Quality Of Anticoagulation In Patients Research Articles

Relationship between silent cerebral infarcts and quality of anticoagulation in patients with prosthetic mitral valves.

Although patients with prosthetic heart valves have an increased risk of clinically overt cerebrovascular events, evidence for the risk of silent cerebral infarction (SCI) is scarce. Serum neuron-specific enolase (NSE) is suggested to be a valid biomarker that allows for the quantification of the degree of neuronal injury. We aimed to assess whether NSE is elevated as a marker of recent SCI in patients with a prosthetic mitral valve. We measured the NSE levels in 103 patients with a prosthetic mitral valve (PMV), admitted to our outpatient clinics for routine evaluation. International normalized ratio (INR) and time in target therapeutic range (TTR) were noted as anticoagulation quality measures. Most of the patients were females (58%), and a mean age was 65 years. NSE values of >12 ng/mL, suggesting a recent SCI, was detected in 25 patients (24%). NSE was negatively correlated with admission INR (r=-0.307, p=0.002). Multivariate analyses demonstrated subtherapeutic INR (INR <2.5) and suboptimal TTR as independent predictors of SCI [odds ratio (OR) 5.420; 95% confidence interval (CI) 1.589 to 18.483; p=0.007, and OR 4.149; 95% CI 1.019 to 16.949; p=0.047, respectively]. Being a current smoker (OR 10.798; 95% CI 2.520 to 46.272; p=0.001), large left atrium (OR 6.763; 95% CI 2.253 to 20.302; p=0.001), and not using aspirin (OR 10.526; 95% CI 1.298 to 83.333; p=0.027) were other independent predictors. Our data suggest that silent brain infarcts are very prevalent among patients with a PMV, as one fourth of them had the event during their routine outpatient visit. Poor quality of anticoagulation partly explains the increased prevalence.

P2753Anticoagulation control and all-cause death in patients with operated valvular heart disease with and without atrial fibrillation receiving vitamin K antagonists

Abstract Introduction Good quality of anticoagulation in patients with valvular heart disease (VHD) is needed to reduce ischaemic complications. There is limited evidence on factors affecting anticoagulation control in patients implanted with mechanical or tissue prosthetic valve(s). Objective To examine quality, factors affecting anticoagulation control and all-cause death in VHD patients with and without atrial fibrillation (AF) receiving a vitamin K antagonist (VKA) oral anticoagulant. The relationship between INR control with all-cause death and ≥1 adverse clinical events (ACE) [thromboembolism, bleeding, cardiovascular hospitalisation and all-cause death] were explored. Methods Anticoagulation control of 456 VHD patients [164 (36%) with AF and 290 (64%) without AF] referred to a hospital-based anticoagulation clinic were assessed retrospectively by time in therapeutic range (TTR) (Rosendaal) and percentage of INRs in range (PINRR) for a median of (IQR) 6.2 years (3.3–8.5). VHD was defined by the presence of mechanical or tissue prosthetic valve at either the mitral or aortic site or both. Results Mean (SD) age 51 (14.7), 64.5% male, mean (SD) CHA2DS2-VASc score 2.0 (1.4), 96.1% mechanical prosthesis and 64% aortic valve replacement. VHD patients with AF had lower mean TTR and PINRR, lower proportion of optimal TTR (i.e.≥70%) despite similar number of INR tests compared to VHD patients without AF [Table 1]. Predictors of poor TTR on multivariate logistic regression analysis were female sex, AF and anaemia/bleeding history. Significantly higher proportions of VHD patients with AF died [Table 1]. More deaths (13.1% vs. 4.1%; p=0.011) and ≥1 ACE (42.7% vs. 27.6%; p=0.006) were seen in VHD patients with TTR &lt;70% vs. TTR≥70%, respectively. Table 1 N (%) Total (N=456) AF (N=164) No AF (N=290) p-value Mean (SD) TTR 58.5 (14.6) 55.7 (14.2) 60.1 (14.6) 0.002 TTR ≥70% 98 (21.5) 23 (14.0) 75 (25.7) 0.004 Mean (SD) PINRR 50.1 (13.8) 47.4 (13.5) 51.6 (13.7) 0.002 Mean (SD) INR tests 96.2 (55.3) 100.7 (58.8) 93.7 (53.1) 0.19 All-cause death 51 (11.2) 34 (20.7) 17 (5.8) &lt;0.001 AF: Atrial fibrillation; IQR: interquartile range; PINRR: percentage of INRs in range; SD: standard deviation; TTR: Time in therapeutic range. Conclusion The quality of anticoagulation in VHD patients with AF was low. The presence of AF, anaemia/bleeding history and female sex independently predicted poor TTR. All-cause death was more common in VHD patients with AF and poor TTR. Closer INR monitoring is needed especially in VHD patients with AF to improve anticoagulation control and prevent adverse clinical outcomes. Acknowledgement/Funding Kementerian Pendidikan Malaysia and Universiti Teknologi MARA for PhD study but not directly for work under consideration

