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Godoy LC, Tomlinson G, Abumuamar AM, Farkouh ME, Rudolph M, Billia F, Cohn I, Marcus G, Kim RH, Rao V, Lawler PR. Association between time to therapeutic INR and length of stay following mechanical heart valve surgery. J Card Surg 2021; 37:62-69. [PMID: 34662458 DOI: 10.1111/jocs.16083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/08/2021] [Accepted: 10/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Warfarin is the only oral anticoagulant approved for use following mechanical valve surgery (MeVS). Patients may experience prolonged hospital length of stay (LOS) following MeVS awaiting an appropriate warfarin effect. We aimed to determine whether an association exists between time to achieve the first therapeutic international normalized ratio (INR) and LOS following MeVS. MATERIALS AND METHODS Retrospective single center cohort study. We included consecutive adult patients undergoing elective MeVS from 2013 to 2018. Landmark analyses and multivariable regression with time-updated INR were used to estimate the association between time to therapeutic INR (TTI) and LOS. RESULTS Among 384 patients (median age: 51 years, interquartile range [IQR]: 41-57; 58.3% male), the median TTI was 4 days (IQR: 2-5). Thirty seven percent of patients were discharged with a subtherapeutic INR, many on bridging anticoagulation or with an INR close to target. Those achieving therapeutic INR had an increased rate of hospital discharge (adjusted hazard ratio: 2.17; 95% confidence interval: 1.71-2.76; p < .0001). Attainment of a therapeutic INR anytime between postoperative Days 4 and 13 was significantly associated with a shorter LOS. CONCLUSIONS Prolonged time to achieve a therapeutic INR was independently associated with prolonged LOS. Future strategies aimed at improving attainment of therapeutic INR following MeVS may reduce hospital LOS.
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Affiliation(s)
- Lucas C Godoy
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Sao Paulo, Brazil
| | - George Tomlinson
- Biostatistics Research Unit, Toronto General Hospital Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Asmaa M Abumuamar
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Madeleine Rudolph
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Iris Cohn
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gil Marcus
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, Shamir Medical Center, Zeriffin, Israel.,Schulich Heart Program, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Raymond H Kim
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Ted Rogers Centre for Heart Research, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology and Hematology, University Health Network, Sinai Health System, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada
| | - Patrick R Lawler
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Self-management of patients with heart valve replacement and its clinical outcomes: a systematic review. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 18:40-49. [PMID: 34552643 PMCID: PMC8442083 DOI: 10.5114/kitp.2021.105186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/15/2021] [Indexed: 11/17/2022]
Abstract
Introduction For patients with heart valve replacement, self-management can play an essential role in the management of their condition. Aim This review aimed to identify the aspects of self-management and its clinical outcomes in patients with heart valve replacement. Material and methods In this systematic review, the peer-reviewed research literature on self-management of patients with heart valve replacement was assessed. Since May 2020, the PubMed, Scopus, and web of science databases were searched regardless of time and language limitations. The eligibility of the articles was assessed by title or abstract according to the search strategy. Article selection was applied regarding to inclusion and exclusion criteria. Also, article screening was conducted by 2 independent authors. Results Twenty-five studies were considered in this systematic review. For inclusion, the self-management of patients had to have prerequisites, appropriate training, and be applicable in the aspects of anticoagulation therapy self-management, international normalized ratio (INR) self-testing, low-dose INR self-management, and heart valve function self-monitoring. In this method, through proper management of INR levels and anticoagulation therapy, the complications rate could be reduced and the patients would be able to diagnose functional disorders in the early stages by monitoring the valve function. This procedure was able to prevent the progression of complications. Conclusions Self-management is an applicable protocol in the field of anticoagulation therapy, INR control, low-dose INR management, and the monitoring of cardiac valve function. This protocol could improve the quality of treatment for these patients through upgrading the care standards.
