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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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Use of SAMe-TT 2R 2 in a racially diverse anticoagulation clinic: prediction of optimal anticoagulation. J Thromb Thrombolysis 2023; 55:175-180. [PMID: 36352057 DOI: 10.1007/s11239-022-02722-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
The SAMe-TT2R2 score predicts optimal long-term oral Vitamin K Antagonist (VKA) anticoagulation for homogenous Caucasian and homogenous Asian populations for non-valvular atrial fibrillation but at different score thresholds. The score that predicts optimal VKA anticoagulation in significantly diverse populations for multiple indications for systemic anticoagulation has not been reported. We determined whether optimal VKA anticoagulation is predicted by SAMe-TT2R2 score in a diverse inner-city population for non-valvular atrial fibrillation (NVAF), unprovoked venous and pulmonary thromboembolic disease (VTE), mechanical prosthetic heart valves and all other indications. All patients on long term VKA's that attended an inner-city anticoagulation clinic between February 2016 and October 2017 were included in this study. Eligible patients were grouped according to oral anticoagulation indication: (1) NVAF, (2) VTE, (3) prosthetic valves and (4) other indications. Each patient's SAMe-TT2R2 score and percent time of INR in the therapeutic range (TTR) was calculated with optimal international normalized ratio (INR) control defined as TTR ≥ 65%. The correlation between SAMe-TT2R2 score and TTR was determined by logistic regression for each oral anticoagulant indication. Receiver operating characteristic curves were then used to identify the best cutoff for prediction of ≥ 65% TTR. Of 316 patients meeting study criteria, 54% were non-Caucasian and there was a significant negative correlation between the SAMe-TT2R2 score and TTR (coefficient - 0.35, P < 0.0001) for all patients. A SAMe-TT2R2 score < 4 was identified as the best threshold for predicting optimal TTR (Youden's J-statistics = 0.238) with accuracy and positive likelihood ratio of 63.4% and 1.73, respectively. The SAMe-TT2R2 score predicts optimal VKA anticoagulation for systemic anticoagulation for multiple indications in a diverse urban population at a higher score than the original report for non-valvular atrial fibrillation of a cohort where < 10% non-Caucasians.
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Alhmoud EN, Elewa H, Abdul Gelil MS, Abd El Samad OB, Elzouki AY. Evaluation of the Validity of SAMe-TT 2R 2 Score in a Cohort of Venous Thromboembolism Patients Treated With Warfarin. Clin Appl Thromb Hemost 2020; 26:1076029620945039. [PMID: 32875827 PMCID: PMC7476333 DOI: 10.1177/1076029620945039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 11/25/2022] Open
Abstract
Low SAMe-TT2R2 score of <2 was validated as a predictor of optimum anticoagulation control, reflected by mean time in therapeutic range (TTR) above 65% to 70%, among warfarin-treated atrial fibrillation patients. This study aimed to validate the ability of SAMe-TT2R2 score and its individual components in predicting anticoagulation control (mean TTR and clinical events) among a cohort of venous thromboembolism (VTE) patients in Qatar. A total of 295 patients were retrospectively evaluated. There was a trend toward statistical significance in mean TTR between low (<2) and high (≥ 2) SAMe-TT2R2 score groups (P = .05), a difference that was not sustained when a cutoff of 3 was used (ie, a score of 3 or more). Patients with poor INR control (TTR <70%) were numerically less likely to have SAMe-TT2R2 score of <2 compared with those with good INR control, though the difference was not statistically significant (16.7% vs 83.3%, respectively, P = .4). No thromboembolic events were reported, and no association was found between the score and risk of bleeding. Non-Caucasian origin was the only significant predictor of good anticoagulation in the studied cohort. In conclusion, SAMe-TT2R2 score could not predict quality of anticoagulation control in a cohort of VTE patients treated with warfarin in Qatar. Contribution of other clinical factors and whether a different scoring may yield better prediction of anticoagulation control remains to be tested.
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Affiliation(s)
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2019; 39:1330-1393. [PMID: 29562325 DOI: 10.1093/eurheartj/ehy136] [Citation(s) in RCA: 1287] [Impact Index Per Article: 257.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. 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;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | | | | | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Ronan Collins
- Age-Related Health Care & Stroke-Service, Tallaght Hospital, Dublin Ireland
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK, and Imperial College
| | - Hein Heidbüchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Antwerp University and University Hospital, Antwerp, Belgium
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Arnar DO, Mairesse GH, Boriani G, Calkins H, Chin A, Coats A, Deharo JC, Svendsen JH, Heidbüchel H, Isa R, Kalman JM, Lane DA, Louw R, Lip GYH, Maury P, Potpara T, Sacher F, Sanders P, Varma N, Fauchier L, Haugaa K, Schwartz P, Sarkozy A, Sharma S, Kongsgård E, Svensson A, Lenarczyk R, Volterrani M, Turakhia M, Obel IWP, Abello M, Swampillai J, Kalarus Z, Kudaiberdieva G, Traykov VB, Dagres N, Boveda S, Vernooy K, Kalarus Z, Kudaiberdieva G, Mairesse GH, Kutyifa V, Deneke T, Hastrup Svendsen J, Traykov VB, Wilde A, Heinzel FR. Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS). Europace 2019; 21:844–845. [DOI: 10.1093/europace/euz046] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/24/2019] [Indexed: 12/22/2022] Open
Abstract
AbstractAsymptomatic arrhythmias are frequently encountered in clinical practice. Although studies specifically dedicated to these asymptomatic arrhythmias are lacking, many arrhythmias still require proper diagnostic and prognostic evaluation and treatment to avoid severe consequences, such as stroke or systemic emboli, heart failure, or sudden cardiac death. The present document reviews the evidence, where available, and attempts to reach a consensus, where evidence is insufficient or conflicting.
