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Jeon SW, Lee N, Lee KH, Ha M, Kim C, Kim YR, Yoon NS, Park HW. Modified application of SAMe-TT2R2 scoring system in Asian patients with atrial fibrillation for the selection of oral anticoagulants. Korean J Intern Med 2024; 39:458-468. [PMID: 38287499 PMCID: PMC11076891 DOI: 10.3904/kjim.2023.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/25/2023] [Accepted: 12/13/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND/AIMS The SAMe-TT2R2 score is used for assessing anticoagulation control (AC) quality with warfarin. However, it is hard to apply SAMe-TT2R2 score in Asian patients with atrial fibrillation (AF), because it has not been proven in those populations. This study aimed to validate the SAMe-TT2R2 score in Asian patients with AF and suggest a modified SAMe- TT2R2 score for this population. METHODS We analyzed 710 Korean patients with AF who were using warfarin. The AC quality was assessed as the mean time in therapeutic range (TTR). Each component of SAMe-TT2R2 score was evaluated for the relationship with AC. Further clinical factors that predict AC were analyzed. Identified factors were re-assorted and constructed as SA2Me-TTR scoring system. RESULTS Of the components of the SAMe-TT2R2 score, female, age, and rhythm control were associated with AC. Heart failure and renal insufficiency were newly identified factors associated with AC. The modified SA2Me-TTR score was reconstructed with the relevant risk factors (S, female gender, 1 point; A, age < 60 yr, 2 points; Me, medical history of heart failure, 1 point; T, treatment for rhythm control, 1 point; T, history of stroke or transient ischemic attack, 1 point; R, renal insufficiency, 1 point). The modified SA2Me-TTR score demonstrated an excellent relationship with the grading of AC. The modified SA2Me-TTR score ≤ 1 identified patients with good AC (hazard ratio 2.46, 95% CI 1.75-3.47). CONCLUSION The modified SA2Me-TTR score was useful for guiding oral anticoagulants selection in Asian patients with AF.
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Affiliation(s)
- Seong Won Jeon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
| | - Nuri Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
| | - Ki Hong Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju,
Korea
| | - Minjeong Ha
- School of Materials Science and Engineering, Gwangju Institute of Science and Technology, Gwangju,
Korea
| | - Changhyun Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
| | - Yoo Ri Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju,
Korea
| | - Nam Sik Yoon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju,
Korea
| | - Hyung Wook Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju,
Korea
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Poonchuay N, Saokaew S, Incomenoy S. SAMe-TT 2R 2 Score to Predict Time in Therapeutic Range of Vitamin K Antagonists in Asian and Non-Asian patients: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2024; 24:211-240. [PMID: 38252269 DOI: 10.1007/s40256-023-00623-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Sex, age, medical history, treatment, tobacco use, and race (SAMe-TT2R2) score helps detect patients at risk of suboptimal anticoagulation control. A score above two suggests poor control; however, non-Caucasian status being assigned two points might hinder the recognition of poor control in patients of other races. OBJECTIVE To evaluate the SAMe-TT2R2 score's ability to predict poor anticoagulation control [defined as time in therapeutic range (TTR) < 60-70%] in Asian and non-Asian populations on vitamin K antagonists (VKAs). METHODS We searched PubMed, Cochrane Library, Scopus, SpringerLink, and Web of Science using the keyword "SAMe-TT2R2." Articles published before April 2022 were screened. We gathered mean TTR and diagnostic accuracy data for different SAMe-TT2R2 thresholds and conducted meta-analyses using random-effects models. RESULTS A total of 30 studies were included (N = 36,690). The overall mean TTR differences were - 4.88 and - 6.41 for the cutoffs of ≥ 3 and ≥ 4, respectively. For non-Asian patients, the mean TTR differences were - 3.86, - 5.12, and - 8.09 for the cutoffs ≥ 2, ≥ 3, and ≥ 4, respectively. For Asian patients, the mean TTR differences were - 3.99 and - 4.07 for the cut-offs ≥ 3 and ≥ 4, respectively. The highest positive likelihood ratio (LR+) for the Asian subgroup was 1.17 [95% confidence interval (CI): 1.06-1.28; I2 = 0%, p heterogeneity = 0.500] at cutoff ≥ 4 and for the non-Asian subgroup, at cut-off ≥ 3, the LR+ was 1.24 (95% CI 1.14-1.34; I2 = 0% p heterogeneity = 0.455). The lowest LR- was found at a lower cutoff for both races (at cutoff ≥ 3 and ≥ 2 for Asian and non-Asian subgroups, respectively). The pooled results of other accuracy parameters were modest at all cutoffs, except for the sensitivity at cutoff ≥ 3 in the Asian subgroup (83.05%). CONCLUSION Our study results suggest that a higher SAMe-TT2R2 score resulted in a greater reduction of TTR among Asian and all races. The accuracy parameters showed the highest sensitivity for poor TTR at the SAMe-TT2R2 cutoff of ≥ 3 for Asian patients. However, the ability to identify patients likely to have poor TTR was limited. Further research is needed to enhance the risk assessment for poor anticoagulation control with VKAs. REGISTRATION The protocol of this systematic review was registered in the International Prospective Register of Scientific Reviews: PROSPERO, registration number CRD42021291865.
