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Özdemir E, Ekinci AS, Emren SV, Balaban S, Tiryaki MM, Karaca M, Tiryaki ENÖ, Nazlı C. Evaluation of the Relationship between Cognitive Impairment and Atria Score Systems in Patients with Atrial Fibrillation. Ann Indian Acad Neurol 2024; 27:46-52. [PMID: 38495254 PMCID: PMC10941894 DOI: 10.4103/aian.aian_674_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 03/19/2024] Open
Abstract
Background Atrial fibrillation (AF) is the main arrhythmia associated with thromboembolic complications and cognitive impairment. In this study, we aimed to evaluate the relationship between cognitive impairment and different scoring systems developed for AF to improve the medical follow-up of cognitive impairment. Methods Between January 2019 and December 2020, 124 patients between the age of 30 and 80 years, diagnosed with AF for at least 5 years and complaining about memory impairment during cardiological follow-up, were included in the study. The patients were divided into two groups based on their cognitive status as assessed by the Mini-Mental State Examination group 1 consisted of 52 patients with cognitive impairment and group 2 comprised 72 patients without cognitive impairment. Results The ATRIA bleeding score had a positive moderate correlation (r = 0.454, P < 0.001), the ATRIA stroke score had a strong correlation (r = 0.738, P < 0.001), and the SAMe-TT2R2 score had a strong correlation (r = 0.688, P < 0.001) with cognitive impairment. However, CHADS2 and CHA2DS2VASc scores were not statistically correlated with cognitive impairment. According to the receiver operating characteristic (ROC) curve, the area under the curve (AUC) of the ATRIA bleeding score was 0.761 with a 95% confidence interval (CI) of 0.678-0.844 and P < 0.001; also, for the ATRIA stroke score, AUC was 0.930 with a 95% CI of 0.886-0.974 and P < 0.001. In addition, for the SAMe-TT2R2 score, AUC was 0.895 with a 95% CI of 0.838-0.952 and P < 0.001. In the pairwise comparison of AUC on ROC curves, the ATRIA stroke score and the SAMe-TT2R2 score were statistically similar (P = 0.324). ATRIA bleeding, ATRIA stroke, and SAMe-TT2R2 scores were greater than CHADS2 stroke score (P: 0.0004, P < 0.0001, and P < 0.0001, respectively), but CHA2DS2-VASc and CHADS2 stroke scores were statistically similar (P: 0.402). Conclusion Both ATRIA stroke and SAMe-TT2R2 scoring systems can provide a better correlation than CHADS2 and CHA2DS2-VASc scores in patients with AF to evaluate their cognitive status. These two scores can be more useful to monitor the patients with AF for medical follow-up of cognitive status.
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Affiliation(s)
- Emre Özdemir
- Department of Cardiology, Ataturk Research and Training Hospital, Izmir Katip Çelebi University, Izmir/Turkey
| | - Ayşen S. Ekinci
- Department of Neurology, Ataturk Research and Training Hospital, Izmir Katip Çelebi University, Izmir/Turkey
| | - Sadık V. Emren
- Department of Cardiology, Ataturk Research and Training Hospital, Izmir Katip Çelebi University, Izmir/Turkey
| | - Simge Balaban
- Department of Neurology, Ataturk Research and Training Hospital, Izmir Katip Çelebi University, Izmir/Turkey
| | - Muhammet M. Tiryaki
- Department of Cardiology, Ataturk Research and Training Hospital, Izmir Katip Çelebi University, Izmir/Turkey
| | - Mustafa Karaca
- Department of Cardiology, Ataturk Research and Training Hospital, Izmir Katip Çelebi University, Izmir/Turkey
| | - Enise N. Özlem Tiryaki
- Department of Neurology, Ataturk Research and Training Hospital, Izmir Katip Çelebi University, Izmir/Turkey
| | - Cem Nazlı
- Department of Cardiology, Ataturk Research and Training Hospital, Izmir Katip Çelebi University, Izmir/Turkey
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Social App to Improve Warfarin Therapy in Post-MHVR Chinese Patients: A Randomized Controlled Trial. Cardiovasc Ther 2023; 2023:2342111. [PMID: 36714197 PMCID: PMC9867580 DOI: 10.1155/2023/2342111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 01/15/2023] Open
Abstract
Background Poor anticoagulation quality was a major problem among warfarin-treated patients, which called for innovative and effective methods to improve it. Objective To investigate whether social app could be used to reduce warfarin-associated adverse events among post-MHVR Chinese patients. Method 735 warfarin-treated patients (aged 50.8 ± 9.6 years, 59.9% female) were enrolled and randomized to a social app care group (warfarin therapy was guided by experienced clinicians via a social app) or a routine care group (warfarin therapy was managed through traditional in-office visits) at a 1 : 1 ratio. Ending points (bleeding and thrombotic events) were recorded during an 18-month follow-up period. Results A total of 718 patients were included in analysis. 57 of them suffered warfarin-associated adverse events, including 30 major bleedings and 27 thrombotic events. The time in the therapeutic range (TTR, Rosendaal method) in the social app group was 71.5%, which was significantly better than 52.6% in the routine care group (difference: 18.8%, 95% CI: 16.8-20.8). Compared with the patients from the social app group, patients under routine care experienced more bleeding (hazard ratio (HR): 2.31, 95% CI: 1.13-4.72). The social app care group had lower variation (0.55 vs. 0.70) in the international normalized ratio (INR) values and fewer incidents of extremely high INR (e.g., INR > 5.0, 0.87% vs. 3.42%) than the routine care group. Conclusions Social app management could significantly improve warfarin control and was associated with a reduction in bleeding risk. This trial was registered with NCT03264937.
