Conclusions:
This quality improvement project increased SGLT2 inhibitor initiation among eligible Veterans, improving prescribing rates across heart failure phenotypes. Adverse reaction and discontinuation rates were low and consistent with those reported in clinical trials. Pharmacist‑led outreach and structured follow‑up supported expanded access to guideline‑directed therapy, with opportunities for future enhancement through automated alerts and dashboard optimization.

Brady Ratliff, Jessica Brumit

Background/Purpose:
Sotalol is a class III antiarrhythmic requiring inpatient monitoring due to the risk of QT prolongation and proarrhythmias. Obesity may alter pharmacokinetics through changes in volume of distribution and renal clearance estimation. While actual body weight (ABW) is recommended per package insert to calculate creatinine clearance (CrCl), this may overestimate renal function in obese patients, potentially leading to drug accumulation and increased proarrhythmic risk. The purpose of this study was to compare the composite rate of inpatient sotalol discontinuation or dose reduction due to QT/QTc prolongation between obese and non-obese patients during monitored initiation.
Methods:
This retrospective cohort study evaluated adult patients admitted for sotalol initiation at a hospital system in Northeast Tennessee and Southwest Virginia from July 2020–June 2025. Patients were stratified by obesity status (BMI ≥30 kg/m2defined as obese). The primary outcome was the composite of inpatient sotalol discontinuation or dose reduction due to QT/QTc prolongation. Secondary outcomes included all-cause discontinuation, all-cause dose reduction, any dose adjustment, bradycardia (HR <50 bpm), sinus rhythm at discharge, serial QT/QTc trends across up to six doses (QT interval applied when HR <60 bpm; QTc applied when HR ≥60 bpm), and differences in CrCl calculated by ABW versus adjusted body weight (AdjBW). Categorical variables were compared using Fisher’s exact test; continuous variables using Mann-Whitney U test.
Results:
A total of 150 patients were included: 91 obese and 59 non-obese. Obese patients were younger (median 69 [IQR 59.5–75] vs. 74 [67–78] years, p=0.003) with significantly higher ABW-based CrCl (102.6 [85.8–140.4] vs. 73.3 [57.1–88.8] mL/min, p<0.001); the median CrCl overestimation using ABW versus AdjBW was 23.8 mL/min in obese patients compared to 7.7 mL/min in non-obese patients (p<0.001). Baseline serum creatinine, electrolytes, QT/QTc, heart rate, rhythm distribution, and starting sotalol dose were similar between groups. The primary composite outcome of discontinuation or dose reduction due to QT/QTc prolongation occurred in 4 obese patients (4.4%) and 3 non-obese patients (5.1%) (OR 0.86 (95% CI 0.19-3.98); p=1). All composite events were discontinuations; no dose reductions attributable to QT/QTc prolongation occurred in either group. All-cause inpatient discontinuation was similar between groups (14.3% vs. 11.9%, p=0.81). All-cause dose reductions were significantly more frequent in non-obese patients (16.9% vs. 3.3%, p=0.006), driven by bradycardia and hypotension rather than QT prolongation. Any dose adjustment did not differ significantly (23.7% vs. 15.4%, p=0.21). Bradycardia rates (18.6% vs. 13.2%, p=0.37), sinus rhythm at discharge (64.4% vs. 58.2%, p=0.5), and serial QT/QTc values at all time points were comparable between groups.
Conclusions:
Obesity was not associated with an increased composite rate of sotalol discontinuation or dose reduction due to QT/QTc prolongation during monitored inpatient initiation. Despite a clinically meaningful overestimation of CrCl using ABW in obese patients, this did not translate into greater QT-mediated adverse events or higher discontinuation rates. Notably, all-cause dose reductions were more frequent in non-obese patients and were driven by bradycardia and hypotension rather than QT prolongation. These findings suggest that obesity alone may not confer additional proarrhythmic risk during standard inpatient sotalol initiation and support current renal dosing guidance regardless of BMI.

Authors: Jalyn Martin, Justin Joy, Brian Tran, Matthew Brown, Susie Sennhauser, Matthew Gold, Daniel Gold, Kunal Bhatt

Background: Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive disease caused by myocardial deposition of misfolded transthyretin (TTR) fibrils, resulting in heart failure. TTR stabilizers, including tafamidis and acoramidis, reduce mortality and hospitalization by preventing tetramer dissociation. However, there is no standardized biomarker to assess treatment response. Clinical follow-up commonly incorporates serum prealbumin, N-terminal pro-B-type natriuretic peptide (NT-proBNP), imaging, and hospitalization rates. Prior studies suggest that lower baseline prealbumin and early post-treatment increases are associated with clinical outcomes, but its prognostic utility in real-world populations remains unclear.

Methods: This was a retrospective chart review of adults diagnosed with ATTR-CM who received TTR stabilizer therapy (i.e. tafamidis, tafamidis meglumine, or acoramidis) at the Emory Advanced Heart Failure Clinic between November 1, 2019, to December 1, 2025. Patients were included in this study if they had both baseline and follow-up (≥ 3 months) prealbumin levels. Ineligible patients were those with previous TTR stabilizer or TTR silencer use, on dual stabilizers, on a concurrent TTR silencer (patisiran, vutrisiran, inotersen, or eplontersen), or enrolled in an active ATTR-CM clinical trial. The primary outcome was the absolute change in prealbumin levels following TTR stabilizer therapy. Secondary outcomes included the association between absolute change in prealbumin and all-cause hospitalization and all-cause mortality (time to event analysis), as well as the absolute change in NT-proBNP following TTR stabilizer initiation. Descriptive statistics, paired t-test, logistical regression, and Cox proportional hazard regression were used to summarize the data.