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Affiliation(s)
- David O Arnar
- Department of Medicine, Landspitali - The National University Hospital of Iceland and University of Iceland, Reykjavik, Iceland
| | | | - Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Hugh Calkins
- Department of Arrhythmia Services, Johns Hopkins Medical Institutions Baltimore, MD, USA
| | - Ashley Chin
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Andrew Coats
- Department of Cardiology, University of Warwick, Warwickshire, UK
| | - Jean-Claude Deharo
- Department of Rhythmology, Hôpital Universitaire La Timone, Marseille, France
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Hein Heidbüchel
- Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Rodrigo Isa
- Clínica RedSalud Vitacura and Hospital el Carmen de Maipú, Santiago, Chile
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Ruan Louw
- Department Cardiology (Electrophysiology), Mediclinic Midstream Hospital, Centurion, South Africa
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Philippe Maury
- Cardiology, University Hospital Rangueil, Toulouse, France
| | - Tatjana Potpara
- Cardiology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia
| | - Frederic Sacher
- Service de Cardiologie, Institut Lyric, CHU de Bordeaux, Bordeaux, France
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Niraj Varma
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Laurent Fauchier
- Service de Cardiologie et Laboratoire d'Electrophysiologie Cardiaque, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | - Kristina Haugaa
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peter Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Milan, Italy
| | - Andrea Sarkozy
- Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium
| | | | - Erik Kongsgård
- Department of Cardiology, OUS-Rikshospitalet, Oslo, Norway
| | - Anneli Svensson
- Department of Cardiology, University Hospital of Linkoping, Sweden
| | | | | | - Mintu Turakhia
- Stanford University, Cardiac Arrhythmia & Electrophysiology Service, Stanford, USA
| | | | | | - Janice Swampillai
- Electrophysiologist & Cardiologist, Waikato Hospital, University of Auckland, New Zealand
| | - Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice, Poland
- Department of Cardiology, Silesian Center for Heart Diseases, Zabrze
| | | | - Vassil B Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
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Wasniewski S, Consuegra-Sánchez L, Conesa-Zamora P, García de Guadiana-Romualdo L, Ramos-Ruiz P, Merelo-Nicolás M, Clavel-Ruipérez FG, Alburquerque-González B, Soria-Arcos F, Castillo-Moreno JA. Low Performance of a Clinical-Genetic Model in the Estimation of Time in Therapeutic Range in Acenocoumarol-Adherent Patients with Nonvalvular Atrial Fibrillation: The Quality of Anticoagulation Challenge. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8012747. [PMID: 30417015 PMCID: PMC6207892 DOI: 10.1155/2018/8012747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 08/01/2018] [Accepted: 09/20/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anticoagulation with vitamin K antagonists continues to be a challenging task given the difficulty of achieving a correct time in therapeutic range (TTR). The SAMeTT2R2 score has been proposed to identify patients that will be good responders. In this study we aimed to analyse clinical and genetic factors involved in a correct level of anticoagulation in patients with atrial fibrillation and thereby potentially improve the diagnostic performance of SAMeTT2R2 score. METHODS We prospectively included 212 consecutive patients with nonvalvular atrial fibrillation under treatment with acenocoumarol for at least 6 months that were attended in a cardiology outpatient clinic and were categorized as adherent to medication. We carried out a multivariate regression analysis to detect the independent predictive factors of good control. In all patients VKORC1, CYP2C9⁎2, CYP2C9⁎3, and MIR133A2 genotyping was performed. RESULTS A total of 128 (60.4%) patients presented TTR <70% (average TTR = 63.2). We identified body mass index (OR 0.94, 95%CI 0.89-0.99, p=0.032) and regular vitamin K intake (OR 0.53, 95%CI 0.28-0.99, p= 0.046) as independent predictors of poor anticoagulation control. The discriminatory power of a clinical-genetic model derived from our cohort was significantly better compared to the SAMeTT2R2 score (C-statistic 0.658 versus 0.524, p<0.001). CONCLUSIONS In our study the SAMeTT2R2 score revealed a poor ability in the prediction of TTR. Besides SAMeTT2R2, body mass index and possibly vitamin K intake should be taken into account when deciding the optimal anticoagulation strategy. The information provided by the identified genotypes was marginal.
