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Ujjin A, Wongcharoen W, Suwanagool A, Chai-Adisaksopha C. Optimal Strategies to Select Warfarin Dose for Thai Patients with Atrial Fibrillation. J Clin Med 2024; 13:2675. [PMID: 38731209 PMCID: PMC11084839 DOI: 10.3390/jcm13092675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Warfarin has been the mainstay treatment for the prevention of stroke and systemic thromboembolism in patients with atrial fibrillation (AF). The optimal starting dose of warfarin remains unclear. Objective: To investigate the most optimal dosing strategies for warfarin starting dose in Thai patients with AF. Material and Methods: We enrolled consecutive AF patients who were starting on warfarin and resulting in a stable INR of 2.0-3.0 at two consecutive time points. We measured the dose of warfarin at which INR achieved the target range. The optimal dosage was defined as the difference from the actual dose within 20%. We compared strategies of warfarin dosing, including warfarin dosing formula, 2.5 mg, 3 mg and 5 mg doses. The primary endpoints were the proportions of patients in optimal, underdosing, and overdosing categories. Results: Among 1207 patients visiting the Outpatient Clinic between October 2011 and September 2021, 531 patients were identified with AF and INR in the therapeutic range of 2.0-3.0 on at least two consecutive visits. The mean age of participants was 68 ± 11 years, and men accounted for 44.4% of the population. The warfarin dosing formula resulted in optimal dosing in 37% and overdosing in 24% of cases, whereas the 2.5 mg, 3 mg and 5 mg doses resulted in optimal dosing in 36%, 39%, and 11%, and overdosing in 33%, 44% and 88% of patients, respectively (p < 0.01). Conclusions: In Thai patients with AF, the optimal warfarin starting dose may be 2.5 mg, 3 mg or a simplified warfarin dosing formula, whereas the 5 mg dose should be avoided due to the high risk of overdosing.
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Affiliation(s)
- Anunya Ujjin
- Division of Medicine, Neurological Institute of Thailand, Bangkok 10400, Thailand
| | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 52000, Thailand
| | - Arisara Suwanagool
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Bangkok 10700, Thailand
| | - Chatree Chai-Adisaksopha
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 52000, Thailand
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Dai MF, Li SY, Zhang JF, Wang BY, Zhou L, Yu F, Xu H, Ge WH. Warfarin anticoagulation management during the COVID-19 pandemic: The role of internet clinic and machine learning. Front Pharmacol 2022; 13:933156. [PMID: 36225580 PMCID: PMC9549053 DOI: 10.3389/fphar.2022.933156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Patients who received warfarin require constant monitoring by hospital staff. However, social distancing and stay-at-home orders, which were universally adopted strategies to avoid the spread of COVID-19, led to unprecedented challenges. This study aimed to optimize warfarin treatment during the COVID-19 pandemic by determining the role of the Internet clinic and developing a machine learning (ML) model to predict anticoagulation quality. Methods: This retrospective study enrolled patients who received warfarin treatment in the hospital anticoagulation clinic (HAC) and “Internet + Anticoagulation clinic” (IAC) of the Nanjing Drum Tower Hospital between January 2020 and September 2021. The primary outcome was the anticoagulation quality of patients, which was evaluated by both the time in therapeutic range (TTR) and international normalized ratio (INR) variability. Anticoagulation quality and incidence of adverse events were compared between HAC and IAC. Furthermore, five ML algorithms were used to develop the anticoagulation quality prediction model, and the SHAP method was introduced to rank the feature importance. Results: Totally, 241 patients were included, comprising 145 patients in the HAC group and 96 patients in the IAC group. In the HAC group and IAC group, 73.1 and 69.8% (p = 0.576) of patients achieved good anticoagulation quality, with the average TTR being 79.9 ± 20.0% and 80.6 ± 21.1%, respectively. There was no significant difference in the incidence of adverse events between the two groups. Evaluating the five ML models using the test set, the accuracy of the XGBoost model was 0.767, and the area under the receiver operating characteristic curve was 0.808, which showed the best performance. The results of the SHAP method revealed that age, education, hypertension, aspirin, and amiodarone were the top five important features associated with poor anticoagulation quality. Conclusion: The IAC contributed to a novel management method for patients who received warfarin during the COVID-19 pandemic, as effective as HAC and with a low risk of virus transmission. The XGBoost model could accurately select patients at a high risk of poor anticoagulation quality, who could benefit from active intervention.