Results: Of 222 patients screened, 150 were excluded, primarily due to missing follow-up prealbumin measurements. A total 72 patients were included in the analysis, all treated with tafamidis. Prealbumin rose significantly after TTR stabilizer initiation, with a mean paired increase of 8.99 mg/dL (95% CI 7.40 to 10.59; p<0.001). The composite outcome of hospitalization and death occurred in 47 (65.3%) patients, with 14 deaths and 47 hospitalizations. After adjustment for age, sex, and race, each 5 mg/dL higher follow-up prealbumin was associated with a lower risk of hospitalization (HR 0.41; 95% CI 0.21 to 0.78; p=0.007) and the composite outcome (HR 0.37; 95% CI 0.20 to 0.69; p=0.002). No significant association was observed for mortality alone with either follow-up prealbumin or change in prealbumin. Mean absolute change in NT-proBNP was 165.7 pg/mL.

Conclusions: Higher prealbumin after TTR stabilizer initiation was associated with a reduced risk of all-cause hospitalizations and composite events. Baseline prealbumin in prealbumin predicted subsequent cardiac-related hospitalizations and all-cause mortality in an exploratory analysis. Further research in larger cohorts with longer follow-up is needed to validate these findings and further identify predictors of response to TTR stabilizer therapy.
  

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Evaluation of the PRECISE-DAPT Score in Predicting CABG Related Bleeding Readmissions
Inyeong Choi, Danielle McPherson, Davide Ventura
AdventHealth Orlando, FL

Background/Purpose: Dual antiplatelet therapy (DAPT) is recommended for patients after coronary artery bypass graft surgery (CABG) with concomitant acute coronary syndrome (ACS) or recent history of percutaneous coronary intervention (PCI). Large scale analyses have confirmed the external validity of the PRECISE-DAPT score demonstrating that high risk patients (score ≥ 25) have a 3- to 4-fold increased risk of major bleeding. The PRECISE-DAPT score is a five-item bleeding risk score validated in the PCI patient population to assist clinician’s informed decision making on duration of DAPT. This score is determined by age, creatinine clearance (CrCl), white blood cell (WBC) count, hemoglobin (Hgb), and history of bleeding at baseline. However, no validated bleeding risk scores exist for the CABG population. Recently, Society of Thoracic Surgeons (STS) registry data at AdventHealth noted a high rate of re-admissions due to bleeding complications. The benefit of DAPT after CABG remains uncertain as recent trials show no clear ischemic advantage at the expense of more bleeding. This study aims to evaluate the association of the PRECISE-DAPT score and bleeding readmissions in patients discharged from DAPT after CABG.

Methodology: This study was a retrospective cohort study conducted from August 2022 to August 2025. This study included patients who were re-admitted after CABG at AdventHealth Orlando and Celebration campuses due to bleeding complications within 90 days. Bleeding complications included gastrointestinal bleeding (GIB), anticoagulation complications , pleural or pericardial effusion requiring intervention, or hemorrhagic stroke. The PRECISE-DAPT score was retrospectively calculated based on age, CrCl, WBC, Hgb, and history of bleeding. The primary outcome was to evaluate the association of the PRECISE-DAPT score and re-admissions due to bleeding complications. The secondary outcomes included bleeding events defined by the Bleeding Academic Research Consortium (BARC) criteria, time to re-admission, transfusion requirements, and any changes to antiplatelet or anticoagulant regimens. Categorical data were analyzed via a Chi-square test or Fischer’s Exact test. Continuous data were analyzed via a Mann-Whitney U test or Kruskal-Wallist test.

Results: A total of 95 patients with CABG with or without valve replacements were included in the final analysis. Twenty-five patients had a PRECISE-DAPT score < 25 (low bleeding risk) and 70 patients had a PRECISE-DAPT score ≥ 25 (high bleeding risk). The high-risk group had an average score of 43 and accounted for 74% of all bleeding complications. Additionally, high-risk patients experienced numerically more clinically relevant bleeding events (BARC type 2 or greater) than the low-risk group (28 vs. 8, p = 0.342). After readmission, 53% of DAPT patients in the high-risk group were transitioned to single antiplatelet therapy (SAPT) compared with 23% in the low-risk group. Transfusion requirements were comparable between the two groups, with 22.9% in the high-risk group and 28% in the low-risk group.

Conclusion: Elevated PRECISE-DAPT scores are associated with increased risk. Though currently validated for PCI patients only, the PRECISE-DAPT score offers a viable tool for risk stratification in CABG patients. Incorporating the PRECISE-DAPT score in surgical patients may inform tailored antithrombotic regimens as a strategy to minimize bleeding readmissions.

Iron Supplementation in Patients with Heart Failure with Reduced Ejection Fraction Following Pharmacist-Led Review
Lauren Finn, Rachel Kile 
CHI Memorial Hospital, Chattanooga, TN 

Background/Purpose: Heart failure is a leading cause of hospitalization for patients older than 65, requiring proper management during inpatient stays. Iron deficiency is common in heart failure with reduced ejection fraction (HFrEF) and negatively impacts patient outcomes. This project aims to describe the impact of pharmacist intervention on the appropriate initiation of iron supplementation in patients with HFrEF, highlighting the pharmacist's role in optimizing HFrEF management.
 