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Affiliation(s)
- Samantha Wasniewski
- Department of Cardiology, Santa Lucía General University Hospital, Cartagena-Murcia, Spain
| | | | - Pablo Conesa-Zamora
- Department of Clinical Analysis, Santa Lucía General University Hospital, Cartagena-Murcia, Spain
| | | | - Pablo Ramos-Ruiz
- Department of Cardiology, Santa Lucía General University Hospital, Cartagena-Murcia, Spain
| | - Marta Merelo-Nicolás
- Department of Cardiology, Santa Lucía General University Hospital, Cartagena-Murcia, Spain
| | | | | | - Federico Soria-Arcos
- Department of Cardiology, Santa Lucía General University Hospital, Cartagena-Murcia, Spain
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Mora-Llabata V, Dubois-Marqués D, Moreno-Prat M, Platas-Valenciano J, Salavert-Nadal MT, Gasull-Inserte S, Pacheco-Arroyo J, Roldán-Torres I. Utilidad marginal de la escala SAMe-TT 2 R 2 en la predicción de la calidad de la anticoagulación oral con acenocumarol en el “mundo real”. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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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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Poli D, Olshansky B, Fauchier L. The SAMe-TT2R2 score and quality of anticoagulation in AF: Can we predict which patient benefits from anticoagulation? Thromb Haemost 2017; 114:657-9. [DOI: 10.1160/th15-06-0518] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 06/26/2015] [Indexed: 12/30/2022]
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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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Zulkifly H, Lip GYH, Lane DA. Use of the SAMe-TT 2R 2 score to predict anticoagulation control in atrial fibrillation and venous thromboembolism patients receiving vitamin K antagonists: A review. Heart Rhythm 2017; 15:615-623. [PMID: 29180122 DOI: 10.1016/j.hrthm.2017.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Indexed: 10/18/2022]
Abstract
Identifying patients who are likely to achieve and maintain a therapeutic international normalized ratio when prescribed a vitamin K antagonist for stroke prevention in atrial fibrillation (AF) and venous thromboembolism (VTE) is challenging. The SAMe-TT2R2 score was developed on the basis of common clinical factors that can highlight patients who may be unable to achieve and maintain good anticoagulation control and for whom a "trial of warfarin" would be inadvisable. This review summarizes the main published prospective and retrospective studies that have validated the SAMe-TT2R2 score in patients with AF and VTE treated with a vitamin K antagonist and how the SAMe-TT2R2 score could aid clinical decision making; 19 studies were included. Taken together, validation studies suggest that the SAMe-TT2R2 score is able to predict good or poor anticoagulation control in patients with AF and VTE, although data on patients with VTE are limited (3 studies). The available evidence suggests that the SAMe-TT2R2 score may be a useful tool to aid clinical decision making for oral anticoagulants in patients with AF and VTE.
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Affiliation(s)
- Hanis Zulkifly
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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13
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Lip GYH, Weber C. Editors’ Choice 2016 papers in Thrombosis and Haemostasis. Thromb Haemost 2017; 117:204-206. [DOI: 10.1160/th16-11-0899] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 11/30/2016] [Indexed: 11/05/2022]
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14
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Lip GY, Freedman B, De Caterina R, Potpara TS. Stroke prevention in atrial fibrillation: Past, present and future. Thromb Haemost 2017; 117:1230-1239. [DOI: 10.1160/th16-11-0876] [Citation(s) in RCA: 289] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 06/09/2017] [Indexed: 01/05/2023]
Abstract
SummaryConcepts and our approaches to stroke prevention in atrial fibrillation (AF) have changed markedly over the last decade. There has been an evolution over the approach to stroke and bleeding risk assessment, as well as new treatment options. An increasing awareness of AF has led to calls to improve the detection of and population screening for AF. Stroke and bleeding risk assessment continues to evolve, and the ongoing debate on balance between simplicity and practicality, against precision medicine will continue. In this review article, we provide an overview of past, present and the (likely) future concepts and approaches to stroke prevention in AF. We propose three simple steps (the Birmingham ‘3-step’) that offers a practical management pathway to help streamline and simplify decision-making for stroke prevention in patients with AF.Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.
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Boned-Ombuena A, Pérez-Panadés J, López-Maside A, Miralles-Espí M, Guardiola Vilarroig S, Adam Ruiz D, Zurriaga O. [Prevalence of oral anticoagulation and quality of its management in primary healthcare: A study by the Health Sentinel Network of the Region of Valencia (Spain)]. Aten Primaria 2017; 49:534-548. [PMID: 28408116 PMCID: PMC6876010 DOI: 10.1016/j.aprim.2016.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/15/2016] [Accepted: 11/09/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To estimate the prevalence of patients with oral anticoagulant therapy (OAT) in the Region of Valencia and to evaluate the quality of management of OAT with vitaminK antagonists (VKA) carried out in primary healthcare. DESIGN Observational cross-sectional study conducted through the Health Sentinel Network of the Region of Valencia, which includes a survey and the retrospective analysis of OAT monitoring. SETTING Primary healthcare, Region of Valencia, Spain. SUBJECTS All patients aged 18years or older on OAT who consulted during the year 2014. The population covered by the 59 doctors of the Health Sentinel Network constitutes 2.2% of the adult population of the Region of Valencia, and it is representative of it. KEY MEASUREMENTS Demographic, socioeconomic and health data as well as information concerning OAT. Quality of OAT management with VKA was assessed by means of the percentage of time in therapeutic range (TTR), computed using the Rosendaal method. RESULTS A total of 1,144 patients were recorded (mean age 74.5±11 years; 49.7% women). Prevalence of OAT in the Region of Valencia is 1.3 cases per 100 population. The characteristic profile of these patients is an old person, with several comorbidities and a low level of education, who lives accompanied. Atrial fibrillation is the most common indication. 82.8% of patients on OAT with VKA were monitored in primary healthcare. The average TTR was 65.0%, and 53.9% of patients had a TTR ≥65%. Among inadequately controlled patients, 74.4% were perceived as well-controlled by their primary care doctor. CONCLUSIONS Prevalence of OAT is high, and it is expected to increase. The degree of control achieved meets the generally accepted quality standard (mean TTR ≥65%), and it is comparable to that observed in other national and international studies. However, there is wide scope for improvement. It is crucial to optimize the management of this therapy in the most effective and cost-effective way. Among other measures, access of physicians to their patients' clinical information should be improved.
