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Olson LM, Nei AM, Dierkhising RA, Joyce DL, Nei SD. Warfarin-Induced Rapid Rise in INR Post-Cardiac Surgery Is Not Associated With Increased Bleeding Risk. Ann Pharmacother 2019; 53:1184-1191. [PMID: 31304766 DOI: 10.1177/1060028019858677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Post-cardiac surgery bleeding can have devastating consequences, and it is unknown if warfarin-induced rapid international normalized ratio (INR) rise during the immediate postoperative period increases bleed risk. Objective: To determine the impact of warfarin-induced rapid-rise INR on post-cardiac surgery bleeding. Methods: This was a single-center, retrospective chart review of post-cardiac surgery patients initiated on warfarin at Mayo Clinic Hospital, Rochester. Patients were grouped based on occurrence or absence of rapid-rise INR (increase ≥1.0 within 24 hours). The primary outcome compared bleed events between groups. Secondary outcomes assessed hospital length of stay (LOS) and identified risk factors associated with bleed events and rapid rise in INR. Results: During the study period, 2342 patients were included, and 56 bleed events were evaluated. Bleed events were similar between rapid-rise (n = 752) and non-rapid-rise (n = 1590) groups in both univariate (hazard ratio [HR] = 1.22; P = 0.594) and multivariable models (HR = 1.24; P = 0.561). Those with rapid-rise INR had longer LOS after warfarin administration (discharge HR = 0.84; P = 0.0002). The most common warfarin dose immediately prior to rapid rise was 5 mg. Risk factors for rapid-rise INR were low body mass index, female gender, and cross-clamp time. Conclusion and Relevance: This represents the first report to assess warfarin-related rapid-rise INR in post-cardiac surgery patients and found correlation to hospital LOS but not bleed events. Conservative warfarin dosing may be warranted until further research can be conducted.
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Lin KJ, Singer DE, Glynn RJ, Blackley S, Zhou L, Liu J, Dube G, Oertel LB, Schneeweiss S. Prediction Score for Anticoagulation Control Quality Among Older Adults. J Am Heart Assoc 2017; 6:e006814. [PMID: 28982676 PMCID: PMC5721874 DOI: 10.1161/jaha.117.006814] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/23/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND Time in the therapeutic range (TTR) is associated with the effectiveness and safety of vitamin K antagonist (VKA) therapy. To optimize prescribing of VKA, we aimed to develop and validate a prediction model for TTR in older adults taking VKA for nonvalvular atrial fibrillation and venous thromboembolism. METHODS AND RESULTS The study cohort comprised patients aged ≥65 years who were taking VKA for atrial fibrillation or venous thromboembolism and who were identified in the 2 US electronic health record databases linked with Medicare claims data from 2007 through 2014. With the predictors identified from a systematic review and clinical knowledge, we built a prediction model for TTR, using one electronic health record system as the training set and the other as the validation set. We compared the performance of the new models to that of a published prediction score for TTR, SAMe-TT2R2. Based on 1663 patients in the training set and 1181 in the validation set, our optimized score included 42 variables and the simplified model included 7 variables, abbreviated as PROSPER (Pneumonia, Renal dysfunction, Oozing blood [prior bleeding], Staying in hospital ≥7 days, Pain medication use, no Enhanced [structured] anticoagulation services, Rx for antibiotics). The PROSPER score outperformed SAMe-TT2R2 when predicting both TTR ≥70% (area under the receiver operating characteristic curve 0.67 versus 0.55) and the thromboembolic and bleeding outcomes (area under the receiver operating characteristic curve 0.62 versus 0.52). CONCLUSIONS Our geriatric TTR score can be used as a clinical decision aid to select appropriate candidates to receive VKA therapy and as a research tool to address confounding and treatment effect heterogeneity by anticoagulation quality.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Daniel E Singer
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Suzanne Blackley
- Clinical and Quality Analysis, Information Systems, Partners HealthCare System, Boston, MA
| | - Li Zhou
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Clinical Informatics, Partners eCare, Partners HealthCare System, Boston, MA
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gina Dube
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lynn B Oertel
- Anticoagulation Management Service, Department of Nursing, Massachusetts General Hospital, Boston, MA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
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3
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Shahid F, Shantsila E, Lip GYH. Use of non-vitamin K antagonist oral anticoagulants in patients with heart failure and atrial fibrillation: does concomitant kidney disease change our practice? Eur J Heart Fail 2016; 18:1172-4. [PMID: 27594178 DOI: 10.1002/ejhf.552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 03/27/2016] [Accepted: 03/28/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- Farhan Shahid
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Eduard Shantsila