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Affiliation(s)
- Meng-Fei Dai
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Shu-Yue Li
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Pharmacy, Shanxi Province Cancer Hospital, Taiyuan, China
| | | | - Bao-Yan Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lin Zhou
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Feng Yu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hang Xu
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- *Correspondence: Hang Xu, ; Wei-Hong Ge,
| | - Wei-Hong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- *Correspondence: Hang Xu, ; Wei-Hong Ge,
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Barrios V, Escobar C, Prieto L, Polo J, Muñiz J, Anguita M, H Lip GY. A new index to predict quality of anticoagulation control in patients on vitamin K antagonists: the DAFNE score. Future Cardiol 2020; 17:685-692. [PMID: 33331173 DOI: 10.2217/fca-2020-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To derive a new clinical score to improve the prediction of those at risk of poor International Normalized Ratio control among patients with atrial fibrillation taking vitamin K antagonists. Materials & methods: The score was calculated using PAULA database and validated in the FANTASIIA population. Results: The DAFNE score (cardiovascular Disease, concomitant treatment with Amiodarone, Food/dietary transgression and taking ≥7 pills daily, fEemale sex) score was related to a higher probability of poor International Normalized Ratio control. C-indexes were 0.611 and 0.576 (De Long test, p = 0.007) for the DAFNE and SAMe-TT2R2 scores, respectively. Conclusion: The DAFNE score is a new clinical score which may potentially help determine those patients with atrial fibrillation who are at high risk of poor anticoagulation control with vitamin K antagonists.
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Affiliation(s)
- Vivencio Barrios
- Cardiology Department, University Hospital Ramon y Cajal, Madrid, Spain
| | - Carlos Escobar
- Cardiology Department, University Hospital La Paz, Madrid, Spain
| | - Luis Prieto
- Medical Biostatistics, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Jose Polo
- Primary Care Health Center Casar de Cáceres, Cáceres, Spain
| | - Javier Muñiz
- Instituto Universitario de Ciencias de la Salud, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade da Coruña, La Coruña, Spain
| | - Manuel Anguita
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, United Kingdom & Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Sridharan K, Al Banna R, Qader AM, Husain A. Evaluation of inter-patient variability in the pharmacodynamic indices of warfarin. Expert Rev Cardiovasc Ther 2020; 18:835-840. [DOI: 10.1080/14779072.2020.1814144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Rashed Al Banna
- Department of Cardiology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
| | - Ali Mohamed Qader
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Aysha Husain
- Department of Cardiology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
- RCSI-Bahrain, Manama, Kingdom of Bahrain
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Li X, Jin Q, Zhang X. Closure Device-Related Thrombosis After Anticoagulation With Dabigatran in Patients Undergoing Percutaneous Left Atrial Appendage Closure: Case Reports and Literature Review. Front Pharmacol 2020; 11:563920. [PMID: 33013399 PMCID: PMC7506050 DOI: 10.3389/fphar.2020.563920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/21/2020] [Indexed: 12/18/2022] Open
Abstract
Percutaneous left atrial appendage closure (LAAC) is an effective and safe operation strategy for stroke prevention in patients who are diagnosed with atrial fibrillation (AF) but cannot tolerate long term anticoagulation medication. We presented four rare cases of thrombosis formation on the occluder device. After the LAAC operation was successfully performed on patients, they followed a course of anticoagulation with dabigatran (110 mg b.i.d.), and device-related thrombosis (DRT) occurred as indicated by a transesophageal echocardiogram (TEE) during the follow-up period. Regressions were achieved after replacing dabigatran with rivaroxaban or warfarin for more than 1 month. No thrombosis or bleeding-related complications occurred in subsequent follow-ups.
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Affiliation(s)
- Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qinchun Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
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Shoji M, Suzuki S, Otsuka T, Arita T, Yagi N, Semba H, Kano H, Matsuno S, Kato Y, Uejima T, Oikawa Y, Matsuhama M, Yajima J, Yamashita T. A Simple Formula for Predicting the Maintenance Dose of Warfarin with Reference to the Initial Response to Low Dosing at an Outpatient Clinic. Intern Med 2020; 59:29-35. [PMID: 31511484 PMCID: PMC6995699 DOI: 10.2169/internalmedicine.3415-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The pharmacodynamic effect of warfarin varies among individuals, and its maintenance dose is widely distributed. Although many formulae for predicting the maintenance dose of warfarin have been developed, most of them are complex and not in practical use. Methods and Materials Among 12,738 new patients visiting the Cardiovascular Institute between 2004 and 2009, we identified 127 patients (66.6±8.8 years, 89 men) with atrial fibrillation for whom warfarin was newly started with an initial dose of 2 mg/day and the international normalized ratio (INR) at 1 year after warfarin was started was within the therapeutic range. The prediction models for the maintenance dose were developed by an exponential equation and a first-order equation. Results The initial response of the INR to the dose of 2 mg/day (initial INR) ranged from 1.00-3.24 (mean 1.43), while the maintenance dose of warfarin ranged from 0.5-14 mg (mean 3.8 mg). The maintenance dose showed an exponential correlation to the initial INR: (predicted maintenance dose) =5.522× (initial INR) -1.556 (R2=0.795, p<0.001). Excluding the patients with a poor response to the initial dose (initial INR <1.1, n=32) permitted a simple correlation with a first-order approximation: (predicted maintenance dose) =-2.009× (initial INR) +6.172 (R2=0.706, p<0.001). Conclusion We developed a simple formula for predicting the maintenance dose of warfarin using the initial response of the INR to low-dose warfarin.