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Affiliation(s)
- Ana Boned-Ombuena
- Departamento de Salud Valencia La Fe, Conselleria de Sanitat Universal i Salut Pública de la Comunitat Valenciana, Valencia, España.
| | - Jordi Pérez-Panadés
- Dirección General de Salud Pública, Conselleria de Sanitat Universal i Salut Pública de la Comunitat Valenciana, Valencia, España
| | - Aurora López-Maside
- Dirección General de Salud Pública, Conselleria de Sanitat Universal i Salut Pública de la Comunitat Valenciana, Valencia, España
| | - Maite Miralles-Espí
- Dirección General de Salud Pública, Conselleria de Sanitat Universal i Salut Pública de la Comunitat Valenciana, Valencia, España
| | - Sandra Guardiola Vilarroig
- Dirección General de Salud Pública, Conselleria de Sanitat Universal i Salut Pública de la Comunitat Valenciana, Valencia, España
| | - Desamparados Adam Ruiz
- Centro de Salud Salvador Allende, Conselleria de Sanitat Universal i Salut Pública de la Comunitat Valenciana, Valencia, España
| | - Oscar Zurriaga
- Dirección General de Salud Pública, Conselleria de Sanitat Universal i Salut Pública de la Comunitat Valenciana, Valencia, España; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, España
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Rivera-Caravaca JM, Roldán V, Esteve-Pastor MA, Valdés M, Vicente V, Lip GYH, Marín F. Importance of time in therapeutic range on bleeding risk prediction using clinical risk scores in patients with atrial fibrillation. Sci Rep 2017; 7:12066. [PMID: 28935868 PMCID: PMC5608893 DOI: 10.1038/s41598-017-11683-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/28/2017] [Indexed: 01/08/2023] Open
Abstract
Bleeding risk with vitamin K antagonists (VKAs) is closely related to the quality of anticoagulation in atrial fibrillation (AF) patients, reflected by time in therapeutic range (TTR). Here we compared the discrimination performance of different bleeding risk scores and investigated if adding TTR would improve their predictive value and clinical usefulness. We included 1361 AF patients stables on VKA for at least 6 months. Bleeding risk was assessed by the HAS-BLED, ATRIA, ORBIT and HEMORR2HAGES scores. Major bleeding events were recorded after a median of 6.5 years follow-up. In this period 250 patients suffered major bleeds. Comparison of receiver operating characteristic (ROC) curves demonstrated that HAS-BLED had the best discrimination performance, but adding the ‘labile INR’ criteria (i.e. TTR <65%) to ATRIA, ORBIT and HEMORR2HAGES increased their ability of discrimination and predictive value, with significant improvements in reclassification and discriminatory performance. Decision curve analyses (DCA) showed improvements of the clinical usefulness and a net benefit of the modified risk scores. In summary, in AF patients taking VKAs, the HAS-BLED score had the best predictive ability. Adding ‘labile INR’ to ATRIA, ORBIT and HEMORR2HAGES improved their predictive value for major bleeding leading to improved clinical usefulness compared to the original scores.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Mariano Valdés
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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Anticoagulation Control in Warfarin-Treated Patients Undergoing Cardioversion of Atrial Fibrillation (from the Edoxaban Versus Enoxaparin-Warfarin in Patients Undergoing Cardioversion of Atrial Fibrillation Trial). Am J Cardiol 2017; 120:792-796. [PMID: 28709650 DOI: 10.1016/j.amjcard.2017.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/16/2017] [Accepted: 06/01/2017] [Indexed: 12/19/2022]
Abstract
In the Edoxaban Versus Enoxaparin-Warfarin in Patients Undergoing Cardioversion of Atrial Fibrillation (ENSURE-AF) study (NCT 02072434), edoxaban was compared with enoxaparin-warfarin in 2,199 patients undergoing electrical cardioversion of nonvalvular atrial fibrillation (AF). In this multicenter prospective randomized open blinded end-point trial, we analyzed patients randomized to enoxaparin-warfarin. We determined time to achieve therapeutic range (TtTR); time in therapeutic range (TiTR); their clinical determinants; relation to sex, age, medical history, treatment, tobacco use, race risk (SAMe-TT2R2) score; and impact on primary end points (composite of stroke, systemic embolic event[SEE], myocardial infarction [MI], and cardiovascular death [CVD] and composite of major + clinically relevant nonmajor bleeding). Among 1,104 patients randomized to enoxaparin-warfarin, 27% were naïve to oral anticoagulants. Mean age was 64.2 ± 11 years and mean congestive heart failure, hypertension, age ≥75 (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65-74, female (CHA2DS2-VASc) score was 2.6. Mean TtTR was 7.7 days (median 7 days) and mean TiTR after reaching an international normalized ratio of 2.0 to 3.0 was 71%. In 695 patients who had an INR <2.0 before the first dose and who reached an INR ≥2.0, 436 had a SAMe-TT2R2 score ≤2 and 259 had a score >2. On multivariate regression, an independent predictor of extended TtTR was creatinine clearance (p = 0.02). TtTR was marginally related to stroke/SEE/MI/CVD (p = 0.06; odds ratio 0.23, 95% confidence interval 0.02 to 1.17) but not to any bleeding. Independent predictors of TiTR were previous vitamin K antagonist experience (p<0.01) and low hypertension, abnormal renal or liver function, stroke, bleeding, labile INRs, age >65, concomitant drugs or alcohol (HAS-BLED) score (p = 0.02). TiTR was related to any bleeding (p = 0.02; odds ratio 0.39, 95% confidence interval 0.16 to 0.88), but not stroke/SEE/MI/CVD. In this cohort of warfarin users with a high TiTR no difference was seen between TtTR and TiTR in relation to SAMe-TT2R2 score. In conclusion, even in this short-term study, TiTR was significantly related to bleeding events.