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Phrommintikul A, Nathisuwan S, Gunaparn S, Krittayaphong R, Wongcharoen W, Sehmi S, Mehta S, Winkles N, Brocklehurst P, Mathers J, Jowett S, Jolly K, Lane D, Thomas GN, Lip GYH. Prospective randomised trial examining the impact of an educational intervention versus usual care on anticoagulation therapy control based on an SAMe-TT 2R 2 score-guided strategy in anticoagulant-naïve Thai patients with atrial fibrillation (TREATS-AF): a study protocol. BMJ Open 2021; 11:e051987. [PMID: 34635526 PMCID: PMC8506852 DOI: 10.1136/bmjopen-2021-051987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The burden of atrial fibrillation (AF) in Thailand is high and associated with increased morbidity, mortality and healthcare costs. Vitamin K antagonists (eg, warfarin), commonly used for stroke prevention in patients with AF in Thailand, are effective but are often suboptimally controlled. We aim to evaluate the impact of an SAMe-TT2R2 score-guided strategy and educational intervention compared to usual care on anticoagulation control expressed by the time in therapeutic range (TTR) at 12 months, in anticoagulant-naïve Thai patients with AF. METHODS AND ANALYSIS Multicentre, open-label, parallel-group, randomised controlled trial conducted in Thailand among adult patients (age: 18 years) with AF who are anticoagulant naïve. Patients will be randomised to one of two groups; an SAMe-TT2R2 score-guided strategy with educational intervention and usual care versus usual care alone. The planned follow-up period is 12 months. The primary outcome is TTR at 12 months. Secondary outcomes include: (1) TTR at 6 months; (2) thromboembolic and bleeding events at 12 months; (3) composite major adverse cardiovascular events at 12 months; (4) change in patients' knowledge of AF between baseline and 6 months and 12 months; (5) cost effectiveness; (6) quality of life at baseline, 6 months and 12 months using EQ-5D-5L (Thai version) and (7) patient satisfaction/perceptions of the TREAT intervention. An embedded qualitative study will assess patient perceptions of the TREAT intervention. ETHICS AND DISSEMINATION The study has been approved by the Ethical Review Committee, Ministry of Public Health of Thailand, and registered in the Thai Clinical Trials Registry. The results of this trial will be submitted for publication in a peer-reviewed journal. Participants will be informed via a link to a preview of the publication. A lay summary will also be provided to all participants prior to publication. TRIAL REGISTRATION NUMBER TCTR20180711003.