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Affiliation(s)
- Masaaki Shoji
- Department of Cardiovascular Medicine, National Cancer Center Hospital, Japan
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Takuto Arita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Naoharu Yagi
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Hiroaki Semba
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Hiroto Kano
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Shunsuke Matsuno
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Yuko Kato
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Tokuhisa Uejima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Yuji Oikawa
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Minoru Matsuhama
- Department of Cardiovascular Surgery, The Cardiovascular Institute, Japan
| | - Junji Yajima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Japan
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7
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Batiushin MM. [The Nephrological Aspects of the Use of Rivaroxaban and Other Direct Peroral Anticoagulants in Non-Valvular Atrial Fibrillation]. KARDIOLOGIIA 2019; 59:60-69. [PMID: 31242842 DOI: 10.18087/cardio.2019.6.n516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 06/09/2023]
Abstract
Chronic kidney disease (CKD) is a powerful cardiovascular risk factor, its presence is accompanied by an increased risk of hospitalization for exacerbation of chronic heart failure (CHF), adverse outcomes in myocardial infarction, and cardiovascular mortality. Among the adverse events, an increased risk of atrial fibrillation (AF) should be noted. This article contains discussion of current approaches to the treatment of AF in patients with different stages of CKD, data on benefits of certain direct oral anticoagulants, as well as comparative characteristics of therapy with direct oral anticoagulants and warfarin. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants, which determine the features of therapy in CKD, are also considered.
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Affiliation(s)
- M M Batiushin
- Federal state budgetary educational institution of higher education "Rostov state medical University" of the Ministry of health of the Russian Federation
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Abstract
Warfarin is the most commonly prescribed anticoagulant in hemodialysis (HD) patients with nonvalvular atrial fibrillation (NVAF). Recent trends show that Nephrologists are increasingly prescribing novel oral anticoagulants, despite the fact that no randomized clinical trials have been conducted in dialysis patients. Difficulties maintaining international normalized ratio in the therapeutic range, increased risk of intracranial hemorrhage and concerns regarding warfarin-induced vascular calcification and calciphylaxis may be responsible. Anticoagulation quality is poor in HD patients. A variety of factors contribute to this: increased antibiotic exposure; comorbid illness; decreased adherence and vitamin K deficiency. Attempts to address this with standardized protocols have been uniformly unsuccessful. In nonadherent patients, thrice weekly observed therapy improved quality. Low-dose vitamin K supplementation improves time in the therapeutic range (TTR) in those with normal kidney function and should be studied in HD patients given their high frequency of vitamin K deficiency. Vascular and valvular calcification associated with warfarin could result from reduced carboxylation of matrix Gla protein (MGP), a well-known inhibitor of vascular calcification. Multiple observational studies also link calciphylaxis to warfarin; warfarin-induced hypercoagulability and decreased carboxylation of MGP could explain this. A large observational study, two meta-analyses, and a systematic review in HD patients with NVAF showed reduced bleeding with apixaban compared to warfarin with similar efficacy in reducing stroke and systemic embolism. Given these results, apixaban is a reasonable alternative to warfarin for anticoagulation of HD patients with NVAF, especially in those with low TTR, until data from randomized clinical trials become available.
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Affiliation(s)
- Robert F Reilly
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.,Division of Nephrology, Medical Service, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Nishank Jain
- Division of Nephrology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Medicine Service, Central Arkansas Veterans Affairs Health Care System, Little Rock, Arkansas
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9
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An Y, Akao M. Who Will Achieve Stable Anticoagulation Therapy With Warfarin? Circ J 2018; 82:17-18. [DOI: 10.1253/circj.cj-17-1257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
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