Methods: This is a single-center, IRB-approved, quasi-experimental study. We conducted a retrospective chart review comparing the proportion of iron-deficient inpatients with an active diagnosis of chronic systolic heart failure who were appropriately initiated on intravenous iron therapy before and after the implementation of a pharmacist-led review process. Appropriate therapy was defined as a course of IV iron of at least 500 mg in iron-deficient patients. Eligible patients were at least 18 years of age with an ejection fraction of forty percent or less and with a ferritin <100 or ferritin between 100 and 300 and TSAT <20%. The primary endpoints analyzed were readmission rates at 30 and 60 days and the number of patients with appropriate iron therapy initiated. Secondary endpoints will include the number of pharmacist-initiated interventions for iron panels, ferritin levels, and iron supplementation. For both study arms, results will be reported with male and female participants combined, as well as sex disaggregated.

Results: There were not statistically significant differences in age, sex, race, or left ventricular ejection fraction between the pre-intervention and post-intervention groups. Additionally, there was not a statistically significant difference in the type of iron administered, and more patients received sodium ferric gluconate compared to iron dextran across both groups. Post-intervention, 39 patients were initiated on appropriate IV iron therapy as opposed to only 7 pre-intervention, This was a statistically significant difference with a p-value of 0.007. Differences in readmission rates at 30 & 60 days were not statistically significant between groups, but a lower percentage of patients was readmitted post-intervention. Of the 39 appropriate IV iron initiations post-intervention, 23 were pharmacist-initiated, with the remaining being provider-led. The number of pharmacist-initiated orders was 18 for iron panels and 21 for ferritin levels. 

Conclusions: Pharmacist-led review significantly improved appropriate IV iron supplementation in patients with HFrEF. Considering that of the 39 patients initiated on appropriate IV iron therapy post-intervention, 23 orders were pharmacist-led, it can be concluded that providers are initiating IV iron therapy as well. Although results for readmission rates were not statistically significant, fewer patients were readmitted post-intervention. Orders for iron panels and ferritin levels were higher in the post-intervention group. Overall, these findings support pharmacist interventions in this patient population to improve adherence to guideline recommendations. 



Contact: [email protected]

Title: Impact of Anticoagulation Strategies on Thrombotic Events in Patients with Durable Left Ventricular Assist Devices (IMPACT-LVAD)
Authors: Asya Bookal, Danielle McPherson, Michelle Dillon

Background/Objective: Advanced heart failure (HF) poses a significant and increasing burden, affecting around 15% of all HF patients. Treatment options for patients with advanced HF include durable left ventricular assist devices (LVAD) which improve 2-year survival by 80% and may be used either as a bridge to heart transplantation or as destination therapy. There are currently three generations of LVADs; newer generations like the HeartMate 3 (HM3) device have a continuous and fully magnetic levitation which improves hemocompatibility and thus safety. Although newer generation devices have less risk of thrombosis, all devices inherently have some; therefore, long-term anticoagulation is recommended. In the acute perioperative period, the competing risks of bleeding and thrombosis must be balanced, which may delay anticoagulation initiation. Institutional anticoagulation strategies have also been impacted post ARIES-HM3 trial. This study aims to evaluate the incidence of thrombotic and bleeding events after HM3 implantation. 

Methods: This retrospective review includes adults who underwent durable LVAD placement with a HM3 device at AdventHealth Orlando between August 1, 2022 and August 31, 2025. Patients were excluded if they received an alternate device, required additional mechanical circulatory support with device placement, had delayed chest closure, or history of heparin-induced thrombocytopenia (HIT). The primary endpoint is incidence of thrombotic events after HM3 implantation, defined as deep vein thrombosis (DVT), pulmonary embolism (PE), cardioembolic stroke, thrombus induced acute coronary syndrome (ACS), or device-associated thrombus. Secondary endpoints include bleeding defined by the Mechanical Circulatory Support Academic Research Consortium (MCS-ARC), time to therapeutic anticoagulation, anticoagulation time in the therapeutic range (TTR), and time to initiation of warfarin.  

Results: Of 124 patients screened, 88 were included in the study. Patients were on average 58 years old (SD ±13), 65 (74%) were male, 42 (48%) had history of atrial fibrillation, 13 (15%) had history of DVT/PE, 44 (50%) were on therapeutic anticoagulation, and 29 (33%) required MCS preoperatively. Bleeding events occurred in 24 (27%) patients with 12 (50%) being type 2 requiring intervention, but no type 5 fatal bleeding events occurred. Fourteen (16%) patients experienced a thrombotic event with 12 (86%) being upper extremity DVT, 1 (7%) cardioembolic stroke, and 1 (7%) pulmonary embolism. Patients were split into aspirin use pre- and post- ARIES-HM3 trial with all 21 (100%) pre-trial receiving aspirin and 35 (52%) post-trial receiving aspirin. Median time to warfarin initiation was 5 days (IQR 3, 7), time to therapeutic INR was 6 days (IQR 4, 7), and time to therapeutic aPTT was 12 hours (IQR 6, 15). Median TTR for warfarin days 6-10 was 60% (IQR 35, 1), median TTR for parenteral anticoagulation days 1-5 was 49% (IQR 33, 64), and time in subtherapeutic aPTT range was 46% (IQR 24, 60).

Conclusions: Patients who underwent HM3 implantation experienced low rates of thrombotic events despite changes in anticoagulation strategies and did not experience fatal bleeding.

