scholarly journals Evaluation of Bleeding Rate and Time in Therapeutic Range in Patients Using Warfarin Before and During the COVID-19 Pandemic—Warfarin Treatment in COVID-19

2021 ◽  
Vol 27 ◽  
pp. 107602962110214
Author(s):  
Zeynep Yapan Emren ◽  
Oktay Şenöz ◽  
Ahmet Erseçgin ◽  
Sadık Volkan Emren
Keyword(s):  
Therapeutic Range ◽  
Treatment Process ◽  
International Normalized Ratio ◽  
Bleeding Complications ◽  
Demographic Parameters ◽  
Bleeding Rate ◽  
Time In Therapeutic Range ◽  
Warfarin Treatment ◽  
The Mean

The treatment process of patients using warfarin is expected to be hindered during the COVID-19 pandemic. Therefore we investigated whether the time in therapeutic range (TTR) and bleeding complications were affected during the COVID-19 pandemic. 355 patients using warfarin were included between March 2019 to March 2021. Demographic parameters, INR (international normalized ratio), and bleeding rates were recorded retrospectively. The TTR value was calculated using Rosendaal’s method. The mean age of the patients was 61 ± 12 years and 55% of them were female. The mean TTR value during the COVID-19 pandemic was lower than the pre-COVID-19 period (56 ± 21 vs 68 ± 21, P < 0.001). Among the patients, 41% had a lack of outpatient INR control. During the COVID-19 pandemic, 71 (20%) patients using VKA suffered bleeding. Among patients with bleeding, approximately 60% did not seek medical help and 6% of patients performed self-reduction of the VKA dose. During the COVID-19 pandemic, TTR values have decreased with the lack of monitoring. Furthermore, the majority of patients did not seek medical help even in case of bleeding.

scholarly journals Poor Time in Therapeutic Range Control is Associated with Adverse Clinical Outcomes in Patients with Non-Valvular Atrial Fibrillation: A Report from the Nationwide COOL-AF Registry

2020 ◽  
Vol 9 (6) ◽  
pp. 1698 ◽  
Author(s):  
Rungroj Krittayaphong ◽  
Thoranis Chantrarat ◽  
Roj Rojjarekampai ◽  
Pongpun Jittham ◽  
Poom Sairat ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Clinical Outcomes ◽  
Therapeutic Range ◽  
Major Bleeding ◽  
Stroke Prevention ◽  
International Normalized Ratio ◽  
Time In Therapeutic Range ◽  
Hazard Ratios ◽  
The Relationship

Background: Warfarin remains the most commonly used oral anticoagulant (OAC) in Thailand for stroke prevention among patients with non-valvular atrial fibrillation (NVAF). The aim of this study was to investigate the relationship between time in therapeutic range (TTR) after warfarin initiation and clinical outcomes of NVAF. Methods: TTR was calculated by the Rosendaal method from international normalized ratio (INR) data acquired from a nationwide NVAF registry in Thailand. Patients were followed-up every six months. The association between TTR and clinical outcomes was analyzed. Results: There was a total of 2233 patients from 27 hospitals. The average age was 68.4 ± 10.6 years. The average TTR was 53.56 ± 26.37%. Rates of ischemic stroke/TIA, major bleeding, ICH, and death were 1.33, 2.48, 0.76, and 3.3 per 100 person-years, respectively. When patients with a TTR < 65% were compared with those with TTR ≥ 65%, the adjusted hazard ratios (aHR) for the increased risks of ischemic stroke/TIA, major bleeding, ICH, and death were 3.07, 1.90, 2.34, and 2.11, respectively. Conclusion: Poor TTR control is associated with adverse clinical outcomes in patients with NVAF who were on warfarin. Efforts to ensure good TTR (≥65%) after initiation of warfarin are mandatory to minimize the risk of adverse clinical outcomes.

scholarly journals Polymorphism of the CYP2C9 and VKORC1 genes in patients on the public health system of a municipality in Southern Brazil