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Affiliation(s)
- Natnicha Poonchuay
- Department of Pharmaceutical Care, School of Pharmacy, Walailak University, Tha Sala, Nakhon Si Thammarat, 80160, Thailand
- Drug and Cosmetics Excellence Center, Walailak University, Tha Sala, Nakhon Si Thammarat, 80161, Thailand
| | - Surasak Saokaew
- Division of Social and Administrative Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand
- Unit of Excellence On Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand
| | - Supatcha Incomenoy
- Department of Pharmaceutical Care, School of Pharmacy, Walailak University, Tha Sala, Nakhon Si Thammarat, 80160, Thailand.
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Zulkifly H, Lip GYH, Lane DA. Anticoagulation Control in Older Atrial Fibrillation Patients Receiving Vitamin K Antagonist Therapy for Stroke Prevention. Int J Clin Pract 2022; 2022:5951262. [PMID: 35685589 PMCID: PMC9159113 DOI: 10.1155/2022/5951262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Efficacy and safety of vitamin K antagonists (VKAs) among atrial fibrillation (AF) patients are enhanced when the International Normalised Ratio (INR) is 2.0-3.0. Anticoagulation control among older patients is perceived to be lower and contributes to poorer initiation and uptake. OBJECTIVE To examine the quality of INR control, adverse clinical outcomes, and factors associated with bleeding in older AF patients (≥80 years). METHODS Anticoagulation control assessed by time in therapeutic range (TTR) (Rosendaal method) and percentage INRs in range (PINRR). Among the 205 patients aged ≥80 years, 58.5% were female, with mean (SD) CHA2DS2-VASc 4.4 (1.3) and HAS-BLED 1.8 (0.8) scores. RESULTS Mean (SD) TTR and PINRR were similar for those aged ≥80 vs. <80 years (66.7 (13.8) vs. 66.7 (13.1)) despite significantly lower INR monitoring intensity (51.2 (22.7) vs. 60.7 (25.8)) and shorter follow-up (4.4 (2.6-6.2) vs. 5.7 years (3.3-7.1)) in those ≥80 years of age. Good anticoagulation control (TTR and PINRR ≥70%) of 44% was seen in both age groups. No significant differences in composite major adverse clinical events were evident for those aged ≥80 vs. <80 years (p = 0.55). Cox regression analysis confirmed that age ≥80 years was associated with higher risk of bleeding (HR 1.90 (1.01-3.56); p = 0.047). CONCLUSIONS Suboptimal (TTR and PINRR <70%) anticoagulation control was evident in all patients. Risk of bleeding increased, but there was no difference in thromboembolic events and all-cause mortality in those aged ≥80 years. Improving TTR to ≥70% and enhancing anticoagulation monitoring of VKA use remain a clinical priority to prevent bleeding complications, particularly among those aged 80 years and above.
