Warfarin treatment quality and prognosis in patients with mechanical heart valve prosthesis

Grzymala-Lubanski, Bartosz; Svensson, Peter; Renlund, Henrik; Jeppsson, Anders; Själander, Anders

doi:10.1136/heartjnl-2016-309585

Cited by 35 publications

(36 citation statements)

References 20 publications

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“…One possible explanation may be excessive dose elevation due to fear of thromboembolic complications in subtherapeutic INR levels, although the actual target INR is only slightly higher than that for AF patients. In fact, this finding is in line with the recent publication by Grzymala-Lubanski et al reporting a higher incidence of bleedings, death and total complications related to higher warfarin intensity in comparison to lower intensity of anticoagulation [14, 29]. …”

Section: Discussionsupporting

confidence: 89%

Incidence and predictors of excessive warfarin anticoagulation in patients with atrial fibrillation—The EWA study

et al. 2017

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Vitamin K antagonist warfarin is widely used in clinical practice and excessive anticoagulation is a well-known complication of this therapy. Little is known about permanent and temporary predictors for severe overanticoagulation. The aim of this study was to investigate the occurrence and predicting factors for episodes with very high (≥9) international normalized ratio (INR) values in warfarin treated patients with atrial fibrillation (AF). Excessive Warfarin Anticoagulation (EWA) study screened all patients (n = 13618) in the Turku University Hospital region with an INR ≥2 between years 2003–2015. Patients using warfarin anticoagulation for AF with very high (≥9) INR values (EWA Group) were identified (n = 412 patients) and their characteristics were compared to a control group (n = 405) of AF patients with stable INR during long-term follow-up. Over 20% (n = 92) of the EWA patients had more than one event of very high INR and in 105 (25.5%) patients EWA led to a bleeding event. Of the several temporary and permanent EWA risk factors observed, strongest were excessive alcohol consumption in 9.6% of patients (OR 24.4, 95% CI 9.9–50.4, p<0.0001) and reduced renal function (OR 15.2, 95% CI 5.67–40.7, p<0.0001). Recent antibiotic or antifungal medication, recent hospitalization or outpatient clinic visit and the first 6 months of warfarin use were the most significant temporary risk factors for EWA. Excessive warfarin anticoagulation can be predicted with several permanent and temporary clinical risk factors, many of which are modifiable.

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Section: Discussionsupporting

confidence: 89%

Incidence and predictors of excessive warfarin anticoagulation in patients with atrial fibrillation—The EWA study

et al. 2017

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“…10 Overall, studies have shown that the risk of outcomes is higher in MMV patients compared with MAV patients. 11,22,24 We found that MMV patients had lower quality of VKA treatment compared with MAV patients, and because lower TTR is associated with higher risk of outcomes, MMV patients are, prima facie, at higher risk of outcomes compared with MAV patients.…”

Section: Discussionmentioning

confidence: 83%

“…Among patients with atrial fibrillation, studies have shown an association between low quality of VKA treatment and the risk of outcomes, whereas studies on patients with mechanical heart valve have shown contradictory results. [8][9][10][11] This nationwide, carefully designed study set out to examine the association between TTR and the risk of thromboembolic events and bleeding in patients with mechanical valve prostheses.…”

Section: Perspectivementioning

confidence: 99%

“…Results: In total, 659 patients undergoing mechanical heart valve replacement were included in the study. Median number of international normalized ratio measurements in the 6-month period after surgery was 13 (interquartile range, [8][9][10][11][12][13][14][15][16][17][18][19]. Median TTR was 54.9% (interquartile range, 39.0%-72.9%) and 29.1% of patients had a TTR !70%.…”

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confidence: 99%

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Time in therapeutic range and risk of thromboembolism and bleeding in patients with a mechanical heart valve prosthesis

Havers-Borgersen

Butt

Vinding

et al. 2020

The Journal of Thoracic and Cardiovascular Surgery

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Objective: Oral anticoagulation with vitamin K antagonists is recommended after mechanical heart valve replacement. However, data regarding the association between the quality of vitamin K antagonist treatment and the risk of complications are sparse.Methods: Patients undergoing mechanical heart valve replacement (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012) with available data on international normalized ratio values were identified in Danish registries. The quality of vitamin K antagonist treatment between discharge after valve replacement and 6 months postdischarge (ie, index) was assessed as time in therapeutic range (TTR) !70% or<70% reflecting the percentage of time in therapeutic international normalized ratio interval. Patients were followed from index until occurrence of an outcome of interest (ie, thromboembolism and bleeding), death, or end of study (December 31, 2012), whichever came first. The risk of outcomes according to quality of vitamin K antagonist treatment was estimated with multivariable Cox regression.See Commentaries on pages 84 and 86.More than 100 million people worldwide experience valve diseases and the prevalence is expected to increase concurrently with increasing life expectancy. 1 Worldwide, From the

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“…51 The low anticoagulant quality was correlated with the increase in risk of bleeding or thromboembolism. [52][53][54] Low TTR (<67%) was associated with the increase in D-dimer level. 55 Moreover, INR variation during the anticoagulation period (INR coefficient of variation, INR-CV%), which is another indicator of anticoagulation quality, was also a cause of the increase in D-dimer level.…”

Section: Use Of D-dimer To Evaluate Anticoagulation Qualitymentioning

confidence: 99%

Use of D‐dimer in oral anticoagulation therapy

Zhang

Long

Xiao

et al. 2018

Int J Lab Hematology

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Individualized anticoagulation management and improvement of the safety and effectiveness of oral anticoagulant have always been the focus of clinicians' attention. D‐dimer, a sensitive marker of thrombosis and coagulation activation, is not only traditionally used in the diagnosis of venous thromboembolism, acute aortic dissection, and disseminated intravascular coagulation but can also be used as a helpful marker in the management of oral anticoagulant, including evaluating the anticoagulation quality, predicting clinical outcomes, and determining the optimal duration and intensity of anticoagulation.

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Warfarin treatment quality and prognosis in patients with mechanical heart valve prosthesis

Cited by 35 publications

References 20 publications

Incidence and predictors of excessive warfarin anticoagulation in patients with atrial fibrillation—The EWA study

Incidence and predictors of excessive warfarin anticoagulation in patients with atrial fibrillation—The EWA study

Time in therapeutic range and risk of thromboembolism and bleeding in patients with a mechanical heart valve prosthesis

Use of D‐dimer in oral anticoagulation therapy

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