2021 ◽  
Vol 20 ◽  
Author(s):  
Christiane Colet ◽  
Mariana Rodrigues Botton ◽  
Karin Hepp Schwambach ◽  
Tânia Alves Amador ◽  
Isabela Heineck
Keyword(s):  
Therapeutic Range ◽  
Genetic Factors ◽  
Human Genetics ◽  
International Normalized Ratio ◽  
Weekly Dose ◽  
The Public ◽  
Significant Difference ◽  
Collection Data ◽  
The Mean ◽  
The Difference

Abstract Background Genetic factors can be responsible for part of the populational and interindividual differences observed in warfarin users. Objectives To identify occurrence of polymorphisms of the CYP2C9 and VKORC1 genes in patients taking warfarin and relate these profiles to their medication dosages and the Time in Therapeutic Range (TTR). Methods Monthly interviews were conducted for data collection. Data were collected on demographic characteristics and medications in use, especially warfarin, including reason for prescription and weekly dose. TTR was calculated as the percentage of days with international normalized ratio (INR) between 2 and 3. The CYP2C9 and VKORC1 genes were analyzed at a Human Genetics Laboratory. Results 49 patients (74.2%) had polymorphisms of the CYP2C9 and/or VKORC1 genes; the remaining 17 (25.8%) did not have these polymorphisms. The average weekly dose of warfarin was lower among those who had a polymorphism for any of the genes compared to those who did not, with a significant difference (p = 0.035). The mean TTR was also lower among patients with polymorphism. However, the difference between the two groups was not significant for this variable (p = 0.438). Conclusions An association was observed between the polymorphisms and the warfarin doses taken by the patients. However, there was no association with adverse events or the time spent within the therapeutic range in this sample.

scholarly journals Discrepancies in International Normalized Ratio Results between Instruments: A Model to Split the Variation into Subcomponents

2010 ◽  
Vol 56 (10) ◽  
pp. 1618-1626 ◽  
Author(s):  
Una Ø Sølvik ◽  
Per H Petersen ◽  
Grete Monsen ◽  
Anne V Stavelin ◽  
Sverre Sandberg
Keyword(s):  
Point Of Care ◽  
International Normalized Ratio ◽  
Patient Specific ◽  
Specific Effects ◽  
Warfarin Treatment ◽  
Analytical Imprecision ◽  
The Mean ◽  
The Difference ◽  
Analytical Variation ◽  
Over Time

BACKGROUND Observed differences between results obtained from comparison of instruments used to measure international normalized ratio (INR) have been higher than expected from the imprecision of the instruments. In this study the variation of these differences was divided into subcomponents, and each of the subcomponents was estimated. METHODS Blood samples were collected at 4 different patient visits from each of 36 outpatients who were receiving warfarin treatment and were included in the study. INR was determined on 1 laboratory instrument (STA Compact®) and 3 point-of-care instruments (Simple Simon®PT, CoaguChek®XS, and INRatio™). All 4 INR instruments were compared in pairs. Linear regression was used to correct for systematic deviations. The remaining variation of the differences was subdivided into between-subject, within-subject, and analytical variation in an ANOVA nested design. RESULTS The mean difference between instruments varied between 1.0% and 14.3%. Between-subject variation of the differences (expressed as CV) varied between 3.3% and 7.4%, whereas within-subject variation of the differences was approximately 5% for all 6 comparisons. The analytical imprecision of the differences varied between 3.8% and 8.6%. CONCLUSIONS The differences in INR between instruments were subdivided into calibration differences, between- and within-subject variation, and analytical imprecision. The magnitude of each subcomponent was estimated. Within results for individual patients the difference in INR between 2 instruments varied over time. The reasons for the between- and within-subject variations of the differences can probably be ascribed to different patient-specific effects in the patient plasma. To minimize this variation in a monitoring situation, each site and patient should use results from only 1 type of instrument.

