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Kaushik R, Mani A, Ganapathi S, Pillai VV, Jayakumar K, S H. Clinical outcomes of bileaflet St. Jude Medical and tilting disc TTK Chitra mechanical heart valve prosthesis: A comparative study. J Card Surg 2022; 37:2367-2374. [PMID: 35577768 DOI: 10.1111/jocs.16605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 03/27/2022] [Accepted: 04/01/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Comparative data on the clinical outcomes of TTK Chitra mechanical heart valve prosthesis (CHVP), an indigenously developed low-cost tilting disc valve and commonly used bileaflet valve, the St. Jude medical (SJM) prosthesis are sparse. METHODS We conducted a retrospective follow-up study of consecutive patients undergoing mitral (MVR) and aortic valve replacement (AVR) with SJM or CHVP mechanical prostheses over a 6-year period at our institution. RESULTS Seven hundred and thirty-five patients who underwent isolated MVR (n = 510) or AVR (n = 225) were included in the study. Patients with CHVP were younger and belonged to a lower socioeconomic class. The study cohort was followed-up for 2836 patient-years (SJM: 1865.1, CHVP: 971.0). All-cause mortality (p = 0.894), valve-related mortality (p = 0.681), prosthetic valve thrombosis (p = 0.155), embolism (p = 0.210), hemorrhage (p = 0.959) and infective endocarditis (IE, p = 0.084) were similar between both valve on follow-up. Estimated event free survival was 2302 ± 1 days in SJM as compared to 2484 ± 65 days in CHVP group (p = 0.393). Valve type was not an independent predictor of adverse events after adjusting for baseline data, time in therapeutic range and aspirin use. Subgroup analysis of patients who underwent MVR and AVR showed similar functional improvement and outcomes, except for a higher incidence of IE with SJM at the aortic position (p = 0.041). CONCLUSION The indigenously developed, low-cost CHVP has comparable midterm clinical performance as SJM in aortic or mitral positions.
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Affiliation(s)
- Rupesh Kaushik
- Department of Cardiology, Sreechitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Avinash Mani
- Department of Cardiology, Sreechitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sanjay Ganapathi
- Department of Cardiology, Sreechitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Vivek V Pillai
- Department of Cardiothoracic Surgery, Sreechitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Karunakaran Jayakumar
- Department of Cardiothoracic Surgery, Sreechitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Harikrishnan S
- Department of Cardiology, Sreechitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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International Normalized Ratio Test Frequency in Left Ventricular Assist Device Patients Affects Anticoagulation Quality and Adverse Events. ASAIO J 2021; 67:157-162. [PMID: 32501824 DOI: 10.1097/mat.0000000000001206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Anticoagulation therapy in patients using left ventricular assist device (LVAD) is essential to reduce hemocompatibility related adverse events (HRAEs). Vitamin K-antagonist dosage must be adapted and monitored by INR point-of-care testing (POCT) in outpatients. The study aims to determine if the frequency of INR POCT in LVAD outpatients has an influence on the quality of anticoagulation therapy (ACQ), HRAEs, and outcomes. This retrospective study included n = 48 patients who received LVAD implantation (HMII, HM3, and HVAD) between 2013 and 2017. ACQ (% of INR tests in range, PTR), outcomes and HRAEs using Kaplan-Meier curves were compared in a daily (n = 36) and 3×/week (n = 12) INR POCT group. Further, based on the achieved PTR ranging from 0-60% (poor), 61-70% (acceptable), and 71-100% (well controlled), HRAEs and outcomes were compared. Daily and 3×/week groups were similar in perioperative risk factors and INR target (p = 0.28). Freedom from any HRAE (38.9% vs. 25.0%, p = 0.44), any readmission (72.2% vs. 75.0%, p = 0.97), and 1 year survival (91.7% vs. 91.7%, p = 0.98) were comparable in both groups. The PTR was significantly higher with the daily self-assessments (73.5% vs. 68.4%, p = 0.006). Well vs. poorly controlled INR POCT patients more often had (p = 0.01) a daily POCT frequency (92%) vs. poorly controlled (54%) and significantly higher freedom from neurologic events (96.0 vs. 69.2%, p = 0.024) as well as hemorrhagic strokes (100% vs. 76.9%, p = 0.011). Well-controlled anticoagulation of LVAD outpatients is associated with less neurologic events. The frequency of INR POCT could be one of the key factors in the reduction of HRAEs, so future prospective, large-scale studies should help to clarify the effects.