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Affiliation(s)
- Hanis Zulkifly
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Department of Pharmacy Practice, Fakulti Farmasi, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
| | - Gregory Y. H. Lip
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A. Lane
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Zulkifly H, Cheli P, Lutchman I, Bai Y, Lip GYH, Lane DA. Anticoagulation control in different ethnic groups receiving vitamin K antagonist therapy for stroke prevention in atrial fibrillation. Thromb Res 2020; 192:12-20. [PMID: 32416364 DOI: 10.1016/j.thromres.2020.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/18/2020] [Accepted: 04/02/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efficacy and safety of vitamin K antagonists (VKAs) is optimised in atrial fibrillation (AF) patients when the International Normalised Ratio (INR) is 2.0-3.0. Anticoagulation control comparing different ethnic groups is limited, although epidemiological studies suggest poorer INR control in non-white cohorts. METHODS VKA control was assessed retrospectively by time-in-the-therapeutic range (TTR) (Rosendaal method) and percentage INR-in-range (PINRR) in 991 White, Afro-Caribbean and South-Asian AF patients [overall mean (SD) age 71.6 (9.4) years; 55% male; mean (SD) CHA2DS2-VASc score 3.4 (1.6)] over a median (IQR) follow-up of 5.2 (3.2-7.0) years. RESULTS Compared to Whites, mean (SD) TTR and PINRR were significantly lower in South-Asians [TTR 67.9% vs. 60.5%; PINRR 58.8% vs. 51.6%, respectively] and Afro-Caribbeans [TTR 67.9% vs. 61.3%; PINRR 58.8% vs. 53.1%, respectively], despite similar INR monitoring intensity. Logistic regression revealed non-white ethnicity [OR 2.62; 95% Confidence Interval [CI] (1.67-4.10) and OR 3.47 (1.44-8.34)] and anaemia [OR 1.65 (1.00-2.70) and OR 6.27 (1.89-20.94)] as independent predictors of both TTR and PINRR < 70%, respectively. At follow-up, 329 (33.2%) patients experienced ≥1 major adverse clinical event. Cardiovascular hospitalisation was significantly higher among South-Asians (32.3%) compared to the Whites and Afro-Caribbeans (21.3% vs 25.6% respectively). CONCLUSIONS Ethnic disparities in quality of anticoagulation control are evident, with South-Asians and Afro-Caribbeans having poorer control compared to Whites, despite similar intensity INR monitoring. Non-white ethnicity remained the strongest independent predictor of poor TTR and PINRR. Interventions to improve anticoagulation control need to be implemented, particularly targeting ethnic minority patients.
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Affiliation(s)
- Hanis Zulkifly
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom; Fakulti Farmasi, Universiti Teknologi MARA Kampus Puncak Alam, Selangor, Malaysia
| | - Paola Cheli
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
| | - Ivana Lutchman
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.
| | - Ying Bai
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Abstract
Background Vitamin K antagonist (VKA) therapy is safer and more effective when patients have a high time within the therapeutic range and low international normalised ratio variability. The SAMe-TT2R2 score aims to identify those at risk for poor VKA control. Objectives To evaluate the predictive value and clinical usefulness of the SAMe-TT2R2 score to identify those at risk for poor VKA control. Methods We performed a systematic review in MEDLINE and Embase for original research papers assessing the SAMe-TT2R2’s relation to poor TTR. We performed a meta-analysis where scores ≥ 2 and ≥ 3 predicting TTR < 70%. When studies evaluated other cutoffs for TTR or SAMe-TT2R2, they were harmonised by multiple simulations with patient characteristics from the individual studies, if the data were available. Results 16 studies were identified and used in the meta-analysis: 4 and 2 times directly, 8 and 8 times harmonised for scores ≥ 2 and ≥ 3, respectively (not all studies provided information about both cutoffs). The sensitivities and specificities were too heterogeneous to pool. The positive likelihood ratios were 1.25 (1.14-1.38) for a score ≥ 2, and 1.24 (1.09-1.40) for a score ≥ 3; the negative ones were 0.87 (0.82-0.93) and 0.96 (0.91-1.02), respectively. This shows that the post-test probabilities hardly differ from the prior probability (prevalence). Conclusion The SAMe-TT2R2 score does predict low TTR, but the effect is small. Its effect on individual patients is too limited to be clinically useful.