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Alkhouli M, Alqahtani F, Simard T, Pislaru S, Schaff HV, Nishimura RA. Predictors of Use and Outcomes of Mechanical Valve Replacement in the United States (2008-2017). J Am Heart Assoc 2021; 10:e019929. [PMID: 33870704 PMCID: PMC8200758 DOI: 10.1161/jaha.120.019929] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Contemporary nationwide data on the use, predictors, and outcomes of mechanical valve replacement in patients less than 70 years of age are limited. Methods and Results We identified hospitalizations for aortic valve replacement (AVR) or mitral valve replacement (MVR) in the Nationwide Inpatient Sample between January 1, 2008, and December 31, 2017. The study's end points included predictors of mechanical valve replacement and risk‐adjusted in‐hospital mortality. Among 253 100 hospitalizations for AVR, the use rate of mechanical prosthesis decreased from 45.3% in 2008 to 17.0% in 2017. Among 284 962 hospitalizations for MVR, mechanical prosthesis use decreased from 59.5% in 2008 to 29.2% in 2017 (P for trend<0.001). In multilogistic regression analyses, female sex, prior sternotomy, prior defibrillator, and South/West geographic location were predictive of mechanical valve use. The presence of bicuspid valve was a negative predictor of mechanical AVR (odds ratio [OR], 0.68; 95% CI, 0.66–0.69; P<0.001), whereas mitral stenosis was associated with higher mechanical MVR (OR, 1.28; 95% CI, 1.22–1.33; P<0.001). Unadjusted in‐hospital mortality decreased over time with AVR but not with MVR, regardless of prosthesis choice. Using years 2008 and 2009 as a reference, risk‐adjusted mortality also decreased over time with AVR but did not decrease after MVR. Conclusions There is a substantial decline in the use of mechanical valve replacement among patients aged ≤70 years in the United States. Long‐term durability data on bioprosthetic valve replacement are needed to better define the future role of mechanical valves in this age group.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Diseases Mayo Clinic School of Medicine Rochester MN
| | - Fahad Alqahtani
- Division of Cardiology West Virginia University Morgantown WV
| | - Trevor Simard
- Department of Cardiovascular Diseases Mayo Clinic School of Medicine Rochester MN
| | - Sorin Pislaru
- Department of Cardiovascular Diseases Mayo Clinic School of Medicine Rochester MN
| | - Hartzell V Schaff
- Department of Cardiovascular Diseases Mayo Clinic School of Medicine Rochester MN
| | - Rich A Nishimura
- Department of Cardiovascular Diseases Mayo Clinic School of Medicine Rochester MN
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Larsen T, Hjortdal V, Christensen T. Self-testing and self-management of oral anticoagulation therapy in children. Thromb Haemost 2017; 106:391-7. [DOI: 10.1160/th11-04-0217] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 05/19/2011] [Indexed: 11/05/2022]
Abstract
SummaryChildren and adolescents on oral anticoagulation therapy (OAT) present special challenges in terms of rapid fluctuations in International Normalised Ratio (INR) values, interruption in daily life due to frequent hospital/doctor visits, and difficulties and pain in the performance of venepuncture. Optimised management of OAT improves the quality of treatment, potentially accomplished by new methods such as patient self-testing (PST) and patient self-management (PSM). A review was performed, identifying 11 trials with children and adolescents. All studies had different methodological problems, predominantly by being non-randomised trials. A total of 284 patients were included with a mean follow-up of 22 months, finding a time within therapeutic INR target range between 63% and 84%. The coagulometers used for estimating the INR values were found to have sufficient precision and accuracy for clinical use, but external quality control is probably advisable. It can be concluded that PST and PSM are at least as good treatment options as conventional management in highly selected children. Larger studies, preferably randomised, controlled trials using clinical endpoints, are obviously needed in order to elucidate whether these new regimens of treatment are superior to conventional management of oral anticoagulation therapy.
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Safety and Efficacy Outcomes of Home and Hospital Warfarin Management Within a Pediatric Anticoagulation Clinic. J Pediatr Hematol Oncol 2016; 38:216-20. [PMID: 26808370 DOI: 10.1097/mph.0000000000000502] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The complexity of managing children with chronic disease has led to an increase in the use of long-term warfarin therapy. Time in therapeutic range (TTR) is the preferred method for determining efficacy and stability of warfarin management. This study aimed to determine the TTR achievement and incidence of adverse events among pediatric warfarin patients managed by an anticoagulation clinic over 12 months and to compare TTR achievement between patients self-testing (PST) at home and those monitored using routine methods. International normalized ratio (INR) results reported for 2012 for children currently having their warfarin therapy managed by a dedicated pediatric anticoagulation clinic were analyzed. Warfarin-related adverse events were recorded. A total of 164 patients were included. In total, 93 children performed PST and 71 children tested their INR at a hospital or pathology service. TTR achievement for the cohort was 67.1% (95% confidence interval, 64.4-69.7). A total of 69.2% of INR tests conducted at home were within the TTR compared with 64.3% of INR tests conducted at a hospital or pathology service (P=0.07). One major bleeding event occurred and there was 1 thrombotic episode. PST demonstrated noninferior warfarin stability compared with routine methods. Routine outcome evaluation of pediatric anticoagulation management within single institutions is necessary to confirm the success of such programs.