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Clinical Impact of the Time in Therapeutic Range on Early Hospital Readmission in Patients with Acute Heart Failure Treated with Oral Anticoagulation in Internal Medicine. ACTA ACUST UNITED AC 2021; 57:medicina57040365. [PMID: 33918627 PMCID: PMC8069311 DOI: 10.3390/medicina57040365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/27/2021] [Accepted: 04/07/2021] [Indexed: 11/17/2022]
Abstract
Background and objectives: Patients with heart failure (HF) often present with non-valvular atrial fibrillation and require oral anticoagulation with coumarin anticoagulants such as acenocoumarol. The objective of this study was to evaluate the relationship between time in therapeutic range (TTR) and the risk of early readmission. Materials and Methods: A retrospective descriptive study was carried out on hospitalized patients with a diagnosis of HF between 2014 and 2018 who had adverse effects due to oral anticoagulation with acenocoumarol (underdosing, overdosing, or hemorrhage). Clinical, analytical, therapeutic, and prognostic variables were collected. TTR is defined as the duration of time in which the patient’s International Normalized Ratio (INR) values were within a desired range. Early readmission was defined as readmission within 30 days after hospital discharge. Patients were divided into two groups depending on whether or not they had a TTR less than 60% (TTR < 60%) over the 6 months prior to the adverse event. Results: In the cohort of 304 patients, the mean age was 82 years, 59.9% of the patients were female, and 54.6% had a TTR < 60%. Patients with TTR < 60% had a higher HAS-BLED score (4.04 vs. 2.59; p < 0.001) and INR (6 vs. 5.31; p < 0.05) but lower hemoglobin (11.67 vs. 12.22 g/dL; p < 0.05). TTR < 60% was associated with early readmission after multivariate analysis (OR: 2.05 (CI 95%: 1.16–3.61)). They also had a higher percentage of hemorrhagic events and in-hospital mortality but without reaching statistical significance. Conclusions: Patients with HF and adverse events due to acenocoumarol often have poor INR control, which is independently associated with a higher risk of early readmission.
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Boon GJAM, van Rein N, Bogaard HJ, Ende-Verhaar YM, Huisman MV, Kroft LJM, van der Meer FJM, Meijboom LJ, Symersky P, Vonk Noordegraaf A, Klok FA. Quality of initial anticoagulant treatment and risk of CTEPH after acute pulmonary embolism. PLoS One 2020; 15:e0232354. [PMID: 32343741 PMCID: PMC7188241 DOI: 10.1371/journal.pone.0232354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pathophysiology of chronic thromboembolic pulmonary hypertension (CTEPH) is not fully understood. Poor-quality anticoagulation may contribute to a higher risk of CTEPH after acute pulmonary embolism (PE), partly explaining the transition from acute PE to CTEPH. We assessed the association between the time in therapeutic range (TTR) of vitamin-K antagonist (VKA) treatment and incidence of CTEPH after a PE diagnosis. METHODS Case-control study in which the time spent in, under and above therapeutic range was calculated in 44 PE patients who were subsequently diagnosed with CTEPH (cases). Controls comprised 150 consecutive PE patients in whom echocardiograms two years later did not show pulmonary hypertension. All patients were treated with VKA for at least 6 months after the PE diagnosis. Time in (TTR), under and above range were calculated. Mean differences between cases and controls were estimated by linear regression. RESULTS Mean TTR during the initial 6-month treatment period was 72% in cases versus 78% in controls (mean difference -6%, 95%CI -12 to -0.1), mainly explained by more time above the therapeutic range in the cases. Mean difference of time under range was 0% (95%CI -6 to 7) and 2% (95CI% -3 to 7) during the first 3 and 6 months, respectively. In a multivariable model, adjusted odds ratios (ORs) for CTEPH were around unity considering different thresholds for 'poor anticoagulation', i.e. TTR <50%, <60% and <70%. CONCLUSION Subtherapeutic initial anticoagulation was not more prevalent among PE patients diagnosed with CTEPH than in those who did not develop CTEPH.
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Affiliation(s)
- Gudula J. A. M. Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Yvonne M. Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J. M. van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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Ting C, Sylvester KW, Schurr JW. Time in the Therapeutic Range for Assessing Anticoagulation Quality in Patients Receiving Continuous Unfractionated Heparin. Clin Appl Thromb Hemost 2018; 24:178S-181S. [PMID: 30213200 PMCID: PMC6714859 DOI: 10.1177/1076029618798944] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Due to variable pharmacokinetic properties, therapeutic anticoagulation with continuous
unfractionated heparin (UFH) requires ongoing laboratory monitoring, generally with
activated partial thromboplastin time (aPTT). In the ambulatory setting, clinicians who
manage warfarin therapy often use time in the therapeutic range (TTR) to estimate a
percentage of time the international normalized ratio is therapeutic. We applied the TTR
concept to aPTT monitoring for therapeutic UFH and used 2 methodologies for estimation:
percentage of aPTT values in range (%aIR) and a modification of the Rosendaal method
(mod-Rosendaal). This study included adult inpatients admitted between September 30, 2015,
and September 30, 2016, at Brigham and Women’s Hospital. For each patient, all available
aPTT values were extracted to calculate 2 individual TTRs according to each methodology.