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Atrial Fibrillation. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00147-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Antonucci E, Lip G, Testa S, Guazzaloca G, Falanga A, Pengo V, Poli D, Palareti G. The SAME-TT2R2 score predicts the quality of anticoagulation control in patients with acute VTE. Thromb Haemost 2017; 115:1101-8. [DOI: 10.1160/th15-10-0830] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/18/2016] [Indexed: 01/01/2023]
Abstract
SummaryThe SAMe-TT2R2 score has recently been proposed to predict the quality of vitamin K antagonist (VKA) anticoagulation control in patients with atrial fibrillation. We aimed at investigating whether the score is effective also in patients with venous thromboembolism (VTE). Patients included in the START-Register because started VKA therapy for a recent VTE episode and with > 3 months follow-up were analyzed. The score was calculated using the baseline patient’s characteristics present in the electronic database of the registry, where all INR results were also available and analysed to calculate the time in therapeutic range (TTR). A total of 1308 patients (53.4 % female, median age 68 years) were analysed. During 998 patient-years followup, the median TTR was 63 %. The maximum score in the patients was 4, with 70 % of them having 0–1. INR controls within range (2.0–3.0) were significantly less prevalent in patients with score ≥ 2 vs 0–1 score (58.5 ± 20 % vs 61.5 ± 19 %, respectively, p = 0.046). Patients with score ≥ 2 vs 0–1 had a highly significant lower TTR during the first 3 months of therapy (53 ± 26 % and 61 ± 26 %, respectively; p=0.0001), difference mainly due to more time spent below 2.0 INR (38 ± 28 % vs 31.3 ± 26.7 %, respectively; p=0.0001). In conclusion, the study proved, for the first time, that the SAMe-TT2R2 score is useful to predict among VTE patients those who will have good (score 0–1) or less good (score ≥ 2) VKA anticoagulation control. The score can help decision-making in everyday clinical practice, especially when choosing between VKA and non-vitamin K antagonists direct anticoagulants.Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.
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Pivatto Junior F, Scheffel RS, Ries L, Wolkind RR, Marobin R, Barkan SS, Amon LC, Biolo A. SAMe-TT2R2 Score in the Outpatient Anticoagulation Clinic to Predict Time in Therapeutic Range and Adverse Events. Arq Bras Cardiol 2017; 108:290-296. [PMID: 28538758 PMCID: PMC5421467 DOI: 10.5935/abc.20170052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/13/2016] [Indexed: 12/23/2022] Open
Abstract
Background The SAMe-TT2R2 score was developed to predict which
patients on oral anticoagulation with vitamin K antagonists (VKAs) will
reach an adequate time in therapeutic range (TTR) (> 65%-70%). Studies
have reported a relationship between this score and the occurrence of
adverse events. Objective To describe the TTR according to the score, in addition to relating the score
obtained with the occurrence of adverse events in patients with nonvalvular
atrial fibrillation (AF) on oral anticoagulation with VKAs. Methods Retrospective cohort study including patients with nonvalvular AF attending
an outpatient anticoagulation clinic of a tertiary hospital. Visits to the
outpatient clinic and emergency, as well as hospital admissions to the
institution, during 2014 were evaluated. The TTR was calculated through the
Rosendaal´s method. Results We analyzed 263 patients (median TTR, 62.5%). The low-risk group (score 0-1)
had a better median TTR as compared with the high-risk group (score ≥
2): 69.2% vs. 56.3%, p = 0.002. Similarly, the percentage of patients with
TTR ≥ 60%, 65% or 70% was higher in the low-risk group (p < 0.001,
p = 0.001 and p = 0.003, respectively). The high-risk group had a higher
percentage of adverse events (11.2% vs. 7.2%), although not significant (p =
0.369). Conclusions The SAMe-TT2R2 score proved to be effective to predict
patients with a better TTR, but was not associated with adverse events.