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Affiliation(s)
- Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Medical Excellence, Faculty of Medicine, Chiang Mai, Thailand
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Siriluck Gunaparn
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sukhi Sehmi
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Samir Mehta
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Neil Winkles
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Deirdre Lane
- Department of Cardiovascular Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - G Neil Thomas
- Department of Public Health and Epidemiology, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg Universitet, Aalborg, Denmark
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Bernaitis N, Badrick T, Anoopkumar-Dukie S. The SAMe-TT 2R 2 score as an indicator of warfarin control for patients with deep vein thrombosis in Queensland, Australia. J Thromb Thrombolysis 2021; 50:614-618. [PMID: 32080812 DOI: 10.1007/s11239-020-02068-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Oral anticoagulation options for patients with venous thromboembolism (VTE) include vitamin K antagonists like warfarin. Good warfarin control is linked to outcomes of therapy, and the SAMe-TT2R2 model has been reported to predict control in atrial fibrillation patients with scores ≥ 2 linked to poor control. There has been limited and conflicting data in VTE populations, therefore this study aimed at determining the predictive ability of this model in Australian patients with deep vein thrombosis. Retrospective data of patients receiving warfarin care at a private pathology clinic in Queensland was collected. The time in therapeutic range (TTR) and SAMe-TT2R2 score was calculated for individual patients. Mean TTR and patients with TTR ≥ 65% were used for analysis and comparison across patients categorised as a score of 0-1 and ≥ 2. Of the 533 patients, the majority had a SAMe-TT2R2 score of 0-1. No significant difference was found in mean TTR between patients with a score of 0-1 and ≥ 2 but there was a significantly higher percentage of patients with a TTR ≥ 65% between groups (93.8% vs. 69.2%, p < 0.0001, respectively). The SAMe-TT2R2 score may assist in identifying patients with VTE likely to achieve good control (TTR ≥ 65%), but further investigation is required to determine the most suitable model for predicting warfarin control in this population.
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Affiliation(s)
- Nijole Bernaitis
- Quality Use of Medicines Network, Griffith University, Gold Coast Campus, QLD, Australia. .,School of Pharmacy and Pharmacology, Griffith University, Gold Coast Campus, QLD, 4222, Australia.
| | - Tony Badrick
- The Royal College of Pathologists of Australasia (RCPA) Quality Assurance Programs, New South Wales, Australia
| | - Shailendra Anoopkumar-Dukie
- Quality Use of Medicines Network, Griffith University, Gold Coast Campus, QLD, Australia.,School of Pharmacy and Pharmacology, Griffith University, Gold Coast Campus, QLD, 4222, Australia
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Lertsanguansinchai P, Huntrakul A, Rungpradubvong V, Chokesuwattanaskul R, Prechawat S. Factors predicting poor anticoagulant control on warfarin in a Thai population with non-valvular atrial fibrillation (NVAF): the ACAChE score. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2021. [DOI: 10.1186/s42444-021-00038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In many low- to middle-income countries in Asia, patients with NVAF usually received warfarin for thromboembolic prevention due to cost-effectiveness. The SAMe-TT2R2 score has been proposed to predict TTR in NVAF patients. However, the SAMe-TT2R2 score has not been much validated in Asian population. Interestingly, it may overestimate patients who had TTR < 65% due to regarding being Asians as a risk factor.
Objectives
To determine the factors predicting poor anticoagulant control on warfarin, create new scoring system, and compare with the SAMe-TT2R2 score in a Thai population with NVAF.
Methods
This is a retrospective study in a tertiary care hospital. We enrolled NVAF patients who received warfarin from January 2014 to December 2018. TTR was calculated based on Rosendaal method. Multiple logistic regression and AUC-ROC curve were used for analysis.
Results
A total of 864 patients were enrolled with mean age of 73.6 ± 11.58 years. The mean TTR was 48.1 ± 25.2%. Using multivariate regression analysis, the predictive factors for TTR < 65% were antiplatelet use (OR 4.49, p ≤ 0.001), LVEF < 40% (OR 1.92, p = 0.037), chronic kidney disease (GFR < 50 ml/min/1.73 m2) (OR 1.68, p = 0.013), history of CHF (OR 1.7, p = 0.047), and age ≥ 75 years (OR 1.4, p = 0.037). Based on the regression coefficients, we developed the new scoring system called ACAChE score [A, antiplatelet use (4 points); C, chronic kidney disease, GFR < 50 ml/min/1.73 m2 (2 points); A, age ≥ 75 years (1 point); Ch, history of CHF (2 points); E, LVEF < 40% (2 points)]. ROC curve showed discrimination performance of the ACAChE score and SAMe-TT2R2 score for prediction of TTR < 65% with the C-statistic of 0.62 (95%CI 0.57–0.65) and 0.54 (95%CI 0.50–0.58), respectively.
Conclusion
In Thai NVAF patients, the ACAChE score (antiplatelet use, chronic kidney disease (GFR < 50 ml/min/1.73 m2), age ≥ 75 years, history of congestive heart failure, and LVEF < 40%) has better prediction for TTR < 65% than SAMe-TT2R2 score. Thus, it expected to guide the selection of oral anticoagulation in Asian patients with NVAF.