Comparison between methods was performed using Student t test, and
correlation was assessed with simple linear regression. A total of 255 patients were
included in this study. The major outcome of TTR estimation was significantly higher using
mod-Rosendaal (43.7% [26.5%]) versus %aIR (37.7% [25.7%], P = .012) by a
mean difference of 6% points (95% confidence interval: 1.3-10.7). Time in the therapeutic
range estimated by mod-Rosendaal significantly correlated with those estimated by %aIR
(r = 0.84, P < .001). Further studies should
evaluate the correlation between TTR and clinical outcomes and establish a benchmark for
quality therapeutic anticoagulation with continuous UFH.
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Affiliation(s)
- Clara Ting
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | | | - James W Schurr
- School of Medicine, Stony Brook University, Stony Brook, NY, USA
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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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Caldeira D. The value of time in therapeutic range in the prediction of outcomes at a populational level in patients treated with vitamin K antagonists. Curr Med Res Opin 2018; 34:499-500. [PMID: 29189082 DOI: 10.1080/03007995.2017.1411794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Daniel Caldeira
- a Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina da Universidade de Lisboa , Lisboa , Portugal
- b Clinical Pharmacology Unit , Instituto de Medicina Molecular , Portugal
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Caldeira D, Rodrigues R, Abreu D, Anes AM, Rosa MM, Ferreira JJ. Suspected adverse drug reaction reports with oral anticoagulants in Portugal: a pharmacovigilance study. Expert Opin Drug Saf 2018; 17:339-345. [DOI: 10.1080/14740338.2018.1439474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Daniel Caldeira
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisbon,Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Raquel Rodrigues
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisbon,Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Daisy Abreu
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisbon,Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Marta Anes
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisbon,Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Unidade de Farmacovigilância de Lisboa e Vale do Tejo, Lisbon, Portugal
| | - Mário M. Rosa
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisbon,Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Unidade de Farmacovigilância de Lisboa e Vale do Tejo, Lisbon, Portugal
| | - Joaquim J. Ferreira
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, Lisbon,Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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van der Meer FJM, Adriaansen HJ, Leebeek FWG, Kruip MJHA, van den Besselaar AMHP, Biedermann JS. Control of anticoagulation with vitamin K antagonists: overestimation of median time in therapeutic range when assessed by linear interpolation. Thromb Haemost 2017; 116:679-86. [DOI: 10.1160/th16-03-0184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/07/2016] [Indexed: 11/05/2022]
Abstract
SummaryPatients receiving vitamin K–antagonists are monitored by regular assessment of the International Normalized Ratio (INR). There are two popular methods for therapeutic control of anticoagulation in patient groups: 1) Time in Therapeutic Range (TTR) assessed by linear interpolation of successive INR measurements; 2) the cross-sectional proportion (CSP) of all patients’ last INRs within range. The purpose of the present study is to compare the two methods using data from 53 Dutch Thrombosis Centres and to develop a semi-quantitative model for TTR based on different types of INR change. Different groups of around 400,000 patients in four consecutive years were evaluated: patients in the induction phase, short-term, long-term, low-target range, high-target range, receiving either acenocoumarol or phenprocoumon, and performing self-management. Each Centre provided TTR and CSP results for each patient group. TTR and CSP were compared using the Wilcoxon signed-rank test. Separately, we analysed the relationship between consecutive INR results regarding in or out of range and their frequency of occurrence in patients of two different cohorts. Good correlation was observed between TTR and CSP (correlation coefficient 0.694–0.950 in low-target range). In long-term acenocoumarol patients (low-target range) the median TTR was significantly higher than CSP (80.0 % and 78.7 %, respectively; p<0.001). In long-term phenprocoumon patients (low-target range) there was no significant difference between median TTR (83.0 %) and median CSP (82.6 %). In conclusion, the correlation between TTR assessed by linear interpolation and CSP was good. TTR assessed by linear interpolation was higher than CSP in patients on acenocoumarol.
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Fitzmaurice DA, Accetta G, Haas S, Kayani G, Lucas Luciardi H, Misselwitz F, Pieper K, ten Cate H, Turpie AGG, Kakkar AK. Comparison of international normalized ratio audit parameters in patients enrolled in GARFIELD-AF and treated with vitamin K antagonists. Br J Haematol 2016; 174:610-23. [DOI: 10.1111/bjh.14084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 02/06/2016] [Indexed: 11/28/2022]
Affiliation(s)
- David A. Fitzmaurice
- Primary Care Clinical Sciences; School of Health and Population Sciences; College of Medical and Dental Sciences; University of Birmingham; Edgbaston, Birmingham UK
| | | | - Sylvia Haas
- Formerly Technical University of Munich; Munich Germany
| | | | | | - Frank Misselwitz
- Global Clinical Development; Bayer HealthCare Pharmaceuticals; Berlin Germany
| | | | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis; Department of Internal Medicine; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center; Maastricht The Netherlands
| | | | - Ajay K. Kakkar
- Thrombosis Research Institute; London UK
- Department of Surgery; University College London; London UK
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