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18
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Lobos-Bejarano JM, Castellanos Rodríguez A, Barrios V, Escobar C, Polo-García J, Del Castillo-Rodríguez JC, Vargas-Ortega D, Lopez-Pineda A, Prieto-Valiente L, Lip GYH. Influence of renal function on anticoagulation control in patients with non-valvular atrial fibrillation taking vitamin K antagonists. Int J Clin Pract 2017; 71. [PMID: 28722795 DOI: 10.1111/ijcp.12974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/10/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Chronic kidney disease (CKD) has been related to poor anticoagulation control and an increased risk of bleeding. This study aims to evaluate the association between impaired renal function (eGFR <60 mL/min/1.73 m2 ) and anticoagulation control in patients with non-valvular atrial fibrillation (AF) on vitamin K antagonists (VKA) therapy. We also assessed whether the predictive value of the SAMe-TT2 R2 score prevailed for subgroups both with and without CKD. METHODS This is an ancillary analysis of 1381 patients from the PAULA study, which was a cross-sectional, retrospective and nationwide multicenter study. RESULTS A total of 370 patients had eGFR <60 mL/min/1.73 m2 . Anticoagulation control levels progressively worsened across each stage of CKD. Multiple linear regression analysis showed CKD as an independent predictor of time in therapeutic range (TTR). In the subgroup of patients with preserved renal function, female sex, diet affecting INR, polypharmacy and amiodarone were associated with poorer TTR. The SAMe-TT2 R2 score had a significant but modest predictive value for TTR<65% (AUC, area under the curve 0.558, P = .002). In the subgroup of patients with CKD, the SAMe-TT2 R2 (>2 points) showed no significant predictive capacity for TTR (AUC 0.528, P = .354). The average TTR was similar for both sexes (P = .255), but with a higher percentage of males subjects with TTR ≥65% (P = .013). CONCLUSION Chronic kidney disease is associated with poor anticoagulation control in patients with non-valvular AF taking VKA. The SAMe-TT2 R2 score was not predictive of poor TTR in the subgroup with CKD, although a modest predictive value for poor TTR was found in those without CKD.
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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
| | | | | | - Diego Vargas-Ortega
- High Resolution Hospitalization Unit, Hospital el Toyo, Hospital de Poniente El Ejido, Almeria, Spain
| | - Adriana Lopez-Pineda
- Clinical Medicine Department, Miguel Hernandez University, San Juan de Alicante, Spain
| | - Luis Prieto-Valiente
- Medical Biostatistics, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
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Liu J, Wang N, Qin L, Liu J, Xi S, Wang X, Li X, Zhang Y, Yin T. Integrating genotypes in the SAMe-TT 2R 2 score for the prediction of anticoagulation control in Chinese patients with atrial fibrillation on warfarin. Int J Cardiol 2017; 241:358-363. [PMID: 28479094 DOI: 10.1016/j.ijcard.2017.04.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/07/2017] [Accepted: 04/26/2017] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The SAMe-TT2R2 score has been proposed to predict whether patients with atrial fibrillation (AF) would be well anti-coagulated with warfarin or not. However, it might over-estimate the number of patients under suboptimal warfarin treatment in non-Caucasians. This study was designed to modify the SAMe-TT2R2 score with genotypes and validate it in Chinese AF patients treated with warfarin. MATERIAL AND METHODS Consented Chinese-Han patients (n=510) with AF under the treatment of warfarin for at least 3months were randomly divided into a derivation (n=310) and a validation cohort (n=200). For each patient, CYP2C9*3 and VKORC1 -1639 A/G genotyping was performed, and the time in therapeutic range (TTR) was calculated over this period. RESULTS The modified SAMe-TT2R2 score was established by adding "warfarin genotype bins" to replace "the non-white race" variable. In the validation cohort, the discrimination performance of the modified score for good anticoagulation control (TTR≥70%) was significantly improved (c- index increased from 0.60 to 0.67). Significantly increased risks of major bleedings (HR: 4.91; 95% CI: 1.03-23.37; adjusted p=0.04) and all bleedings (HR: 1.93; 95% CI: 1.14-3.25; adjusted p=0.01) were found in patients with modified scores ≥2, as compared with patients with modified scores of 0-1. CONCLUSIONS The modified SAMe-TT2R2 score could improve the ability for the identification of good anticoagulation control, and the prediction of major bleeding events in Chinese patients with AF treated by warfarin.
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Affiliation(s)
- Jia Liu
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Nina Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Liuan Qin
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jun Liu
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Shaozhi Xi
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xuyun Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiaoqi Li
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yuxiao Zhang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Tong Yin
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China.