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Affiliation(s)
| | | | - Lucas Ries
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brazil
| | | | - Roberta Marobin
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brazil
| | | | - Luís Carlos Amon
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brazil
| | - Andréia Biolo
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brazil
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Fairman KA, Davis LE, Kruse CR, Sclar DA. Financial Impact of Direct-Acting Oral Anticoagulants in Medicaid: Budgetary Assessment Based on Number Needed to Treat. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:203-214. [PMID: 27896681 DOI: 10.1007/s40258-016-0295-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Faced with rising healthcare costs, state Medicaid programs need short-term, easily calculated budgetary estimates for new drugs, accounting for medical cost offsets due to clinical advantages. OBJECTIVE To estimate the budgetary impact of direct-acting oral anticoagulants (DOACs) compared with warfarin, an older, lower-cost vitamin K antagonist, on 12-month Medicaid expenditures for nonvalvular atrial fibrillation (NVAF) using number needed to treat (NNT). METHOD Medicaid utilization files, 2009 through second quarter 2015, were used to estimate OAC cost accounting for generic/brand statutory minimum (13/23%) and assumed maximum (13/50%) manufacturer rebates. NNTs were calculated from clinical trial reports to estimate avoided medical events for a hypothetical population of 500,000 enrollees (approximate NVAF prevalence × Medicaid enrollment) under two DOAC market share scenarios: 2015 actual and 50% increase. Medical service costs were based on published sources. Costs were inflation-adjusted (2015 US$). RESULTS From 2009-2015, OAC reimbursement per claim increased by 173 and 279% under maximum and minimum rebate scenarios, respectively, while DOAC market share increased from 0 to 21%. Compared with a warfarin-only counterfactual, counts of ischemic strokes, intracranial hemorrhages, and systemic embolisms declined by 36, 280, and 111, respectively; counts of gastrointestinal hemorrhages increased by 794. Avoided events and reduced monitoring, respectively, offset 3-5% and 15-24% of increased drug cost. Net of offsets, DOAC-related cost increases were US$258-US$464 per patient per year (PPPY) in 2015 and US$309-US$579 PPPY after market share increase. CONCLUSIONS Avoided medical events offset a small portion of DOAC-related drug cost increase. NNT-based calculations provide a transparent source of budgetary-impact information for new medications.
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Affiliation(s)
- Kathleen A Fairman
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ, 85308, USA.
| | - Lindsay E Davis
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ, 85308, USA
| | - Courtney R Kruse
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ, 85308, USA
| | - David A Sclar
- Department of Pharmacy Practice, College of Pharmacy-Glendale, Midwestern University, 19555 N. 59th Avenue, Glendale, AZ, 85308, USA
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Kataruka A, Kong X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Krol GD, Kaatz S, McNamara MW, Froehlich JB, Barnes GD. SAMe-TT 2R 2 predicts quality of anticoagulation in patients with acute venous thromboembolism: The MAQI 2 experience. Vasc Med 2017; 22:197-203. [PMID: 28145152 DOI: 10.1177/1358863x16682863] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Akash Kataruka
- 1 Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Xiaowen Kong
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Brian Haymart
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Eva Kline-Rogers
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Steve Almany
- 3 Department of Cardiology, William Beaumont Hospital, Royal Oak, MI, USA
| | | | | | - Scott Kaatz
- 5 Henry Ford Health System, Detroit, MI, USA
| | | | - James B Froehlich
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
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Lip GYH, Potpara T, Boriani G, Blomström-Lundqvist C. A tailored treatment strategy: a modern approach for stroke prevention in patients with atrial fibrillation. J Intern Med 2016; 279:467-76. [PMID: 27001354 DOI: 10.1111/joim.12468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The main priority in atrial fibrillation (AF) management is stroke prevention, following which decisions about rate or rhythm control are focused on the patient, being primarily for management of symptoms. Given that AF is commonly associated with various comorbidities, risk factors such as hypertension, heart failure, diabetes mellitus and sleep apnoea should be actively looked for and managed in a holistic approach to AF management. The objective of this review is to provide an overview of modern AF stroke prevention with a focus on tailored treatment strategies. Biomarkers and genetic factors have been proposed to help identify 'high-risk' patients to be targeted for oral anticoagulation, but ultimately their use must be balanced against that of more simple and practical considerations for everyday use. Current guidelines have directed focus on initial identification of 'truly low-risk' patients with AF, that is those patients with a CHA2 DS2 -VASc [congestive heart failure, hypertension, age ≥75 years (two points), diabetes mellitus, stroke (two points), vascular disease, age 65-74 years, sex category] score of 0 (male) or 1 (female), who do not need any antithrombotic therapy. Subsequently, patients with ≥1 stroke risk factors can be offered effective stroke prevention, that is oral anticoagulation. The SAMe-TT2 R2 [sex female, age <60 years, medical history (>2 comorbidities), treatment (interacting drugs), tobacco use (two points), race non-Caucasian (two points)] score can help physicians make informed decisions on those patients likely to do well on warfarin (SAMe-TT2 R2 score 0-2) or those who are likely to have a poor time in therapeutic range (SAMe-TT2 R2 score >2). A clinically focused tailored approach to assessment and stroke prevention in AF with the use of the CHA2 DS2 VASc, HAS-BLED [hypertension, abnormal renal/liver function (one or two points), stroke, bleeding history or predisposition, labile international normalized ratio, elderly (>65 years) drugs/alcohol concomitantly (one or two points)] and SAMeTT2 R2 scores to evaluate stroke risk, bleeding risk and likelihood of successful warfarin therapy, respectively, is discussed.