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Barrios V, Escobar C, Prieto L, Polo J, Muñiz J, Anguita M, H Lip GY. A new index to predict quality of anticoagulation control in patients on vitamin K antagonists: the DAFNE score. Future Cardiol 2020; 17:685-692. [PMID: 33331173 DOI: 10.2217/fca-2020-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To derive a new clinical score to improve the prediction of those at risk of poor International Normalized Ratio control among patients with atrial fibrillation taking vitamin K antagonists. Materials & methods: The score was calculated using PAULA database and validated in the FANTASIIA population. Results: The DAFNE score (cardiovascular Disease, concomitant treatment with Amiodarone, Food/dietary transgression and taking ≥7 pills daily, fEemale sex) score was related to a higher probability of poor International Normalized Ratio control. C-indexes were 0.611 and 0.576 (De Long test, p = 0.007) for the DAFNE and SAMe-TT2R2 scores, respectively. Conclusion: The DAFNE score is a new clinical score which may potentially help determine those patients with atrial fibrillation who are at high risk of poor anticoagulation control with vitamin K antagonists.
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Affiliation(s)
- Vivencio Barrios
- Cardiology Department, University Hospital Ramon y Cajal, Madrid, Spain
| | - Carlos Escobar
- Cardiology Department, University Hospital La Paz, Madrid, Spain
| | - Luis Prieto
- Medical Biostatistics, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Jose Polo
- Primary Care Health Center Casar de Cáceres, Cáceres, Spain
| | - Javier Muñiz
- Instituto Universitario de Ciencias de la Salud, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, La Coruña, Spain
| | - Manuel Anguita
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, United Kingdom & Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Boriani G, Ruff CT, Kuder JF, Shi M, Lanz HJ, Antman EM, Braunwald E, Giugliano RP. Edoxaban versus Warfarin in Patients with Atrial Fibrillation at the Extremes of Body Weight: An Analysis from the ENGAGE AF-TIMI 48 Trial. Thromb Haemost 2020; 121:140-149. [PMID: 32920808 DOI: 10.1055/s-0040-1716540] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The effects of anticoagulants at extremes of body weight (BW) are not well described. The aim of this study was to analyze the pharmacokinetics/pharmacodynamics and clinical outcomes in patients randomized to warfarin, higher dose edoxaban (HDER), and lower dose edoxaban (LDER) regimens at extremes of BW in ENGAGE AF-TIMI 48. METHODS AND RESULTS We analyzed three BW groups: low BW (LBW: <5th percentile, ≤55 kg, N = 1,082), middle BW (MBW: 45th-55th percentile, 79.8-84 kg, N = 2,153), and high BW (HBW: >95th percentile, ≥120 kg, N = 1,093). In the warfarin arm, LBW patients had higher rates of stroke/systemic embolism (SSE: 6.5 vs. 4.7 in MBW vs. 1.6% in HBW, P trend < 0.001), major bleeding (MB: 9.3 vs. 7.7 vs. 6.5%, P trend = 0.08), and worse net clinical outcome of systemic embolic event, MB, or death (31.5 vs. 19.1 vs. 16.0%, P trend < 0.0001). The time-in-therapeutic range with warfarin was lowest in LBW patients (63.0 vs. 69.3 vs. 70.1% patients, P trend < 0.001). The pharmacokinetic/pharmacodynamic profile of edoxaban was consistent across BW groups. The risk of SSE was similar between HDER and warfarin for each of the three weight groups (P int = 0.52, P int-trend = 0.86). MB was reduced by LDER versus warfarin (P int = 0.061, P int-trend = 0.023), especially in LBW patients. Net clinical outcomes were improved by HDER versus warfarin (P int = 0.087, P int-trend = 0.027), especially in LBW patients. CONCLUSION Patients with LBW in ENGAGE AF-TIMI 48 had in general a more fragile clinical status and poorer international normalized ratio control. The pharmacokinetic/pharmacodynamic profile of edoxaban was consistent across extremes of BW, resulting in similar efficacy compared with warfarin, while major or clinically relevant non-MB and net outcomes were most favorable with edoxaban as compared to warfarin in LBW patients.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena University Hospital, Modena, Italy
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Julia F Kuder
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Minggao Shi
- Daiichi Sankyo Inc., Basking Ridge, New Jersey, United States
| | | | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
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Del-Toro-Cervera J, Demelo-Rodriguez P, Galeano-Valle F, Fidalgo Á, Sampériz Á, Muñoz-Torrero JFS, Lima J, Sigüenza P, Tufano A, Monreal M. Evaluation of the SAMe-TT2R2 score to predict the quality of anticoagulation control in patients with venous thromboembolism treated with vitamin K antagonists: Findings from the RIETE registry. Thromb Res 2020; 194:178-182. [PMID: 32788113 DOI: 10.1016/j.thromres.2020.