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Dzeshka MS, Shahid F, Shantsila A, Lip GYH. Hypertension and Atrial Fibrillation: An Intimate Association of Epidemiology, Pathophysiology, and Outcomes. Am J Hypertens 2017; 30:733-755. [PMID: 28338788 DOI: 10.1093/ajh/hpx013] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 01/18/2023] Open
Abstract
Atrial fibrillation (AF) is the most prevalent sustained arrhythmia found in clinical practice. AF rarely exists as a single entity but rather as part of a diverse clinical spectrum of cardiovascular diseases, related to structural and electrical remodeling within the left atrium, leading to AF onset, perpetuation, and progression. Due to the high overall prevalence within the AF population arterial hypertension plays a significant role in the pathogenesis of AF and its complications. Fibroblast proliferation, apoptosis of cardiomyocytes, gap junction remodeling, accumulation of collagen both in atrial and ventricular myocardium all accompany ageing-related structural remodeling with impact on electrical activity. The presence of hypertension also stimulates oxidative stress, systemic inflammation, rennin-angiotensin-aldosterone and sympathetic activation, which further drives the remodeling process in AF. Importantly, both hypertension and AF independently increase the risk of cardiovascular and cerebrovascular events, e.g., stroke and myocardial infarction. Given that both AF and hypertension often present with limited on patient wellbeing, treatment may be delayed resulting in development of complications as the first clinical manifestation of the disease. Antithrombotic prevention in AF combined with strict blood pressure control is of primary importance, since stroke risk and bleeding risk are both greater with underlying hypertension.
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Affiliation(s)
- Mikhail S Dzeshka
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
- Grodno State Medical University, Grodno, Belarus
| | - Farhan Shahid
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Alena 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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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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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 GY, Waldo AL, Ip J, Martin DT, Bersohn MM, Choucair WK, Akar JG, Wathen M, Halperin JL. Determinants of Time in Therapeutic Range in Patients Receiving Oral Anticoagulants (A Substudy of IMPACT). Am J Cardiol 2016; 118:1680-1684. [PMID: 27665206 DOI: 10.1016/j.amjcard.2016.08.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 08/19/2016] [Accepted: 08/19/2016] [Indexed: 10/21/2022]
Abstract
Implanted cardiac arrhythmia devices can detect atrial tachyarrhythmias (atrial high-rate episodes [AHREs]) that are considered to correlate with atrial fibrillation and risk of stroke. In the IMPACT trial, oral anticoagulation was initiated when AHREs were detected by implanted cardioverter-defibrillators and withdrawn when they abated, according to a protocol accounting both for AHRE duration as detected by remote device monitoring and stroke risk assessment. In this analysis, we ascertained determinants of time in therapeutic range (TTR) among protocol-determined vitamin K antagonist-treated patients during the trial. We enrolled 2,718 patients with at least 1 additional stroke risk factor (CHADS2 score ≥1) at 104 arrhythmia centers. The sex, age <60, medical history, treatments interacting with VKA, tobacco use (2 points) and race (2 points for non-Caucasian) (SAMe-TT2R2) score is a simple clinical-derived score designed to aid decision-making on whether a patient is likely to achieve good anticoagulation control on vitamin K antagonist (e.g., warfarin), which was calculated and related to TTR achieved using the Rosendaal method. We analyzed 229 patients (mean age 66.7 years; mean CHADS2 score 2.85 [SD 1.1]) with mean TTR of 0.536 (SD 0.23) overall. Univariate analysis identified 5 variables associated with differences in mean TTR. Mean TTR was lower in those who were women (p = 0.031), of black race (p = 0.005) and in New York Heart Association class IV (p = 0.014), whereas hemoglobin >13.5 g/dl (p = 0.010) and New York Heart Association class I (p = 0.037) were associated with higher mean TTR. There was a significant difference in mean TTR value between US and non-US sites (Canada and Germany) (mean TTR for US: 0.513 vs non-US: 0.686; p <0.0001). Mean TTR was significantly lower (Δ = 0.1382, 95% CI 0.0382 to 0.2382) for patients with SAMe-TT2R2 scores of 4 (p = 0.007) and higher (Δ = 0.0612, 95% CI 0.0005 to 0.1219) for patients with SAMe-TT2R2 scores of 1 (p = 0.048). Linear regression confirmed a significant association between lower SAMe-TT2R2 score and improved anticoagulation control (p = 0.0021) with a 1-unit decrease in SAMe-TT2R2 score associated with an increase in TTR of 0.0404 (95% CI 0.0149 to 0.0659). In conclusion, clinical, geographical, and demographic factors were associated with the quality of anticoagulation control as reflected by TTR. Although overall TTR in this population was poor, lower SAMe-TT2R2 scores were associated with better TTR.
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Lip GYH. How to REVISIT the increasing "real world" evidence for stroke prevention in non-valvular atrial fibrillation? Curr Med Res Opin 2016; 32:2055-2057. [PMID: 27790919 DOI: 10.1080/03007995.2016.1254604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Gregory Y H Lip
- a University of Birmingham, Institute of Cardiovascular Sciences, City Hospital , Birmingham , UK
- b Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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Massaro AR, Lip GYH. Stroke Prevention in Atrial Fibrillation: Focus on Latin America. Arq Bras Cardiol 2016; 107:576-589. [PMID: 28558081 PMCID: PMC5210462 DOI: 10.5935/abc.20160116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 12/25/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 1-2% in North America and Europe. The increased prevalence of AF in Latin America is associated with an ageing general population, along with poor control of key risk factors, including hypertension. As a result, stroke prevalence and associated mortality have increased dramatically in the region. Therefore, the need for effective anticoagulation strategies in Latin America is clear. The aim of this review is to provide a contemporary overview of anticoagulants for stroke prevention. The use of vitamin K antagonists (VKAs, eg, warfarin) and aspirin in the prevention of stroke in patients with AF in Latin America remains common, although around one fifth of all AF patients receive no anticoagulation. Warfarin use is complicated by a lack of access to effective monitoring services coupled with an unpredictable pharmacokinetic profile. The overuse of aspirin is associated with significant bleeding risks and reduced efficacy for stroke prevention in this patient group. The non-VKA oral anticoagulants (NOACbs) represent a potential means of overcoming many limitations associated with VKA and aspirin use, including a reduction in the need for monitoring and a reduced risk of hemorrhagic events. The ultimate decision of which anticoagulant drug to utilize in AF patients depends on a multitude of factors. More research is needed to appreciate the impact of these factors in the Latin American population and thereby reduce the burden of AF-associated stroke in this region.