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Affiliation(s)
- G Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - T Potpara
- Cardiology Clinic, Clinical Centre of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - G Boriani
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - C Blomström-Lundqvist
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden
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Esteve-Pastor MA, Roldán V, Valdés M, Lip GYH, Marín F. The SAMe-TT2R2score and decision-making between a vitamin K antagonist or a non-vitamin K antagonist oral anticoagulant in patients with atrial fibrillation. Expert Rev Cardiovasc Ther 2015; 14:177-87. [DOI: 10.1586/14779072.2016.1116941] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17:1467-507. [PMID: 26324838 DOI: 10.1093/europace/euv309] [Citation(s) in RCA: 793] [Impact Index Per Article: 88.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 02/10/2015] [Indexed: 12/24/2022] Open
Abstract
The current manuscript is an update of the original Practical Guide, published in June 2013[Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-51; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-106]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with non-valvular atrial fibrillation (AF). Both physicians and patients have to learn how to use these drugs effectively and safely in clinical practice. Many unresolved questions on how to optimally use these drugs in specific clinical situations remain. The European Heart Rhythm Association set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group defined what needs to be considered as 'non-valvular AF' and listed 15 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 15 topics are (i) practical start-up and follow-up scheme for patients on NOACs; (ii) how to measure the anticoagulant effect of NOACs; (iii) drug-drug interactions and pharmacokinetics of NOACs; (iv) switching between anticoagulant regimens; (v) ensuring adherence of NOAC intake; (vi) how to deal with dosing errors; (vii) patients with chronic kidney disease; (viii) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?; (xi) management of bleeding complications; (x) patients undergoing a planned surgical intervention or ablation; (xi) patients undergoing an urgent surgical intervention; (xii) patients with AF and coronary artery disease; (xiii) cardioversion in a NOAC-treated patient; (xiv) patients presenting with acute stroke while on NOACs; and (xv) NOACs vs. VKAs in AF patients with a malignancy. Additional information and downloads of the text and anticoagulation cards in >16 languages can be found on an European Heart Rhythm Association web site (www.NOACforAF.eu).
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Lip GYH, Heinzel FR, Gaita F, Juanatey JRG, Le Heuzey JY, Potpara T, Svendsen JH, Vos MA, Anker SD, Coats AJ, Haverkamp W, Manolis AS, Chung MK, Sanders P, Pieske B. European Heart Rhythm Association/Heart Failure Association joint consensus document on arrhythmias in heart failure, endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Eur J Heart Fail 2015; 17:848-74. [PMID: 26293171 DOI: 10.1002/ejhf.338] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Lip GYH, Heinzel FR, Gaita F, Juanatey JRG, Le Heuzey JY, Potpara T, Svendsen JH, Vos MA, Anker SD, Coats AJ, Haverkamp W, Manolis AS, Chung MK, Sanders P, Pieske B, Gorenek B, Lane D, Boriani G, Linde C, Hindricks G, Tsutsui H, Homma S, Brownstein S, Nielsen JC, Lainscak M, Crespo-Leiro M, Piepoli M, Seferovic P, Savelieva I. European Heart Rhythm Association/Heart Failure Association joint consensus document on arrhythmias in heart failure, endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Europace 2015; 18:12-36. [PMID: 26297713 DOI: 10.1093/europace/euv191] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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