Impact of provision of time in therapeutic range value on anticoagulation management in atrial fibrillation patients on warfarin

2018 ◽  
Vol 94 (1110) ◽  
pp. 207-211 ◽  
Author(s):  
Duo Huang ◽  
Chi-Lap Wong ◽  
Kwan-Wa Cheng ◽  
Pak-Hei Chan ◽  
Wen-Sheng Yue ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Therapeutic Range ◽  
Clinic Visit ◽  
Controlled Study ◽  
Anticoagulation Management ◽  
Time In Therapeutic Range ◽  
Randomised Controlled Study ◽  
The Mean ◽  
Randomised Controlled ◽  
The Impact

IntroductionThe importance of time in therapeutic range (TTR) in patients prescribed warfarin therapy for stroke prevention in atrial fibrillation (AF) cannot be overemphasised.AimTo evaluate the impact of provision of TTR results during clinic visits on anticoagulation management.DesignSingle-centred, randomised controlled study.SettingFifteen arrhythmia clinics in Hong Kong.PatientsAF patients prescribed warfarin.InterventionsProvision of TTR or no provision of TTR.Main outcome measuresA documented discussion between doctors and patients about switching warfarin to a non-vitamin K oral anticoagulant (NOAC).ResultsFour hundred and eighty one patients with AF prescribed warfarin were randomly assigned to (1) a TTR provision group or (2) control. Their mean age was 73.6±12.0 years and 60.7% were men. The mean CHA2DS2-VASc score was 3.2±1.6 and the mean HASBLED score was 1.7±1.2. The mean TTR was 63.9%±29.9%. At the index clinic visit, 71 of 481 patients (14.8%) had a documented discussion about switching warfarin to a NOAC. Patients with provision of TTR results were more likely to discuss switching warfarin to a NOAC than controls (19.1% vs 10.6%, P=0.03), especially those with a TTR <65% (35.2% vs 10.6%, P<0.001). A higher proportion of patients with provision of TTR results switched to a NOAC (5.9% vs 4.1%, P=0.49).ConclusionsThe provision of TTR among patients on warfarin was associated with a discussion about switching from warfarin to a NOAC in those with TTR <65%, but did not result in actual switching to a NOAC, suggesting additional barriers.

scholarly journals Accuracy of an adherence score and time in therapeutic range among patients on chronic use of vitamin K antagonists

2021 ◽  
Vol 10 (8) ◽  
pp. e59510816523
Author(s):  
Sérgio Henrique Simonetti ◽  
Gustavo Bernardes de Figueiredo Oliveira ◽  
Fabiana Cristina Lourenço ◽  
França João Ítalo Dias
Keyword(s):  
Educational Intervention ◽  
Vitamin K ◽  
Therapeutic Range ◽  
High Performance ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
Time In Therapeutic Range ◽  
Adherence Score ◽  
Chronic Use

To validate and analyze the accuracy of the Simonetti adherence score among patients on chronic use of vitamin K antagonists and their time in therapeutic range (TTR) of the international normalized ratio as a measure of quality of anticoagulation. A prospective cohort study with a nonrandomized intervention in patients from an anticoagulation center of a public hospital. Baseline data were collected from May to September 2017, and follow-up data were obtained eight months after a nurse-led  educational intervention, which was given to all patients after consent form and after applying the adherence score (N=205). The intervention was undertaken through 30-40 min conversation about relevant factors that had been previously identified in the score derivation study, which comprised drug-drug interactions, inadequate OAC use, comorbidities, effects of food on vitamin K absorption, and invasive procedures. A receiver operating characteristic (ROC) curve was applied to validate the adherence score in terms of prediction of INR out of recommended therapeutic range. At baseline, mean adherence score was 44.69 and standard deviation (SD) was 18.37, and   mean TTR was 41.07 (SD 15.40). Patients were reassessed after   8 months. At follow-up, there were significant improvements in mean adherence score 54.28 (SD 13.13), and in mean TTR 50.99 (SD 26.10). The Simonetti adherence score yielded high performance and accuracy in clinical practice among patients on chronic use of vitamin K antagonists. Our data indicate that nurse led educational intervention yielded favorable impact in terms of adherence score and TTR improvements.