Title: Pharmacogenomic- and Drug-Drug Interaction-Guided Antiplatelet Therapy in Veterans Taking Clopidogrel and Omeprazole
Authors: Sydney Magrath, Julianne Isaac, David Deen
Background:
Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality, with antiplatelet therapy as the foundation for secondary prevention. Clopidogrel, a widely prescribed P2Y12 inhibitor, exhibits variable efficacy due to CYP2C19 genetic polymorphisms and drug-drug interactions, especially with proton-pump inhibitors (PPIs), such as omeprazole. Consensus statements and leading medical journals have begun to recommend utilizing genotype-guided therapy to optimize outcomes in specific indications, such as acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI), to optimize outcomes, yet implementation in clinical practice remains limited. The objective of this project is to reduce category X drug-drug interactions between clopidogrel and omeprazole and assess the feasibility of pharmacogenomic testing in Veterans with ASCVD at high risk for major adverse cardiovascular events (MACE).
Methods:
This prospective, interventional quality improvement project utilized a data query to identify Veterans with ASCVD or post-PCI who were prescribed clopidogrel and omeprazole from September 2022 to December 2025 at the Ralph H Johnson VA Health Care System. Veterans were contacted to discuss pharmacogenomic testing and drug-interaction risks and offered to switch to a non-interacting PPI, de-escalate off PPI or to a histamine-2 receptor antagonist where appropriate. Veteran’s most recent blood pressure, lipid panel, and medication list were reviewed for guideline-recommended interventions. Primary outcome was composite implementation rate, defined as proportion of patients contacted who (1) underwent PPI modification and/or (2) have a final antiplatelet regimen that follows Clinical Pharmacogenetics Implementation Consortium (CPIC) and American College of Cardiology (ACC) recommendations. Secondary outcome was incidence of thrombotic events, bleeding, ticagrelor-associated dyspnea, and worsening dyspepsia following intervention. Tertiary outcome was to assess pharmacist interventions.
Results: 
Of the 82 patients on clopidogrel and omeprazole with an included ICD-10 code or procedure code, 59 met inclusion criteria and 51 were successfully contacted. At visit 1, 50 of 51 patients agreed to PPI modification and 43 completed pharmacogenomic testing. Nine of the 43 were CYP2C19 intermediate metabolizers, suggesting possible indication for antiplatelet therapy change. All but one patient with CAD indicated for clopidogrel change accepted a therapy modification. Ultimately, 50 of 51 patients had final antiplatelet regimens aligned with CPIC and ACC guidance therefore 98% meeting composite implementation rate.
No thrombotic or bleeding events occurred. Among patients switched to ticagrelor, 1 of 2 experienced dyspnea. Five patients reported worsening dyspepsia after PPI modification, of whom 85% were CYP2C19 rapid metabolizers. Pharmacist interventions included 14 medication reconciliations, 48 adherence counseling sessions, 10 lipid-related interventions, and one antihypertensive intervention.
Conclusion:
This project demonstrated high implementation rates and strong patient acceptance in addressing high-risk clopidogrel-omeprazole DDIs. Genotype-guided antiplatelet therapy was feasible in routine practice and did not result in thrombotic or bleeding events during the project period. Reported adverse effects were minimal and consistent with known drug profiles. These findings support the integration of pharmacist-driven pharmacogenomics and medication optimization into cardiovascular risk-reduction efforts within the Veteran population. Future pathways include identifying eligible patients during inpatient ACS/PCI admissions for earlier PPI modification and pharmacogenomic testing, followed by coordinated outpatient follow-up to optimize antiplatelet therapy.
 

Authors: Joan M. Jakab, William W. Feese, Mitchell S. Hutson, A. Shaun Rowe, & Kaylee W. Behal 
Background: Patients with heart failure have complex medication regimens, often involving a need for additional education and care. Multidisciplinary care improves medication adherence and dose optimization of the four pillars of heart failure therapy. Outpatient multidisciplinary integration in heart failure clinics has shown enhanced medication optimization and reduced hospital admission thus the need to assess inpatient multidisciplinary care. The purpose of this study is to evaluate the impact of a multidisciplinary cardiology-focused unit on guideline directed medical therapy (GDMT) at hospital discharge for patients with heart failure with reduced ejection fraction (HFrEF). 
Methods: This retrospective cohort study examines 364 patients with HFrEF grouped according to discharge location from either the cardiology-focused multidisciplinary unit or any other   unit. Multidisciplinary cardiology-focused units receive heart failure education tailored to each specialty such as disease specific education courses for registered nurses, importance of intake and output documentation, daily weights, and movement by exercise physiology. The primary outcome is GDMT score at discharge. Secondary outcomes include the change in GDMT score from admission to discharge and the percentage of pillars of therapy on each patient’s medication regimen. The subgroup analysis includes pharmacist initiation of GDMT as determined by clinical intervention documentation in the electronic medical record. The secondary safety endpoint includes hospital readmissions at 30 or 90 days.  
Results: At discharge, patients admitted to the multidisciplinary cardiology-focused unit achieved higher GDMT scores compared with patients admitted to other units (5 [2, 6] vs. 3 [1, 5]; p=0.0003). The change in GDMT scores from admission to discharge was significantly greater in the cardiology unit (1 [0, 5] vs. 0 [0, 1]; p<0.0001). Patients discharged from cardiology-focused units had a higher number of GDMT medications prescribed (3 [2, 4] vs. 2 [1, 3]; p=0.0005). Thirty or ninety day heart failure-related readmission rates were similar between groups (8 [6.4%] vs. 13 [5.4%]; p=0.7089). Patients admitted to cardiology-focused units were more likely to have at least one heart failure-related pharmacist clinical intervention during admission (61 [48.8%] vs. 63 [26.4%]; p<0.0001; OR 2.7, 95% CI 1.7–4.2). 
Conclusions: In this retrospective study, patients with HFrEF who were admitted to the multidisciplinary cardiology-focused unit had higher GDMT scores at discharge indicating greater optimization of GDMT. These findings suggest that a multidisciplinary team plays a critical role in identifying gaps in therapy and promoting evidence-based medication optimization during hospitalization. 