Cost of Healthcare Associated With Deep Vein Thrombosis in Patients Treated With Warfarin in Turkey: 2010-2013 Database Analysis of a Tertiary Care Center

ObjectivesTo evaluate the cost of healthcare with respect to the quality of anticoagulation in patients with deep vein thrombosis (DVT) treated with warfarin in daily practice via the database analysis of a tertiary care center in the period 2010 to 2013. MethodsOf 258 307 records in total, 42 582 unique patients with DVT and 32 012 patients with international normalized ratio (INR) measurements were included. Overall, 6720 unique patients with DVT diagnosis and one or more INR measurements were identified, and the records of 4377 out of 6720 unique patients were validated and included in the analysis data set. The cost analysis was based on direct medical costs from the payer’s perspective. Cost items were related to healthcare resource utilization (inpatient and outpatient services) during the study period, which provided a basis for calculation of per-patient, outpatient, inpatient, and total direct medical costs. ResultsMean outpatient, inpatient, and total hospital admission costs were $578, $2195, and $2785, respectively, for patients with time in the therapeutic range of 70% or more, whereas the same costs were $571, $2163, and $3192, respectively, for patients with time in the therapeutic range of less than 70%. ConclusionsOur findings for a retrospective cohort of patients with DVT undergoing warfarin therapy reveal that patients spent 70% or more, as opposed to less than 70%, of follow-up time within the therapeutic INR range and that outpatient care, as opposed to inpatient care, was associated with lower healthcare costs. Given the significant contribution that hospital stay makes to the cost burden of DVT, our findings also highlight the association between poor warfarin anticoagulant control and increased hospitalization costs.

ICUSI questionnaire validation. Quality of anticoagulation in patients with atrial fibrillation treated with vitamin K antagonists

Introduction and objectivesVitamin K antagonists (VKAs) are still widely used for stroke prevention in atrial fibrillation. However, the access to international normalised ratio (INR) determinations is sometimes difficult and the time in therapeutic range (TTR) is not always available. The aim of this study was to design and validate a simple and easy-to-use questionnaire that enables the identification of atrial fibrillation patients with poor quality of anticoagulation. MethodsThis is a national, multi-centre, observational, and cross-sectional study including consecutive non-valvular atrial fibrillation patients receiving VKA therapy and followed up at cardiology clinics. At inclusion, INR determinations during the last 6 months were analysed to determine the TTR and the ICUSI questionnaire was completed. A TTR < 65% was considered suboptimal. ResultsA total of 813 patients (55% men, 75±9 years old) were available for the analyses. The mean TTR was 62.2%±20.3% and 427 (52.5%) patients had a TTR < 65%. The final version of the ICUSI questionnaire included 4 questions and the mean ICUSI score was 1.19±1.17. The predictive ability of the ICUSI questionnaire for predicting TTR < 65% was moderate (c-index, 0.707; 95%CI, 0.670–0.740; P<.001). An ICUSI score of 1 showed a sensitivity of 80.8% and a specificity of 45.6%, whereas an ICUSI score of 2 showed a sensitivity of 43.2% and a specificity of 88.1%. ConclusionsThe ICUSI questionnaire has shown a good predictive performance for the identification of poor TTR in the absence of full access to the INR determinations in atrial fibrillation patients under VKA therapy.