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/16/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The time in therapeutic range (TTR) of patients with venous thromboembolism (VTE) treated with vitamin K antagonists (VKA) is usually below recommended, leading to higher frequency of vascular events, bleeding and mortality. The SAMe-TT2R2 prediction score discriminates those patients with high or low probability of obtaining poor INR control and its use is recommended in patients with atrial fibrillation. Its usefulness has been evaluated in patients with VTE, with conflicting results. METHOD We included consecutive patients enrolled in Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective multicenter VTE registry, treated with VKA for >90 days and a minimum of 3 INR determinations. We analyzed the relationship between the SAMe-TT2R2 score and TTR, determined by the Rosendaal method and by the percentage of INR determinations (after excluding the first month). A ROC curve was calculated considering a cut-off point of TTR ≥65% for good anticoagulation control. RESULTS 3893 patients were included and classified in high (1411 patients) or low (2482 patients) probability of obtaining poor INR control according to the total score obtained (0-1 points versus 2 points, respectively). TTR, calculated by direct method and Rosendaal method, was 51.2 (±23.4) and 55.4 (±25.9) in the high probability group; and 54.4 (±23.0) and 58.2 (±25.6) in the low probability group, respectively (p < 0.001 for both comparisons). The outcomes were similar between groups. The predictive capacity of the SAMe-TT2R2 score showed an area under the ROC curve of 0.54 (CI 95% 0.52-0.56) and 0.53 (CI 95% 0.51-0.55). CONCLUSIONS In patients with VTE treated with VKA, the SAMe-TT2R2 score discriminated those patients with high probability of obtaining poor INR control, but with a low predictive capacity. Further studies are required to assess the usefulness of the score in clinical decision-making.
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Affiliation(s)
- Jorge Del-Toro-Cervera
- Venous Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain; Universidad Complutense de Madrid, Spain
| | - Pablo Demelo-Rodriguez
- Venous Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain; Universidad Complutense de Madrid, Spain.
| | - Francisco Galeano-Valle
- Venous Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain; Universidad Complutense de Madrid, Spain
| | - Ángeles Fidalgo
- Department of Internal Medicine, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Ángel Sampériz
- Department of Internal Medicine, Hospital Reina Sofía, Tudela, Navarra, Spain
| | | | - Jorge Lima
- Department of Pneumonology, Hospital Universitario Virgen de Valme, Sevilla, Spain
| | - Patricia Sigüenza
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain; Universidad Autónoma de Barcelona, Barcelona, Spain
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Fontil V, Kazi D, Cherian R, Lee SY, Sarkar U. Evaluation of a Health Information Technology-Enabled Panel Management Platform to Improve Anticoagulation Control in a Low-Income Patient Population: Protocol for a Quasi-Experimental Design. JMIR Res Protoc 2020; 9:e13835. [PMID: 31929105 PMCID: PMC6996764 DOI: 10.2196/13835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/29/2019] [Accepted: 09/04/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Warfarin is one of the most commonly prescribed medications in the United States, and it causes a significant proportion of adverse drug events. Patients taking warfarin fall outside of the recommended therapeutic range 30% of the time, largely because of inadequate laboratory monitoring and dose adjustment. This leads to an increased risk of blood clots or bleeding events. We propose a comparative effectiveness study to examine whether a technology-enabled anticoagulation management program can improve long-term clinical outcomes compared with usual care. OBJECTIVE Our proposed intervention is the implementation of an electronic dashboard (integrated into a preexisting electronic health record) and standardized workflow to track patients' laboratory results, identify patients requiring follow-up, and facilitate the use of a validated nomogram for dose adjustment. The primary outcome of this study is the time in therapeutic range (TTR) at 6 months post intervention (a validated metric of anticoagulation quality among patients receiving warfarin). METHODS We will employ a pre-post quasi-experimental design with a nonequivalent usual-care comparison site and a difference-in-differences approach to compare the effectiveness of a technology-enabled anticoagulation management program compared with usual care at a large university-affiliated safety-net clinic. RESULTS We used a commercially available health information technology (HIT) platform to host a registry of patients on warfarin therapy and create the electronic dashboard for panel management. We developed the intervention with, and for, frontline clinician users, using principles of human-centered design. This study is funded until September 2020 and is approved by the University of California, San Francisco Institutional Review Board until June 22, 2020. We completed data collection in September 2019 and expect to complete our proposed analyses by February 2020. CONCLUSIONS We anticipate that the intervention will increase TTR among patients taking warfarin and that the use of this HIT platform will facilitate tracking and monitoring of patients on warfarin, which could enable outreach to those overdue for visits or laboratory monitoring. We will use these findings to iteratively improve the platform in preparation for a larger, multiple-site, pragmatic clinical trial. If successful, our study will demonstrate the integration of HIT platforms into existing electronic health records to improve patient care in real-world clinical settings. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/13835.