Background: Despite its prevalence in clinical practice and its widely accepted role in dual antiplatelet therapy regimens, clopidogrel has demonstrated significant interpatient pharmacokinetic variability and pharmacodynamic responses. Poor metabolizers are at increased risk of cardiovascular events following coronary stenting secondary to their inability to properly metabolize the inactive compound into its active form. Platelet reactivity testing measures the degree of platelet aggregation following the administration of an antiplatelet. Using the VerifyNow-P2Y12 Assay, a P2Y12 reaction unit (PRU) ≤208 indicates adequate platelet inhibition, while a PRU >208 indicates inadequate platelet inhibition.  Current acute coronary syndrome guidelines do not recommend platelet function testing, however the JACC International Consensus Statement on Platelet Function and Genetic Testing in Percutaneous Coronary Intervention recommends consideration of platelet function testing to guide escalation strategies, de-escalation strategies, or in patients being considered for antiplatelet monotherapy with clopidogrel. In response to a sentinel event at Prisma Health where a patient with a PRU >208 was discharged on clopidogrel, PRU results were added to clinical monitoring for pharmacist assessment. The goal of this research is to assess pharmacist intervention following platelet function testing and characterize clopidogrel utilization in response to PRU levels.
Methods: This is a retrospective, observational cohort study including patients admitted to Prisma Health with coronary stenting and a platelet function test performed with resulting PRU level on clopidogrel. Patient cohorts include those with levels ≤208 (clopidogrel responders) and those with levels >208 (clopidogrel non-responders). The primary endpoint is the percentage of patients on clopidogrel with a PRU >208 that were intervened on by a pharmacist. Secondary endpoints include percentage of patients with high-risk characteristics, contraindications to a preferred P2Y12 inhibitor, appropriate PRU timing and transition to alternative P2Y12 inhibitor, and cardiovascular outcomes.  
Results: In progress
Conclusion: In progress

Title: Impact of an Inpatient Heart Failure Consult Service on Readmission Rates and Guideline-Directed Medical Therapy Prescribing: A Single-Center Pre-Post Intervention Study
Authors: Margaret Matthews, Jessica Yarbrough, Rachel Robinson
Purpose: The 2022 AHA/ACC/HFSA Heart Failure Guideline endorses the initiation, continuation, and reinitiation of guideline-directed medical therapy (GDMT) during hospitalization to improve clinical outcomes for patients with heart failure. GDMT use often varies in the hospital setting based on the patient’s clinical status, individual provider preference, concerns about transitions-of-care, and the dynamic course of acute heart failure. To standardize inpatient management and enhance GDMT optimization, our institution implemented an interdisciplinary inpatient heart failure consult service composed of an advanced heart failure cardiologist, clinical pharmacist, and nurse navigator. This study evaluated the impact of the service on 30-day readmission rates and GDMT prescribing patterns at our rural community hospital.
Methods: This single center, retrospective, pre-post intervention study included patients ≥ 18 years old admitted with a primary diagnosis of heart failure. Exclusion criteria followed the Centers for Medicare & Medicaid Services’ Hospital Readmissions Reduction Program criteria for heart failure readmissions. The pre-implementation period occurred from January 2024 to June 2024, and the post-implementation period occurred from June 2025 to November 2025. The data collected included patient demographics, renal function, heart failure type, discharging provider, GDMT changes during admission, GDMT prescribed at discharge, and documented contraindications. The primary outcome was 30-day-all-cause readmission rate. Secondary outcomes included 30-day heart failure-related readmission rate and change in GDMT from admission to discharge. Primary and secondary outcomes were compared between the pre- and post-implementation groups using descriptive statistics, with continuous data reported as means and categorical data reported as frequencies and percentages.
Results: A total of 447 patients were included in the analysis, with 254 patients in the pre-intervention group and 193 patients in the post-intervention group. Baseline demographics were similar between groups. Thirty-day all-cause readmission rates remained unchanged following implementation of the inpatient heart failure consult service (27% pre-intervention vs 27% post-intervention). Heart failure-related readmissions among readmitted patients decreased numerically from 51% in the pre-intervention group to 45% in the post-intervention group. Appropriate GDMT prescribing improved from admission to discharge in both groups, with a greater absolute improvement observed post-intervention (+38%, 36% to 74%) compared with pre-intervention (+13%, 41% to 54%). The largest post-intervention increases in individual GDMT classes were observed with mineralocorticoid receptor antagonists (+28%) and sodium-glucose cotransporter-2 inhibitors (+20%). Among post-intervention patients, 40% received a heart failure consult, with 27% readmitted within 30 days.
Conclusion: Implementation of an inpatient heart failure consult service was associated with increased use of GDMT at discharge and supported a more standardized approach to care. No difference in 30-day readmission rates was observed; however, not all eligible patients received a consult, which may have limited the overall impact of the intervention. Greater consult utilization and continued acceptance may further improve clinical outcomes, including readmissions.