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Chen QL, Dong L, Dong YJ, Zhao SL, Fu B, Wang YQ, Jiang H. Security and cost comparison of INR self-testing and conventional hospital INR testing in patients with mechanical heart valve replacement. J Cardiothorac Surg 2015; 10:4. [PMID: 25592732 PMCID: PMC4308889 DOI: 10.1186/s13019-015-0205-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 01/07/2015] [Indexed: 02/05/2023] Open
Abstract
Background International normalized ratio (INR) self-testing can improve the management of anticoagulation therapy with warfarin for the patients following mechanical heart valve replacement. Several reviews and studies have demonstrated self-management as an option to improve patient’s outcome considerably after mechanical heart valve replacement. We sought to analyze the security, economy and discuss the prospect of self-testing of anticoagulation therapy in patients following mechanical heart valve replacement in China, and evaluate the accuracy and stability of CoaguChek XS portable INR-testing device. Methods This was a prospective self-controlled clinical study conducted with 526 patients receiving oral warfarin anticoagulation therapy after mechanical heart valve replacement in the period of Mar.1, 2012 – Nov.1, 2012 in Cardiovascular Surgery Department of West China Hospital of Sichuan University. The same patient performed INR testing with CoaguChek XS portable coagulometer (group1) and central lab (group 2) in parallel. The follow-up time was 6 months. Meanwhile, a questionnaire was handed out to survey the expenses required for the re-examination visits to the hospital, time, and anticoagulation complications. Results No severe anticoagulation complications occurred in all the patients. No significant difference of the INR results were observed between group 1 and group 2, they showed significant relevance, r = 0.953(p < 0.05). Compared with the conventional method of INR testing in hospital, the portable coagulometer is convenient, quick and less traumatic. Self-testing of anticoagulation therapy reduced the cost and the time required for re-examination. Conclusions Results of CoaguChek XS monitor are precise and have a good consistency and stability as compared with traditional laboratory testing. For the patients receiving anticoagulation therapy after mechanical heart valve replacement, the self-testing of anticoagulation therapy with portable coagulometer is a safe choice, and it has a promising future application in China.
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Affiliation(s)
- Qiu-lin Chen
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P R China.
| | - Li Dong
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P R China.
| | - Yi-jun Dong
- Department of Oncology, West China Hospital, Sichuan University, Chengdu, 610041, P R China.
| | - Shu-lin Zhao
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P R China.
| | - Bo Fu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P R China.
| | - Yu-qing Wang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P R China.
| | - Hong Jiang
- Department of Clinical Laboratory, West China Hospital, Sichuan University, Chengdu, 610041, P R China.
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Anticoagulation early after mechanical valve replacement: improved management with patient self-testing. J Thorac Cardiovasc Surg 2012; 146:599-604. [PMID: 22921821 DOI: 10.1016/j.jtcvs.2012.03.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 03/15/2012] [Accepted: 03/28/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Self-testing to determine the international normalized ratio improves management with warfarin and reduces the risks of adverse events. Self-testing usually begins several weeks after hospital dismissal after valve replacement. We aimed to compare the in-hospital initiation of international normalized ratio self-testing with usual care in mechanical heart valve recipients. METHODS A total of 200 adult mechanical heart valve recipients were randomly assigned to in-hospital international normalized ratio self-testing instruction or usual care. Instruction for self-testing patients began on the fourth postoperative day. The patients were followed up for 3 months to compare the number of international normalized ratio tests, percentage of time in the therapeutic range, and adverse events. RESULTS The baseline characteristics were similar between the 2 groups. During the first 3 postoperative months, the usual-care group underwent an average of 10 international normalized ratio tests, and the self-testing group completed 14 international normalized ratio tests. The mean ± SD percentage of international normalized ratio tests within the therapeutic range was 45% ± 22% for the usual-care group and 52% ± 22% for the self-testing group (P = .05). Within 90 days after dismissal, transient ischemic attack occurred in 1 patient in the usual-care group and 2 patients in the self-testing group. Bleeding complications occurred in 3 patients in the usual-care group and 5 patients in the self-testing group. CONCLUSIONS Management of anticoagulation with warfarin after mechanical valve replacement is improved with self-testing, even during the early postoperative phase when international normalized ratio testing is performed frequently. Although the incidence of adverse events was similar in the 2 groups, better control of the international normalized ratio would be expected to improve outcome in large populations of patients.
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Christensen TD, Larsen TB. Precision and accuracy of point-of-care testing coagulometers used for self-testing and self-management of oral anticoagulation therapy. J Thromb Haemost 2012; 10:251-60. [PMID: 22118602 DOI: 10.1111/j.1538-7836.2011.04568.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Oral anticoagulation therapy is monitored by the use of the International Normalized Ratio (INR). Patients who perform self-testing or self-management use a point-of-care testing (POCT) coagulometer (INR monitor) to estimate their INRs. A precondition for a correct dosage of coumarins is a correct INR estimation, and the method and apparatus used for providing the INR measurements are crucial in this context. Several studies have been published regarding the precision and accuracy of these POCT coagulometers, and have led to diverse conclusions. It is difficult and challenging to perform an overview of the literature, owing to the vast amount of papers, with differences in design, statistical analysis, etc. OBJECTIVES The aim of this systematic review was to analyze the current literature, especially regarding the precision and accuracy of the POCT coagulometers, to provide recommendations for clinical use and quality control, and to point out areas for future research. METHODS We included a total of 22 studies, of which four were characterized as high-quality studies. RESULTS The precision of the POCT coagulometers was generally adequate for clinical use. Their performance in terms of accuracy has to be viewed in the context of the inherent inaccuracies of INR measurements. CONCLUSIONS The accuracy of POCT coagulometers seems, in this respect, to be generally acceptable, and they can be used in a clinical setting.
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Affiliation(s)
- T D Christensen
- Department of Cardiothoracic and Vascular Surgery & Institute of Clinical Medicine, Aarhus University Hospital, Aarhus N., Denmark.
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