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Affiliation(s)
- Valy Fontil
- Center for Vulnerable Populations, University of California, San Francisco, CA, United States
| | - Dhruv Kazi
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Roy Cherian
- Center for Vulnerable Populations, University of California, San Francisco, CA, United States
| | - Shin-Yu Lee
- Outpatient Pharmacy, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Urmimala Sarkar
- Center for Vulnerable Populations, University of California, San Francisco, CA, United States
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Krittayaphong R, Winijkul A, Pirapatdit A, Chiewvit P, Komoltri C, Boonyapisit W, Arunsiriwattana S, Bunyapipat T, Apiyasawat S, Rattanasumawong K, Yindeengam A. SAMe-TT2R2 score for prediction of suboptimal time in therapeutic range in a Thai population with atrial fibrillation. Singapore Med J 2019; 61:641-646. [PMID: 31680175 DOI: 10.11622/smedj.2019143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION International normalised ratio (INR) control is an important factor in patients with non-valvular atrial fibrillation (NVAF) being treated with warfarin. INR control was previously reported to be poorer among Asians compared to Westerners. We aimed to validate the SAMe-TT2R2 score for prediction of suboptimal INR control (defined as time in therapeutic range [TTR] < 65% in the Thai population) and to investigate TTR among Thai NVAF patients being treated with warfarin. METHODS INR data from patients enrolled in a multicentre NVAF registry was analysed. Clinical and laboratory data was prospectively collected. TTR was calculated using the Rosendaal method. Baseline data was compared between patients with and without suboptimal INR control. Univariate and multivariate analyses were performed to identify variables independently associated with suboptimal INR control. RESULTS A total of 1,669 patients from 22 centres located across Thailand were included. The average age was 69.1 ± 10.7 years, and 921 (55.2%) were male. The mean TTR was 50.5% ± 27.5%; 1,125 (67.4%) had TTR < 65%. Univariate analysis showed hypertension, diabetes mellitus, heart failure, renal disease and SAMe-TT2R2 score to be significantly different between patients with and without optimal TTR. The SAMe-TT2R2 score was the only factor that remained statistically significant in multivariate analysis. The C-statistic for the SAMe-TT2R2 score in the prediction of suboptimal TTR was 0.54. CONCLUSION SAMe-TT2R2 score was the only independent predictor of suboptimal TTR in NVAF patients being treated with warfarin. However, due to the low C-statistic, the score may have limited discriminative power.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Arjbordin Winijkul
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Atthasit Pirapatdit
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pollakrit Chiewvit
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chulalak Komoltri
- Department of Research Promotion, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Warangkna Boonyapisit
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Sirin Apiyasawat
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Ahthit Yindeengam
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Liang HF, Du X, Zhou YC, Yang XY, Xia SJ, Dong JZ, Lip GYH, Ma CS. Control of Anticoagulation Therapy in Patients with Atrial Fibrillation Treated with Warfarin: A Study from the Chinese Atrial Fibrillation Registry. Med Sci Monit 2019. [PMID: 31232394 PMCID: PMC6604671 DOI: 10.12659/msm.917131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Several factors determine the efficacy of warfarin anticoagulation in patients with non-valvular atrial fibrillation (NVAF). This study aimed to use data from the Chinese Atrial Fibrillation Registry study to assess the control of anticoagulation therapy in Chinese patients with NVAF treated with warfarin. Material/Methods From the Chinese Atrial Fibrillation Registry study the anticoagulant use and dosing, the time in therapeutic range (TTR) of the international normalized ratio (INR), and standard deviation of the observed INR values (SDINR), and their influencing factors were evaluated. Results The median INR and SDINR were 2.04 (IQR 1.71–2.41) and 0.50 (IQR, 0.35–0.69), respectively. The median TTR was 51.7% (IQR, 30.6–70.1%) and only 25.1% had a TTR ≥70%. Age was ≥70 years (OR, 0.72; 95% CI, 0.55–0.94; P=0.015), bleeding history (OR 0.48; 95% CI, 0.23–0.89; P=0.029), the use of a single drug (OR, 0.62; 95% CI, 0.42–0.92; P=0.016), more than drug (OR, 0.60; 95% CI, 0.41–0.88; P=0.009), and lack of assessment of bleeding risk (OR, 0.72; 95% CI, 0.54–0.97; P=0.033) were associated with TTR <70% (INR 2.0–3.0). Coronary heart disease (CHD) and peripheral artery disease (PAD) (OR, 0.69; 95% CI, 0.52–0.90; P=0.007) and diabetes mellitus (OR, 0.79; 95% CI, 0.62–0.99; P=0.044) were associated with increased variability in INR (SDINR ≥0.5). Conclusions In Chinese patients with NVAF, warfarin anticoagulation was associated with lower TTR and less stable anticoagulation than in current guidelines, and risk factors for reduced safety and efficacy were identified.