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Affiliation(s)
| | - Gregory Y H Lip
- City Hospital, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
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Antiplatelet and Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Coronary Stenting. Interv Cardiol Clin 2016; 6:91-117. [PMID: 27886825 DOI: 10.1016/j.iccl.2016.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Stroke prevention is the main priority in the management cascade of atrial fibrillation. Most patients require long-term oral anticoagulation (OAC) and may require percutaneous coronary intervention. Prevention of recurrent cardiac ischemia and stent thrombosis necessitate dual antiplatelet therapy (DAPT) for up to 12 months. Triple antithrombotic therapy with OAC plus DAPT of shortest feasible duration is warranted, followed by dual antithrombotic therapy of OAC and antiplatelet agent, and OAC alone after 12 months. Because of elevated risk of hemorrhagic complications, new-generation drug-eluting stents, lower-intensity OAC, radial access, and routine use of gastric protection with proton pump inhibitors are recommended.
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Rivera-Caravaca JM, Viedma-Viedma I, Roldán V. Factors Affecting the Quality of Anticoagulation With Vitamin K Antagonists in Venous Thromboembolism Patients. Biol Res Nurs 2016; 19:198-205. [DOI: 10.1177/1099800416671211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Introduction: Treatment of venous thromboembolism (VTE) is classically based on oral vitamin K antagonists (VKAs). Due to the disadvantages and side effects of these drugs, monitoring the quality of anticoagulation by assessing time within therapeutic range (TTR) is recommended. Variables altering the TTR in patients with VTE are yet to be determined. The aim of this study was to analyze the quality of anticoagulation in patients with VTE treated with VKAs and to identify factors associated with poor-quality anticoagulation. Methods: A retrospective observational study was performed in a cohort of 94 patients diagnosed with VTE undergoing treatment with VKAs. The TTR at 6 months was analyzed by the Rosendaal method. Univariate and a multivariate logistic regression analyses were performed to unravel factors that increase risk of poor-quality anticoagulation. Results: The TTR at 6 months in this cohort was 60.5%; 54 patients had a TTR < 65%. In the univariate analysis, female sex, age ≥ 65 years, and renal impairment were significantly associated with poor-quality anticoagulation. However, in the multivariate logistic regression model, only renal impairment was independently associated with poor-quality anticoagulation (odds ratio = 3.31, 95% confidence interval [1.049, 10.486], p = .041). Discussion: The average quality of anticoagulation was 60.5%, and a high percentage of patients had a quality of anticoagulation below recommended levels. Study findings indicate that renal impairment is an independent risk factor for poor-quality anticoagulation in patients with VTE treated with VKAs.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, Spain
- School of Nursing, Universidad Católica de Murcia, Murcia, Spain
| | | | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, Spain
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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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Relation of the SAMe-TT 2 R 2 score to quality of anticoagulation control and thromboembolic events in atrial fibrillation patients: Observations from the SPORTIF trials. Int J Cardiol 2016; 216:168-72. [DOI: 10.1016/j.ijcard.2016.04.131] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 03/29/2016] [Accepted: 04/16/2016] [Indexed: 12/20/2022]
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Escobar C, Barrios V, Lobos JM, Prieto L. Puntuación SAMe-TT2R2: ¿es útil en todos los pacientes con fibrilación auricular no valvular? Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2016.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Escobar C, Barrios V, Lobos JM, Prieto L. SAMe-TT2R2 Score: Useful in All Patients With Nonvalvular Atrial Fibrillation? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2016; 69:798. [PMID: 27328996 DOI: 10.1016/j.rec.2016.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/06/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Carlos Escobar
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain.
| | - Vivencio Barrios
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Luis Prieto
- Bioestadística Médica, Universidad Católica San Antonio de Murcia, Murcia, Spain
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Lobos-Bejarano JM, Barrios V, Polo-García J, Escobar C, Vargas-Ortega D, Marín-Montañés N, Prieto-Valiente L, Fuentes S, Prieto MA, García-Ortiz L. Evaluation of SAMe-TT2R2 score and other clinical factors influencing the quality of anticoagulation therapy in non-valvular atrial fibrillation: a nationwide study in Spain. Curr Med Res Opin 2016; 32:1201-7. [PMID: 26967541 DOI: 10.1185/03007995.2016.1164676] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the major clinical factors affecting the quality of anticoagulation and evaluate the predictive value of the SAMe-TT2R2 score to identify patients who will achieve a high average time in therapeutic range (T.T.R.) with vitamin K antagonist (V.K.A.) treatment. RESEARCH DESIGN AND METHODS This observational, cross-sectional, retrospective and nationwide multicenter study included 1524 patients from the primary care setting with non-valvular atrial fibrillation receiving V.K.A. (≥12 months). We performed a bivariate analysis to identify factors individually associated with the T.T.R. and a multiple regression analysis to identify the independent predictive factors. For the validation of the SAMe-TT2R2 score, the receiver operating characteristic (R.O.C.) curve was calculated and the Hosmer-Lemeshow test was used to test calibration. RESULTS A total of 94.8% of patients received acenocumarol (4.8% warfarin). A progressive decrease in mean T.T.R. was found when the SAMe-TT2R2 score increased from 0 points (72.1 ± 17.1%) to 4 points (64.1 ± 23.2%), p < 0.001. Other risk scores (CHADS2 and CHA2DS2-VASc, HAS-BLED) were also associated with the mean T.T.R. We found a significant association between low T.T.R. and the following clinical factors: female sex, three or more comorbidities, amiodarone treatment, dietary habits, bleeding history and the intake of ≥7 tablets per day besides V.K.A. (p < 0.01). Regarding SAMe-TT2R2 score validation, the R.O.C. curve showed significant capability, although not high, of discriminating good anticoagulation control (T.T.R. ≥65%) with an area under the curve of 0.562 (95% C.I. 0.533-0.592, p < 0.001) which increased, remaining modest, to 0.594 (95% C.I. 0.564-0.624, p < 0.001) when the factors not included in SAMe-TT2R2 score were added. CONCLUSION In this cohort, the SAMe-TT2R2 score had a significant, although modest, ability to assess the likelihood of good international normalized ration (I.N.R.) control, and its predictive value might slightly improve by adding other simple clinical factors. Further research is needed to refine the predictive scales.