Low-dose Oral Vitamin K Reliably Reverses Over-anticoagulation due to Warfarin

1998 ◽  
Vol 79 (06) ◽  
pp. 1116-1118 ◽  
Author(s):  
D. Donovan ◽  
L. Harrison ◽  
J. McGinnis ◽  
J. Ginsberg ◽  
M. A. Crowther
Keyword(s):  
Cohort Study ◽  
Prospective Cohort Study ◽  
Vitamin K ◽  
Prospective Cohort ◽  
Tertiary Care ◽  
International Normalized Ratio ◽  
Teaching Hospitals ◽  
Bleeding Complications ◽  
Oral Vitamin ◽  
The Mean

SummaryBackground: Patients receiving long-term warfarin frequently develop asymptomatic excessive prolongation of their international normalized ratio (INR) results. The most appropriate management strategy in these patients is unknown. This prospective cohort study was designed to address whether 1 mg of oral vitamin K effectively reduces the INR value of such patients. Methods: A prospective cohort study was performed in two tertiary care teaching hospitals, in which 62 patients receiving warfarin who had INR values between 4.5 and 10.0 received 1 mg of oral vitamin K. All patients had daily INR values and clinical assessments performed. Results: The mean INR value at presentation was 5.79 (95% confidence interval (CI) 5.48 to 6.09, range 4.5 to 9.5). Sixteen hours after receiving the 1 mg of oral vitamin K, the mean INR was 2.86 (95% CI 2.50 to 3.23). On the second and third days after vitamin K, the mean INR values were 2.20 (1.93 to 2.47) and 2.14 (1.85 to 2.44), respectively. No adverse events or bleeding complications were observed. In three patients (6%) the INR value rose between the time of vitamin K administration and the next INR determination; two patients received a further 2 mg dose of subcutaneous vitamin K. Conclusions: In patients receiving warfarin who have asymptomatic excessive prolongations in their INR results, 1 mg of oral vitamin K reliably reduces the INR to the therapeutic range within 24 h. This therapy is more convenient, less expensive, and might be safer than parenteral vitamin K. Thus, it should be considered in all non-bleeding patients receiving warfarin, who present with INR results of 4.5 to 9.5.Dr. Crowther is the recipient of a Medical Research Council of Canada Research Fellowship.Dr. Ginsberg is a Career Investigator of the Heart and Stroke Foundation of Ontario.

scholarly journals Decreased warfarin sensitivity among patients treated with elbasvir and grazoprevir for hepatitis C infection

2019 ◽  
Vol 76 (17) ◽  
pp. 1273-1280
Author(s):  
Douglas D DeCarolis ◽  
Yi-Chieh Chen ◽  
Anders D Westanmo ◽  
Christopher Conley ◽  
Amy A Gravely ◽  
...  
Keyword(s):  
Hepatitis C ◽  
Therapeutic Range ◽  
Antiviral Agents ◽  
Warfarin Dose ◽  
International Normalized Ratio ◽  
Sensitivity Index ◽  
Veterans Health ◽  
Health Administration ◽  
Hepatitis C Infection ◽  
The Mean

Abstract Purpose We previously reported an interaction with warfarin anticoagulation when initiating treatment with direct-acting antiviral agents for hepatitis C infection. A decreased warfarin sensitivity led to subtherapeutic anticoagulation. To study this interaction further, we expanded our research to include patients treated with the combination of elbasvir and grazoprevir concurrent with warfarin anticoagulation and investigated changes in warfarin sensitivity during and after treatment. Methods Using electronic health records of the Veterans Health Administration, patients starting treatment with elbasvir–grazoprevir for hepatitis C infection concurrent with warfarin anticoagulation were identified. Inclusion required stable warfarin anticoagulation prior to 12 weeks of treatment with elbasvir–grazoprevir. A warfarin sensitivity index (WSI) was calculated at the start and end of treatment and 12 weeks after treatment. The primary endpoint was the difference in WSI from pre- to end-treatment. The secondary endpoint was the WSI difference from pretreatment to 12 weeks posttreatment. Changes in International Normalized Ratio, warfarin doses, and time in therapeutic range were measured. Results In the final sample of 43 patients, the mean WSI decreased during treatment from 0.53 to 0.40, or 25.2%. After treatment, the mean WSI rose to 0.51. Although the mean weekly warfarin dose increased from 40.3 to 44.6 mg during treatment, the mean International Normalized Ratio decreased from 2.40 to 1.96, recovering to 2.59 after treatment. The time spent in therapeutic range decreased from 74.1% before treatment to 39.8% during treatment and back to 64.9% 12 weeks posttreatment. Conclusion When elbasvir–grazoprevir was added to stable warfarin anticoagulation, warfarin sensitivity decreased significantly during treatment and returned to baseline after treatment.

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