A Comparison between TTR and FIR as a Measure of the Quality of Anticoagulation in Patients with Atrial Fibrillation

Abstract Background: Atrial fibrillation (AF) is a growing concern worldwide. In order to prevent AF-related adverse vascular events, adequate oral anticoagulation with warfarin is essential. The Rosendaal method has long been used to calculate time in therapeutic range (TTR) in clinical trials to assess the quality of anticoagulation but now suffers dwindling popularity due to its tedious method of calculation and inability to account for the duration spent in an out-of-range international normalized ratio (INR). Frequency in range (FIR) is being reassessed as to its value as it is easier to calculate. Objectives: We aimed to compare FIR and TTR (using the Rosendaal method) as a measure to assess the quality of anticoagulation with warfarin in a cohort of 102 consecutive patients with valvular and non-valvular AF at a tertiary South African hospital. Secondary objectives were to assess the predictive ability of FIR to categorize patients with a TTR ≥ 65% as well as to compare the CHA2DS2VASc and HASBLED scores with TTRs and FIRs. Methods: We retrospectively analysed the INR values for all patients over a 2-year period and calculated both individual and overall mean TTR and FIR and assessed the agreement between these parameters. Results: The mean overall TTR was 58.1% ± 16% and the mean FIR was 50.8% ± 16.7%. The mean TTR was significantly higher than the mean FIR (p &lt; 0.0001). At the individual level, FIR was positively correlated with TTR in a linear fashion ( r = 0.93, p &lt; 0.001). However, the Bland–Altman method plot indicated lack of agreement between TTR and FIR, with a bias of 7.4% (95% CI: 6.1%–8.6%) and limits of agreement −4.6% to 19.3%, standard deviation (SD) = 6.1%. A cut-off value of FIR ≥ 53.3% was found to be a good predictor of TTR ≥65%. Conclusion: Our study shows that although TTR and FIR are highly correlated with the individual INR levels, they are not equal. The two methods cannot be used interchangeably to assess warfarin control, and TTR should probably remain the gold standard.

Anticoagulation Control and Factors Affecting Quality of Anticoagulation in Patients with Non-Valvular Atrial Fibrillation in a Secondary Care Hospital in Malaysia

Background: Vitamin K antagonists (VKA) decrease the risk of stroke by 60% in patients with atrial fibrillation (AF). Time in therapeutic range (TTR) is a measure of anticoagulation therapy. TTR > 65% is essential for patients to benefit from anticoagulation therapy. TTR among the Asian population is poor but there is paucity of data on the predictors of poor TTR in this population.

SAMe-TT2R2 predicts quality of anticoagulation in patients with acute venous thromboembolism: The MAQI2 experience.

A high SAMe-TT2R2 score predicted poor warfarin control and adverse events among atrial fibrillation patients. However, the SAMe-TT2R2 score has not been well validated in venous thromboembolism (VTE) patients. A cohort of 1943 warfarin-treated patients with acute VTE was analyzed to correlate the SAMe-TT2R2 score with time in therapeutic range (TTR) and clinical adverse events. A TTR <60% was more frequent among patients with a high (>2) versus low (0-1) SAMe-TT2R2 score (63.4% vs 52.3%, p<0.0001). A high SAMe-TT2R2 score (>2) correlated with increased overall adverse events (7.9 vs 4.5 overall adverse events/100 patient years, p=0.002), driven primarily by increased recurrent VTE rates (4.2 vs 1.5 recurrent VTE/100 patient years, p=0.0003). The SAMe-TT2R2 score had a modest predictive ability for international normalized ratio (INR) quality and adverse clinical events among warfarin-treated VTE patients. The utility of the SAMe-TT2R2 score to guide clinical decision-making remains to be investigated.

Factors Affecting the Quality of Anticoagulation With Vitamin K Antagonists in Venous Thromboembolism Patients.