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Affiliation(s)
- Hai-Feng Liang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China (mainland).,Department of Cardiology, Fuxing Hospital, Capital Medical University, Beijing, China (mainland)
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China (mainland)
| | - Ying-Chun Zhou
- East China Normal University, Shanghai, China (mainland)
| | - Xiao-Yi Yang
- East China Normal University, Shanghai, China (mainland)
| | - Shi-Jun Xia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China (mainland)
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China (mainland)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China (mainland)
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12
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The SAMe-TT 2R 2 Score Predicts Warfarin Control in an Australian Population with Atrial Fibrillation. J Clin Med 2019; 8:jcm8060882. [PMID: 31226834 PMCID: PMC6616538 DOI: 10.3390/jcm8060882] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/10/2019] [Accepted: 06/15/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Warfarin requires regular monitoring with the time in therapeutic range (TTR), a common indicator of control and TTR > 70% is indicative of efficient anticoagulation. The SAMe-TT2R2 (sex, age, medical history, treatment, tobacco use, race) model has been utilised as a predictor of warfarin control, with a score ≥ 2 indicative of poor control. However, it has been suggested that race may be over-represented in this model. To date, no Australian studies have applied this model, possibly because race is not routinely recorded. Therefore, the aim of this study was to apply the SAMe-TT2R2 model in an Australian population on warfarin managed by both a warfarin care program (WCP) and general practitioner (GP). Methods: Retrospective data was collected for patients receiving warfarin via a WCP in Queensland and whilst being managed by a GP. Patient data was used to calculate the SAMe-TT2R2 score and the TTR for each patient. Mean TTR was used for analysis and comparison with the categorised SAMe-TT2R2 score. Results: Of the 3911 patients managed by a WCP, there was a significantly lower mean TTR for patients with a SAMe-TT2R2 score ≥ 2 compared to 0–1 (78.6 ± 10.7% vs. 80.9 ± 9.5%, p < 0.0001). Of these patients, 200 were analysed whilst managed by a GP and the categorised SAMe-TT2R2 score did not result in a statistically different mean TTR (69.3 ± 16.3% with 0–1 vs. 63.6 ± 15.0% with ≥2, p = 0.089), but a score ≥2 differentiated patients with a TTR less than 65%. Conclusions: The SAMe-TT2R2 model differentiated Australian patients with reduced warfarin control, despite the exclusion of race. In Australia, the SAMe-TT2R2 score could assist clinicians in identifying Australian patients who may obtain reduced warfarin control and benefit from additional interventions such as a dedicated WCP.
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13
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Proietti M, Lane DA, Boriani G, Lip GY. Stroke Prevention, Evaluation of Bleeding Risk, and Anticoagulant Treatment Management in Atrial Fibrillation Contemporary International Guidelines. Can J Cardiol 2019; 35:619-633. [DOI: 10.1016/j.cjca.2019.02.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 12/17/2022] Open
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Pastori D, Menichelli D, Gingis R, Pignatelli P, Violi F. Tailored Practical Management of Patients With Atrial Fibrillation: A Risk Factor-Based Approach. Front Cardiovasc Med 2019; 6:17. [PMID: 30915342 PMCID: PMC6422871 DOI: 10.3389/fcvm.2019.00017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/12/2019] [Indexed: 12/25/2022] Open
Abstract
The management of antithrombotic therapy for thromboprophylaxis in patients with atrial fibrillation (AF) has been recently evolved by the progressive replacement of vitamin K antagonists with the non-vitamin K antagonist oral anticoagulants (NOACs). However, while these drugs are effective in reducing ischemic stroke/systemic embolism, a still high rate of cardiovascular events is present in the AF population. A tailored integrated approach to patients with AF is therefore necessary to reduce both thromboembolic events and cardiovascular disease. This approach should consist in the assessment of individual risk factors for ischemic and bleeding events in order to choose the most appropriate anticoagulant treatment according to patient's characteristics and preference. To this purpose, several risk scores have been developed and validated to stratify thromboembolic and hemorrhagic risk. This review provides an individual-based strategy for the management of patients with AF, from a risk-factor based approach to a tailored prescription and monitoring of NOACs. In particular, we reported an updated practical management strategy for AF patients in specific clinical situations such as those (1) experiencing a major bleeding, (2) requiring a switch to another antithrombotic regimen, (3) restarting anticoagulation after acute ischemic stroke, (4) suffering from an acute coronary artery disease (acute coronary syndrome or undergoing cardiac revascularization).