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Affiliation(s)
| | - Vivencio Barrios
- b Cardiology Department , University Hospital Ramon y Cajal , Madrid , Spain
| | | | - Carlos Escobar
- d Cardiology Department , University Hospital La Paz , Madrid , Spain
| | - Diego Vargas-Ortega
- e High Resolution Hospitalization Unit, Hospital el Toyo, Hospital de Poniente El Ejido , Almeria , Spain
| | | | - Luis Prieto-Valiente
- g Medical Biostatistics, Universidad Católica San Antonio de Murcia , Murcia , Spain
| | | | - Miguel Angel Prieto
- i Vallobín-La Florida Primary Care Health Center , Oviedo , Spain
- j Medicine Preventive Department , Oviedo University , Asturias , Spain
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Lip GY, Nielsen PB. Should Patients With Atrial Fibrillation and 1 Stroke Risk Factor (CHA
2
DS
2
-VASc Score 1 in Men, 2 in Women) Be Anticoagulated? Circulation 2016; 133:1498-503; discussion 1503. [DOI: 10.1161/circulationaha.115.016713] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Gregory Y.H. Lip
- From University of Birmingham Institute of Cardiovascular Sciences, City Hospital, UK (G.Y.H.L.); and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (G.Y.H.L., P.B.N.)
| | - Peter Brønnum Nielsen
- From University of Birmingham Institute of Cardiovascular Sciences, City Hospital, UK (G.Y.H.L.); and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (G.Y.H.L., P.B.N.)
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Proietti M, Lip GYH. Edoxaban in venous thromboembolism and stroke prevention: an appraisal. Vasc Health Risk Manag 2016; 12:45-51. [PMID: 27013883 PMCID: PMC4778780 DOI: 10.2147/vhrm.s81569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Oral anticoagulation is the therapeutic cornerstone in preventing thromboembolic risk in both atrial fibrillation (AF) and venous thromboembolism (VTE). After decades of the sole therapeutic oral anticoagulation option being warfarin, the introduction of non-vitamin K antagonist oral anticoagulants has heralded a new era. Edoxaban is the latest addition to these available for clinical use. Edoxaban was as effective and safer than warfarin in preventing thromboembolic risk in AF patients. Similarly, edoxaban effectiveness and safety was evident when treating VTE patients to prevent recurrent VTE or VTE-related death. Therefore, edoxaban represents a valuable alternative in treating thromboembolic risk for AF and VTE patients.
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Affiliation(s)
- Marco Proietti
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK; Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | - 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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Voukalis C, Lip GY, Shantsila E. Emerging Tools for Stroke Prevention in Atrial Fibrillation. EBioMedicine 2016; 4:26-39. [PMID: 26981569 PMCID: PMC4776061 DOI: 10.1016/j.ebiom.2016.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/07/2016] [Accepted: 01/14/2016] [Indexed: 02/02/2023] Open
Abstract
Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile.
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Key Words
- Atrial fibrillation
- CKD, chronic kidney disease
- CrCl, creatinine clearance
- DM, diabetes mellitus
- ESRF, end stage renal failure
- HF, heart failure
- HTN, hypertension
- ICH, intracranial haemorrhage
- INR, international normalised ratio
- LV, left ventricle
- NCB, net clinical benefit
- NICE, National institute for Health and Care Excellence
- NVAF, non-valvular atrial fibrillation
- Net clinical benefit
- Non-vitamin K oral anticoagulants
- Oral anticoagulation
- PCI, percutaneous coronary intervention
- RSM, risk stratification model
- Risk stratification
- SE, systemic embolism
- Stroke prevention
- TE, thromboembolic episode
- TIA, transient ischaemic attack
- TTR, time in therapeutic range
- eGFR, estimated glomerular filtration rate
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Affiliation(s)
| | | | - Eduard Shantsila
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
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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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Lip GYH. Stroke prevention in atrial fibrillation: Where are we now? Indian Heart J 2015; 67 Suppl 2:S1-3. [PMID: 26688147 PMCID: PMC4688448 DOI: 10.1016/j.ihj.2015.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/04/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, England, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.
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Lip GYH, Lane DA. Assessing bleeding risk in atrial fibrillation with the HAS-BLED and ORBIT scores: clinical application requires focus on the reversible bleeding risk factors. Eur Heart J 2015; 36:3265-7. [PMID: 26351397 DOI: 10.1093/eurheartj/ehv415] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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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: 723] [Impact Index Per Article: 80.3] [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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