ASSESSMENT OF ADHERENCE TO AN INSTITUTIONAL aPTT LEVEL MONITORING PROTOCOL FOR UNFRACTIONATED HEPARIN INFUSIONS
George Saied, Rachel Hemberger, Mary Beth Brinkman
TriStar Centennial Medical Center – Nashville, TN
Background: The use of continuous infusion unfractionated heparin (UFH) is common for treatment and prophylaxis of venous thromboembolism (VTE), myocardial infarctions (MI), anticoagulant bridging, and is used second line in several other disease states. UFH has been labeled a “High-Risk Medication” since the early 2000s and has severe adverse effects associated with bleeding and platelet abnormalities. The use of UFH requires close monitoring of laboratory findings, specifically the use of Activated Partial Thromboplastin Time (aPTT), to ensure patient safety and medication efficacy. Supratherapeutic aPTT levels result in increased bleeding risk while subtherapeutic aPTT levels result in increased clotting risk. Due to the frequency of aPTT monitoring, there is potential for delays in blood collection and necessary dose adjustments, thus increasing the risk of patient-safety events. Additionally, there is also potential for aPPT protocol recommendation to be misinterpreted or for the dose to be titrated inappropriately, thus leading to patient-safety events. This study seeks to evaluate adherence to our heparin protocol and identify specific areas for process improvement.

Methods: This was an Institutional Review Board-approved, single-center, retrospective cohort study of adult patients (≥18 years) who received a continuous heparin infusion at TriStar Centennial Medical Center from March 22, 2025 through March 31, 2025. The primary endpoint was adherence to the institutional UFH nursing protocol, defined as appropriate heparin bolus administration, dose titration, and timely aPTT ordering per protocol recommendation. Secondary endpoints included reasons for protocol nonadherence, percentage of aPTT values within the goal therapeutic range, time to achieve therapeutic range, and incidence of bleeding and thrombosis. Drips were followed for the first 72 hours after initiation. Descriptive statistics were used for data analysis.

Results: A total of 59 patients were included (Cardiac Serv, n = 36; DVT/PE, n = 23). The primary outcome of full protocol adherence was achieved in only 7 of 59 patients (11.9%). The most common drivers of non-adherence was incorrect initial drip rate and inappropriate dose titration. The mean percentage of aPTT values within the therapeutic range was 43.6%. Patients who experienced an adverse drug reaction (n=9, 15.3%) had a lower mean percentage of aPTT values in goal compared to those without an ADR (28.6% vs. 46.3%; p=0.056). Time to first therapeutic aPTT was significantly longer in the Cardiac Serv cohort compared to the DVT/PE cohort (0.87 days vs. 0.42 days; p = 0.001). Bleeding events occurred in 6 (10.2%) patients (Cardiac Serv 5.6% vs. DVT/PE 17.4%; p = 0.196) and thrombotic events in 7 (11.9%) patients (Cardiac Serv 8.3% vs. DVT/PE 17.4%; p=0.414). No statistically significant difference in adverse events was identified between cohorts, but trends do support increased risk in DVT/PE versus Cardiac Serv protocols.

Conclusions: Protocol adherence to institutional UFH aPTT monitoring was below goal, with fewer than 1 in 8 patients receiving fully adherent care. Non-adherence was primarily driven by incorrect initial rates and incorrect dose titration. Patients who experienced an ADR spent significantly less time within the therapeutic range, which highlights the clinical consequences of protocol deviations. The Cardiac Serv cohort took a longer time to reach first therapeutic aPTT compared to the DVT/PE cohort. These findings show clear opportunities for targeted nursing education, protocol clarification, and system-level process improvements to optimize UFH therapy and enhance patient safety.

 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.

Title: Retrospective Evaluation of an Antiarrhythmic Monitoring Program
Authors: Kaitlin A Roberts, Rebecca Holt, Cynthia Pohland
Objective: Assess the James H Quillen Veterans’ Affairs Medical Center (JHQVAMC)’s adherence to monitoring recommendations for seven different antiarrhythmic medications (amiodarone, dronedarone, sotalol, dofetilide, mexiletine, propafenone, flecainide).
Self-Assessment Question: Which of the following antiarrhythmics showed significant improvement in adherence to monitoring recommendations between the 2022-2023 resident project and the current resident project? A. Dofetilide, B. Propafenone, C. Dronedarone, D. Flecainide
Background: The purpose of this quality improvement project was to evaluate the current compliance with antiarrhythmic drug (AAD) monitoring program collaboratively developed after a 2023 residency project identified low compliance with routine monitoring.
Methods: Participants were identified by presence of AAD prescription and eligibility was assessed. Patients receiving care at and prescribed an AAD at JHQVAMC between June 2024 – June 2025 were included. Participants were excluded if they were not prescribed an AAD by a VA provider. No more than 50 participants on each antiarrhythmic medication were randomly sampled and retrospectively reviewed to collect the following: demographics (age, sex, race/ethnicity); number of appointments with electrophysiology (EP) providers, non-EP cardiology providers, and cardiology pharmacists; frequency of lab monitoring (potassium (K), magnesium (Mg), liver function tests (LFTs), serum creatinine (SCr), thyroid stimulating hormone (TSH); and frequency of electrocardiograms (EKG). Results of descriptive statistics were used to evaluate compliance with monitoring. The results will then be disseminated to the local EP cardiology team to enhance current practice.
Result: Percentage of appropriate monitoring visits for dronedarone, sotalol, amiodarone, dofetilide, flecainide, mexiletine, and propafenone were 53%, 60%, 80%, 74%, 66%, 90%, and 80% respectively. Percentage of appropriate EKG monitoring for dronedarone, sotalol amiodarone, dofetilide, flecainide, mexiletine, and propafenone was 65%, 66%, 72%, 80%, 72%, 95%, and 80% respectively. The percentage of appropriately monitored labs was as follows: dronedarone had 58% K and LFTs, 16% Mg and TSH; sotalol had 84% K, 46% Mg, 88% SCr; amiodarone had 78% K, 24% Mg, 70% LFTs, 26% TSH; dofetilide had 94% K and SCr, 76% Mg; flecainide had 82% K, 20% Mg, 80% LFTs; mexiletine had 100% K and LFTs, 76% Mg; propafenone had 100% K and LFTs, 40% magnesium.
Conclusions: After pharmacist intervention, JHQVAMC was monitoring the majority of patients on AAD appropriately, with few exceptions that can be improved upon through process improvement such as the creation of lab order sets.