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Centre, Department of Internal Medicine and Medical Specialties of Sapienza University, Rome, Italy
| | - Danilo Menichelli
- I Clinica Medica, Atherothrombosis Centre, Department of Internal Medicine and Medical Specialties of Sapienza University, Rome, Italy
| | - Rony Gingis
- I Clinica Medica, Atherothrombosis Centre, Department of Internal Medicine and Medical Specialties of Sapienza University, Rome, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Centre, Department of Internal Medicine and Medical Specialties of Sapienza University, Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Centre, Department of Internal Medicine and Medical Specialties of Sapienza University, Rome, Italy
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15
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Joung B, Lee JM, Lee KH, Kim TH, Choi EK, Lim WH, Kang KW, Shim J, Lim HE, Park J, Lee SR, Lee YS, Kim JB. 2018 Korean Guideline of Atrial Fibrillation Management. Korean Circ J 2018; 48:1033-1080. [PMID: 30403013 PMCID: PMC6221873 DOI: 10.4070/kcj.2018.0339] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/08/2018] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. This guideline is based on recent data of the Korean population and the recent guidelines of the European Society of Cardiology, European Association for Cardio-Thoracic Surgery, American Heart Association, and Asia Pacific Heart Rhythm Society. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF. This guideline deals with optimal stroke prevention, screening, rate and rhythm control, risk factor management, and integrated management of AF.
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Affiliation(s)
- Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Jung Myung Lee
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Ki Hong Lee
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Tae Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Woon Kang
- Division of Cardiology, Eulji University College of Medicine, Daejeon, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hong Euy Lim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Junbeom Park
- Department of Cardiology, Ewha Woman University, Seoul, Korea
| | - So Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Soon Chun Hyang University Hospital, Seoul, Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University, Daegu, Korea
| | - Jin Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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17
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Pastori D, Pignatelli P, Cribari F, Carnevale R, Saliola M, Violi F, Lip GY. Time to therapeutic range (TtTR), anticoagulation control, and cardiovascular events in vitamin K antagonists-naive patients with atrial fibrillation. Am Heart J 2018; 200:32-36. [PMID: 29898846 DOI: 10.1016/j.ahj.2018.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/03/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vitamin K antagonists (VKAs) reduce cardiovascular events (CVEs) in atrial fibrillation (AF) when a time in therapeutic range (TiTR) >70% is achieved. Factors affecting the time to achieve the TR (TtTR) are unknown. METHODS Prospective observational study including 1,406 nonvalvular AF patients starting VKAs followed for a mean of 31.3months (3,690 patient/year); TiTR, TtTR, and SAMe-TT2R2 score were calculated, and CVEs were recorded. RESULTS Median TtTR was 8.0days (interquartile range 5.0-18.0). Patients with high TtTR (ie, >75th percentile) were more likely to be in AF than in sinus rhythm at entry (odds ratio [OR]: 1.423, P=.011). Median TiTR was 60.0%; low TiTR (below median) was associated with SAMe-TT2R2 score (OR: 1.175, P=.001), high TtTR (>75th percentile, OR: 1.357, P=.017), and number of international normalized ratio checks (OR: 0.998, P=.049). We recorded 113 CVEs (3.1%/y), with a higher rate seen in patients with TtTR >75th percentile compared to those below (log-rank test, P=.006). A multivariable Cox regression analysis showed that SAMe-TT2R2 score (hazard ratio [HR]: 1.331, P<.001), TtTR >75th percentile (HR: 1.505, P=.047), TiTR <70% (HR: 1.931, P=.004), number of international normalized ratio checks (HR: 0.988, P<.001), digoxin (HR: 1.855, P=.008), and proton-pump inhibitors (HR: 0.452, P<.001) were independently associated with CVEs. CONCLUSIONS High TtTR is associated with poorer long-term quality of VKAs therapy. Patients with TtTR >18days or with high SAMe-TT2R2 score should be considered for treatment with non-vitamin K oral anticoagulants.
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy; Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Cribari
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy; Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Mirella Saliola
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Gregory Yh Lip
- Institute for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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