Time to therapeutic range (TtTR), anticoagulation control, and cardiovascular events in vitamin K antagonists–naive patients with atrial fibrillation

Abstract Introduction Good quality of anticoagulation in patients with valvular heart disease (VHD) is needed to reduce ischaemic complications. There is limited evidence on factors affecting anticoagulation control in patients implanted with mechanical or tissue prosthetic valve(s). Objective To examine quality, factors affecting anticoagulation control and all-cause death in VHD patients with and without atrial fibrillation (AF) receiving a vitamin K antagonist (VKA) oral anticoagulant. The relationship between INR control with all-cause death and ≥1 adverse clinical events (ACE) [thromboembolism, bleeding, cardiovascular hospitalisation and all-cause death] were explored. Methods Anticoagulation control of 456 VHD patients [164 (36%) with AF and 290 (64%) without AF] referred to a hospital-based anticoagulation clinic were assessed retrospectively by time in therapeutic range (TTR) (Rosendaal) and percentage of INRs in range (PINRR) for a median of (IQR) 6.2 years (3.3–8.5). VHD was defined by the presence of mechanical or tissue prosthetic valve at either the mitral or aortic site or both. Results Mean (SD) age 51 (14.7), 64.5% male, mean (SD) CHA2DS2-VASc score 2.0 (1.4), 96.1% mechanical prosthesis and 64% aortic valve replacement. VHD patients with AF had lower mean TTR and PINRR, lower proportion of optimal TTR (i.e.≥70%) despite similar number of INR tests compared to VHD patients without AF [Table 1]. Predictors of poor TTR on multivariate logistic regression analysis were female sex, AF and anaemia/bleeding history. Significantly higher proportions of VHD patients with AF died [Table 1]. More deaths (13.1% vs. 4.1%; p=0.011) and ≥1 ACE (42.7% vs. 27.6%; p=0.006) were seen in VHD patients with TTR <70% vs. TTR≥70%, respectively. Table 1 N (%) Total (N=456) AF (N=164) No AF (N=290) p-value Mean (SD) TTR 58.5 (14.6) 55.7 (14.2) 60.1 (14.6) 0.002 TTR ≥70% 98 (21.5) 23 (14.0) 75 (25.7) 0.004 Mean (SD) PINRR 50.1 (13.8) 47.4 (13.5) 51.6 (13.7) 0.002 Mean (SD) INR tests 96.2 (55.3) 100.7 (58.8) 93.7 (53.1) 0.19 All-cause death 51 (11.2) 34 (20.7) 17 (5.8) <0.001 AF: Atrial fibrillation; IQR: interquartile range; PINRR: percentage of INRs in range; SD: standard deviation; TTR: Time in therapeutic range. Conclusion The quality of anticoagulation in VHD patients with AF was low. The presence of AF, anaemia/bleeding history and female sex independently predicted poor TTR. All-cause death was more common in VHD patients with AF and poor TTR. Closer INR monitoring is needed especially in VHD patients with AF to improve anticoagulation control and prevent adverse clinical outcomes. Acknowledgement/Funding Kementerian Pendidikan Malaysia and Universiti Teknologi MARA for PhD study but not directly for work under consideration

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Relationship between Mediterranean diet and time in therapeutic range in atrial fibrillation patients taking vitamin K antagonists

EP Europace ◽

10.1093/europace/euv127 ◽

2015 ◽

Vol 17 (8) ◽

pp. 1223-1228 ◽

Cited By ~ 9

Author(s):

Pasquale Pignatelli ◽

Daniele Pastori ◽

Tommasa Vicario ◽

Tommaso Bucci ◽

Maria Del Ben ◽

...

Keyword(s):

Atrial Fibrillation ◽

Mediterranean Diet ◽

Vitamin K ◽

Therapeutic Range ◽

Vitamin K Antagonists ◽

Time In Therapeutic Range

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Heart Failure, Nonvalvular Atrial Fibrillation and Anticoagulation Control With Vitamin K Antagonists

Revista Española de Cardiología (English Edition) ◽

10.1016/j.rec.2015.08.017 ◽

2016 ◽

Vol 69 (1) ◽

pp. 75-76

Author(s):

Manuel Anguita Sánchez ◽

Vicente Bertomeu Martínez ◽

Ángel Cequier Fillat

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Nonvalvular Atrial Fibrillation ◽

Anticoagulation Control

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Inadequate anticoagulation by Vitamin K Antagonists is associated with Major Adverse Cardiovascular Events in patients with atrial fibrillation

International Journal of Cardiology ◽

10.1016/j.ijcard.2015.08.054 ◽

2015 ◽

Vol 201 ◽

pp. 513-516 ◽

Cited By ~ 44

Author(s):

Daniele Pastori ◽

Pasquale Pignatelli ◽

Mirella Saliola ◽

Roberto Carnevale ◽

Tommasa Vicario ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Cardiovascular Events ◽

Vitamin K Antagonists ◽

Major Adverse Cardiovascular Events

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Quality of Chronic Anticoagulation Control in Patients with Intracranial Haemorrhage due to Vitamin K Antagonists

Stroke Research and Treatment ◽

10.1155/2018/5613103 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6

Author(s):