Abstract 
Background and Purpose 
Hypotension is a common barrier to optimization of guideline-directed medical therapy (GDMT) in patients with heart failure with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF). Midodrine, an oral α₁-adrenergic agonist approved for orthostatic hypotension, has been used off-label to support blood pressure and facilitate GDMT initiation or titration in hypotensive heart failure patients. However, data evaluating its impact on clinical outcomes remains limited. This study aimed to evaluate the association between midodrine use at hospital discharge and 30-day all-cause readmission in hypotensive heart failure patients. 
 
Methods 
This retrospective cohort study included adult patients (≥18 years) admitted to the AdventHealth Central Florida Division between October 2024 and November 2025 with HFrEF or HFmrEF (EF <50%) and documented hypotension. Patients were grouped based on discharge with midodrine versus discharge without midodrine. Clinical data was extracted from the electronic health record, including baseline characteristics, use of GDMT at admission and discharge, length of stay (LOS), 30-day all-cause readmission, 30-day mortality, and adverse events such as hypertension and bradycardia. 
 
Results 
A total of 142 patients were included (65 intervention, 77 control). Baseline demographics and clinical characteristics were similar between groups. The 30-day all-cause readmission rate was identical between patients discharged on midodrine and those not discharged on midodrine (34% vs 34%, p=0.99). 30-day mortality was low and comparable between groups (2% vs 1%, p=0.49). Median length of stay did not differ significantly (11 vs 9 days, p=0.54). 
Hypertensive events occurred more frequently in those discharged with midodrine (31% vs 20%), though this difference was not statistically significant (p=0.11). Rates of bradycardia were similar (21% vs 17%, p=0.95). Changes in GDMT dosing from admission to discharge were comparable between groups, with no significant improvement in GDMT up-titration associated with midodrine use. 
 
Conclusions 
In this retrospective cohort of hypotensive HFrEF and HFmrEF patients, discharge on midodrine was not associated with reduced 30-day readmission, mortality, or length of stay compared to patients not discharged on midodrine. While midodrine was frequently used as a supportive agent, its use did not translate into meaningful GDMT optimization and was associated with a numerically higher incidence of hypertensive events.  

Background: Cardiovascular (CV) disease is the leading cause of death worldwide, accounting for nearly eighteen million deaths annually. Among patients with acute coronary syndrome (ACS), up to twenty percent experience a recurrent major adverse cardiovascular event (MACE) within two years. Optimizing lipid lowering therapies to achieve a goal low-density lipoprotein (LDL) is a cornerstone of secondary prevention and reduces the residual risk of MACE. Injectable-lipid lowering therapies have a prominent role in LDL goal achievement for patients deemed statin-intolerant or those who need additional lipid-lowering in addition to their maximally tolerated statin therapy. Despite the proven efficacy of injectable lipid-lowering therapies, their usage remains suboptimal due to access, cost, and workflow barriers. Pharmacist-led lipid clinics have shown to bridge the gap to initiation of injectable lipid-lowering therapy by increasing the use of guideline-directed therapy, identifying and managing statin-intolerance, and improved calculated low-density lipoprotein (LDL-C) goal achievement. This project evaluates the impact of an inpatient pharmacist-led referral process to a pharmacist-managed lipid clinic on the timely initiation of injectable lipid-lowering therapies in post-ACS patients.  
Methods: This single-center, retrospective cohort with pre-post analysis included adults who survived hospitalization for ACS, including non-ST-elevated myocardial infarction (NSTEMI) or ST-elevated myocardial infarction (STEMI), with an LDL greater than or equal to 55 mg/dL or statin-intolerant. Patients were excluded if they were already on injectable lipid-lowering therapy or pregnant or breastfeeding. Patients who met the inclusion criteria were eligible to be referred by the inpatient pharmacy team to a pharmacist-led lipid clinic for ambulatory lipid management post-ACS. A collaborative practice agreement (CPA) allowed clinical pharmacists practitioners (CPPs) to independently conduct lipid management visits, initiate, titrate, or discontinue antihyperlipidemic medications, order and evaluate laboratory tests, provide adherence and lifestyle counseling, and document all care in the electronic health record for physician review. The primary outcome assessed was the proportion of patients that were started on injectable lipid lowering therapy within four weeks of discharge post-ACS event. Secondary outcomes were proportion of patients started on injectable lipid lowering therapy within 12 weeks of discharge post-ACS event, proportion of patients seen in lipid clinic within four and 12 weeks of discharge post-ACS event, median time to seen in lipid clinic, median time to started on injectable lipid-lowering therapy post-discharge, and percent reduction of LDL from baseline to eight or more weeks post-initiation of injectable lipid-lowering therapy. 
Results: A total of 196 patients were screened with 45 patients being included in the pre-PharmD referral group and 151 patients in the post-PharmD referral group. A higher proportion of patients in the post-referral to pharmacist-managed lipid clinic group were initiated on injectable lipid-lowering therapies within four weeks of ACS discharge compared to the pre-referral group [15 (23.8%) vs 0 (0%); p=0.002]. Patients in the post-referral group were also more likely to be seen in lipid clinic within four weeks (OR 0.13; p=0.003) and 12 weeks (OR 0.32; p=0.04) of discharge. 
Conclusion: Implementation of a standardized referral process to an outpatient pharmacist managed lipid clinic post-ACS discharge enhance transitions of care and implementation of guideline-directed lipid-lowering therapy to reduce residual risk of MACE for patients post-ACS. This standardized process increased the number of patients seen by a pharmacist and initiated on injectable lipid-lowering therapies within four and 12 weeks of ACS discharge. These findings suggest that pharmacist-managed lipid clinics can bridge the gap in post-ACS care by ensuring lipid therapy optimization to reduce the risk of recurrent MACE. 
Presentation Objective: Describe the impact of an inpatient pharmacist-led referral process to an outpatient pharmacist-managed lipid clinic on the initiation of injectable lipid-lowering therapies in post-ACS patients. 
Self-Assessment: What are some advantages of referring post-ACS patients to an outpatient pharmacist-led lipid clinic? 