Treatment of venous thromboembolism (VTE) is classically based on oral vitamin K antagonists (VKAs). Due to the disadvantages and side effects of these drugs, monitoring the quality of anticoagulation by assessing time within therapeutic range (TTR) is recommended. Variables altering the TTR in patients with VTE are yet to be determined. The aim of this study was to analyze the quality of anticoagulation in patients with VTE treated with VKAs and to identify factors associated with poor-quality anticoagulation. A retrospective observational study was performed in a cohort of 94 patients diagnosed with VTE undergoing treatment with VKAs. The TTR at 6 months was analyzed by the Rosendaal method. Univariate and a multivariate logistic regression analyses were performed to unravel factors that increase risk of poor-quality anticoagulation. The TTR at 6 months in this cohort was 60.5%; 54 patients had a TTR < 65%. In the univariate analysis, female sex, age ≥ 65 years, and renal impairment were significantly associated with poor-quality anticoagulation. However, in the multivariate logistic regression model, only renal impairment was independently associated with poor-quality anticoagulation (odds ratio = 3.31, 95% confidence interval [1.049, 10.486], p = .041). The average quality of anticoagulation was 60.5%, and a high percentage of patients had a quality of anticoagulation below recommended levels. Study findings indicate that renal impairment is an independent risk factor for poor-quality anticoagulation in patients with VTE treated with VKAs.

Anticoagulation for the prevention of stroke in non-valvular AF in general practice: room for improvement.

Objective:Our aim was to assess whether the recommendations and guidelines for thromboprophylaxis in patients with atrial fibrillation (AF) have been adopted in general practice (GP).Methods:We conducted a retrospective study using the GP computer database (Hatfield, UK) on all 9400 patients to assess the quality of anticoagulation in patients with a recorded diagnosis of AF.Results:Of the 180 patients with a diagnosis of AF, 107 (59.4%) were treated with warfarin, 19 (10.6%) with a novel oral anticoagulant (NOAC), 31 (17.2%) with aspirin or clopidogrel, and 23 (12.8%) received none. Thirty-seven patients (34.6%) who were taking warfarin had a time in the therapeutic range (TTR) of less than 65%. Forty-five (27.6%) of the 163 patients who had a CHA2DS2VASc score of two or more were not prescribed a vitamin K antagonist (VKA) or a NOAC. None had a HAS-BLED greater than the CHA2DS2VASc score.Conclusion:Our study demonstrates that one in four patients with non-valvular AF, at risk of a stroke, is not being adequately treated with an oral anticoagulant in primary care. The majority were treated with warfarin, a third of which had a low TTR. A high proportion of patients are prescribed antiplatelet therapy instead. This is despite overwhelming evidence that VKAs and NOACs, and not aspirin or clopidogrel, improve outcome in patients with non-valvular AF. We suggest that a review of GP practice databases should be considered to identify patients with non-valvular AF, at risk of a disabling or fatal event, and measures taken to initiate anticoagulant therapy.

Quality of oral anticoagulation in patients with atrial fibrillation: A cross-sectional study in general practice

Objective: To evaluate the quality of management of oral anticoagulation among patients on oral anticoagulation for atrial fibrillation, and to verify the relation between patient performance and the risk of an event due to therapy. Methods: In a retrospective cross-sectional study involving 66 general practices, international normalized ratio (INR) values obtained over a 6-mo period were analysed. All INR values were determined by a single clinical laboratory, and additional medical information was provided by GPs. Results: 395 patients were included in the study, with a mean age of 74±9.6 y. In total, 3111 INR values were obtained. The mean number of tests/month per patient was 2.7±4.3. A total of 49 728 d of therapy was evaluated. Fifty-three per cent of the day values were within 0.5 INR units of the target (and 69% within 0.75 INR units of the target). The incidence rate for major bleeding was 4.4/100 patient years (and 2.9/100 patient years for thromboembolic events). There was a significant relation between patient performance and the presence of an event (p=0.017), with an odds ratio of 2.8 (95% CI 1.3–6.3).Conclusion: The quality of oral anticoagulation in patients with atrial fibrillation is suboptimal. This is significantly related to an increased risk of haemorrhagic events.