Carlos Estevez-Fraga ◽

Maria Molina-Sanchez ◽

Rodrigo Alvarez-Velasco ◽

Pablo Agüero-Rabes ◽

Leticia Crespo-Araico ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Stroke Unit ◽

Intracranial Haemorrhage ◽

Vitamin K Antagonists ◽

Prosthetic Valves ◽

Increased Risk ◽

Study Population ◽

Anticoagulation Control

Introduction. Patients treated with vitamin K antagonists (VKA) are at increased risk of intracranial haemorrhage (ICH). The purpose of our study was to determine the quality of previous anticoagulation control in patients with VKA-associated ICH. Materials and Methods. We prospectively assessed every consecutive patient admitted to our stroke unit with VKA-associated ICH between 2013 and 2016. Demographic, clinical, and radiological variables, as well as consecutive international normalized ratios (INR) during 7 previous months, were extracted. Time in therapeutic range (TTR), time over range (TOR), time below range (TBR), and percentage of INR within range (PINRR) were calculated. Results and Discussion. The study population comprised 53 patients. Mean age was 79 years; 42% were women. Forty-eight patients had atrial fibrillation (AF) and 5 mechanical prosthetic valves. Therapeutic or infratherapeutic INR on arrival was detected in 64.4% of patients (95% CI 2.7 to 3.2). TTR was 67.8% (95% CI: 60.2 to 75.6 %) and PINRR was 75% (95% CI: 49.9-100). TOR was 17.2% (95% CI: 10.4 to 23.9% ) and TBR was 17% (95% CI: 10.6 to 23.9%). Conclusion. VKA-associated ICH happens usually in the context of good chronic anticoagulation control. Newer risk assessment methods are required.

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Rationale and design of the eXplore the efficacy and safety of once-daily oral riVaroxaban for the prEvention of caRdiovascular events in patients with nonvalvular aTrial fibrillation scheduled for cardioversion trial: A comparison of oral rivaroxaban once daily with dose-adjusted vitamin K antagonists in patients with nonvalvular atrial fibrillation undergoing elective cardioversion

American Heart Journal ◽

10.1016/j.ahj.2013.12.024 ◽

2014 ◽

Vol 167 (5) ◽

pp. 646-652 ◽

Cited By ~ 19

Author(s):

Michael D. Ezekowitz ◽

Riccardo Cappato ◽

Allan L. Klein ◽

A. John Camm ◽

Chang-Sheng Ma ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Cardiovascular Events ◽

Vitamin K Antagonists ◽

Efficacy And Safety ◽

Nonvalvular Atrial Fibrillation ◽

Once Daily

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Relation of Renal Dysfunction to Quality of Anticoagulation Control in Patients with Atrial Fibrillation: The FANTASIIA Registry

Thrombosis and Haemostasis ◽

10.1160/th17-06-0416 ◽

2018 ◽

Vol 118 (02) ◽

pp. 279-287 ◽

Cited By ~ 7

Author(s):

María Esteve-Pastor ◽

José Rivera-Caravaca ◽

Inmaculada Roldán-Rabadán ◽

Vanessa Roldán ◽

Javier Muñiz ◽

...

Keyword(s):

Atrial Fibrillation ◽

Major Bleeding ◽

Cardiovascular Mortality ◽

Real World ◽

Cardiovascular Events ◽

Vitamin K Antagonists ◽

Major Adverse Cardiovascular Events ◽

Anticoagulation Control

Background One-third of atrial fibrillation (AF) patients have chronic kidney disease (CKD), a condition that itself increases thromboembolic and major bleeding risks, especially in patients with severe CKD. Bleeding would be accentuated by suboptimal anticoagulation control with vitamin K antagonists (VKA). Purpose This article aimed to investigate the incidence of cardiovascular events, mortality and quality of anticoagulation in relation to CKD in a ‘real-world’ prospective cohort of AF patients included in the FANTASIIA registry. Methods We analysed consecutive AF patients who were prospectively recruited with a year of follow-up. The quality of anticoagulation was estimated by time in therapeutic range (TTR). The annual incidence of events was analysed. Results We studied 1,936 patients (male: 55.7%, mean: 73.8 ± 9.4 years): 445 (22.9%) had normal function, 698 (36.1%) had mild CKD, 713 (36.8%) had moderate CKD and 80 (4.2%) had severe CKD. Patients with estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 (severe CKD) had lower TTR (53.3 ± 25.6% vs. 61.8 ± 25.1%, p = 0.007) and higher proportion of poor TTR (67.2 vs. 51.8%; p = 0.014) than patients with eGFR ≥30 mL/min/1.73 m2. Severe CKD was significantly associated with cardiovascular mortality (hazard ratio [HR]: 9.33; p = 0.002), major bleeding (HR: 2.94; p = 0.036) and major adverse cardiovascular events (MACE) (HR: 4.93; p = 0.004). Importantly, 375 patients (21.1%) showed a deteriorating eGFR of ≥10 mL/min during the follow-up, with significantly higher mortality and cardiovascular events. Conclusion In a prospective and real-world AF registry, approximately 67% of patients with severe CKD had poor anticoagulation control while taking VKA. The presence of severe CKD was an independent factor for cardiovascular mortality, MACE and major bleeding. Worsening eGFR of only ≥10 mL/min during follow-up was significantly associated with mortality and major bleeding.

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