AUTHORS: Sherique S. Shaw, Jeremy Bennett, Brianna Rhodes, Kalyn D. Pounders

BACKGROUND: Approximately 6.7 million American adults over the age of 20 were diagnosed with heart failure (HF) in 2024. This number is expected to rise to 8.7 million by 2030. Heart failure hospitalizations accounted for the highest healthcare costs among cardiovascular related hospitalization at $18.5 billion. The first 30 days following hospital discharge, patients with HF are highly vulnerable to readmission due to residual symptoms, medication changes, and gaps in care transitions.  During the 2024-2025 fiscal year [FY25] at the Atlanta VA only 35-42% of HF admission patients received any follow up by a provider (primary care, cardiologist, or Clinical Pharmacist practitioner (CPP)) within 14 days of discharge. Previous studies have highlighted the role that clinical pharmacists can play in improving hospital readmission rates for patients with heart failure. In FY25, no standardized process existed to enable CPPs to systematically follow up with and intervene for discharged heart failure patients. The Atlanta VA Health Care System implemented a protocol in FY26 Q1 [October 1, 2025 – December 31, 2025] enabling clinical pharmacists to assess and optimize medication regimens for patients discharged following heart failure diagnosis or exacerbation. This project aims to assess the impact of follow-up intervention or optimization via pharmacist involvement on heart failure discharges on 30-day cardiac readmission rates in veterans with heart failure at the Atlanta VA Health Care System.

METHODOLOGY: This project is a retrospective quality improvement project comparing 30-day readmission rates among patients who were assessed by a CPP within 30 days of hospital discharge versus those who did not receive CPP intervention or follow-up. Inclusion criteria for the study are adults 18 years or older who were hospitalized at the Atlanta VA hospital for FYQ1 2025 and FYQ1 2026  and received a diagnosis of heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). Exclusion criteria included veterans who are pregnant, complex heart failure, terminally ill or hospice enrolled and if the veterans were discharged to a non-home environment. Eligible Veterans will be identified using the following methods: heart failure diagnosis ICD-10 codes, heart failure population-management dashboard, the 2-day post-discharge dashboard (monitored by primary care nurses who notify CPPs of actionable patients), referrals from the inpatient team via Pharmacotherapy Heart Failure Discharge Consults, and referrals from any primary care team member or specialist. Once identified, CPPs will provide an intervention and document the interaction under the note titled "Pharmacotherapy Heart Failure Post-discharge Note". Intervention for this research is defined as initiating, titrating, or maintaining GDMT at target or maximally tolerated doses. For this project, a readmission is defined as a hospitalization within 30 days of initial discharge for a HF exacerbation. Readmissions will be identified through discharge summaries tab in computerized patient record system [CPRS] or notes filtered by ICD-10 codes under the post-discharge category. We also will be collecting demographic and clinical characteristics including, age, gender, time of hospitalization, active GDMT prescription before hospitalization, active GDMT prescriptions after CPP assessment, patient readmission, primary care provider or clinic, EF classification prior to admission, type of intervention/optimization provided if any. After capturing the data, we will calculate the percentage of HF readmissions with and without CPP intervention for each fiscal year. Upon review of the data, the impact of the pharmacotherapy task force post discharge follow up will be assessed in order to identify areas for quality improvement.

RESULTS:
In FYQ1 2025, there was a total of 106 HF patients, and 16%(17/106) were readmitted within thirty days. In FYQ1 2026, there was a total of 63 HF patients and 24% (15/63) of HF patient readmitted within 30 days. Only 13% (8/63) of the HF patients in FYQ1 2026 received CPP follow up from the intervention team. Of the HF patients that received a CPP follow up, 13% (1/8) were readmitted in 30 days compared to 26% (14/53) of the HF patients that did not receive CPP follow up.
Veterans were identified for intervention after discharge using the multiple methods such as ICD-10 codes, the 2-day post-discharge dashboard, and the pharmacotherapy heart failure discharge consults. Of the 8 patients that received a CPP intervention, 63%(5/8) were identified through pharmacotherapy heart failure discharge consults. All patients identified through this consult (5/5) remained readmission-free at 30 days.

CONCLUSIONS: It is recommended to provide additional education to staff of available options to notify CPPs to heart failure discharge patients to make a greater impact. CPP intervention had lower percentage of 30 day readmission rate.