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Dallalzadeh LO, Go AS, Chang Y, Borowsky LH, Fang MC, Singer DE. Stability of High-Quality Warfarin Anticoagulation in a Community-Based Atrial Fibrillation Cohort: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. J Am Heart Assoc 2016; 5:JAHA.116.003482. [PMID: 27451456 PMCID: PMC5015384 DOI: 10.1161/jaha.116.003482] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Warfarin reduces ischemic stroke risk in atrial fibrillation (AF) but increases bleeding risk. Novel anticoagulants challenge warfarin as stroke-preventive therapy for AF. They are available at fixed doses but are more costly. Warfarin anticoagulation at a time in therapeutic range (TTR) ≥70% is similarly as effective and safe as novel anticoagulants. It is unclear whether AF patients with TTR ≥70% will remain stably anticoagulated and avoid the need to switch to a novel anticoagulant. We assessed stability of warfarin anticoagulation in AF patients with an initial TTR ≥70%. METHODS AND RESULTS Within the community-based Anticoagulation and Risk Factors in AF (ATRIA) cohort followed from 1996 to 2003, we identified 2841 new warfarin users who continued warfarin over 9 months. We excluded months 1 to 3 to achieve a stable dose. For the 987 patients with TTR ≥70% in an initial 6-month period (TTR1; months 4-9), we described the distribution of TTR2 (months 10-15) and assessed multivariable correlates of persistent TTR ≥70%. Of patients with TTR1 ≥70%, 57% persisted with TTR2 ≥70% and 16% deteriorated to TTR2 <50%. Only initial TTR1 ≥90% (adjusted odds ratio 1.47, 95% CI 1.07-2.01) independently predicted TTR2 ≥70%. Heart failure was moderately associated with marked deterioration (TTR2 <50%); adjusted odds ratio 1.45, 95% CI 1.00-2.10. CONCLUSIONS Nearly 60% of AF patients with high-quality TTR1 on warfarin maintained TTR ≥70% over the next 6 months. A minority deteriorated to very poor TTR. Patient features did not strongly predict TTR in the second 6-month period. Our analyses support watchful waiting for AF patients with initial high-quality warfarin anticoagulation before considering alternative anticoagulants.
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Affiliation(s)
| | - Alan S Go
- Division of Research, Kaiser Permanente of Northern California, Oakland, CA Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco, CA Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA
| | - Yuchiao Chang
- Harvard Medical School, Boston, MA Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Leila H Borowsky
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, CA
| | - Daniel E Singer
- Harvard Medical School, Boston, MA Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
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Anguita Sánchez M, Bertomeu Martínez V, Cequier Fillat Á. Insuficiencia cardiaca, fibrilación auricular no valvular y control de la anticoagulación con antagonistas de la vitamina K. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2015.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Anguita Sánchez M, Bertomeu Martínez V, Cequier Fillat Á. Heart Failure, Nonvalvular Atrial Fibrillation and Anticoagulation Control With Vitamin K Antagonists. ACTA ACUST UNITED AC 2015; 69:75-6. [PMID: 26589883 DOI: 10.1016/j.rec.2015.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 08/24/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Manuel Anguita Sánchez
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain; Departamento de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain.
| | - Vicente Bertomeu Martínez
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain; Departamento de Cardiología, Hospital Universitario San Juan, Alicante, Spain
| | - Ángel Cequier Fillat
- Agencia de Investigación de la Sociedad Española de Cardiología, Madrid, Spain; Departamento de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Zeitler EP, Eapen ZJ. Anticoagulation in Heart Failure: a Review. J Atr Fibrillation 2015; 8:1250. [PMID: 27957180 DOI: 10.4022/jafib.1250] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/11/2015] [Accepted: 06/23/2015] [Indexed: 12/19/2022]
Abstract
Heart failure (HF) with reduced left ventricular function inflicts a large and growing burden of morbidity and mortality in the US and across the globe. One source of this burden is stroke. While it appears that HF itself may impose some risk of stroke, it is in the presence of other risk factors, like atrial fibrillation, that the greatest risks are observed. Therapeutic anticoagulation is the mainstay of risk reduction strategies in this population. While warfarin was the only available therapy for anticoagulation for many decades, there are now four direct oral anticoagulants available. In three of these four, outcomes in the specific subgroup of patients with heart failure have been examined. In this review, we provide some pathophysiologic basis for the risk of stroke in heart failure. In addition, the available therapeutic options for stroke risk prevention in heart failure are described in detail including how these options are incorporated into relevant professional society guidelines.
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Affiliation(s)
- Emily P Zeitler
- Duke Clinical Research Institute and Duke University Medical Center, Durham NC
| | - Zubin J Eapen
- Duke Clinical Research Institute and Duke University Medical Center, Durham NC
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Sindone AP, Freedman SB. Is risk-benefit of warfarin for atrial fibrillation with heart failure determined by heart failure severity? Thromb Haemost 2015; 114:1-3. [PMID: 25947352 DOI: 10.1160/th15-04-0297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 04/10/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Andrew P Sindone
- Prof. Andrew Sindone, Department of Cardiology, Concord Hospital, Sydney, NSW 2139, Australia, E-mail:
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