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Cho JG, Lee KH, Kim YR, Kim S, Gwak J, Cho E, Sin Y, Shin SY, Park HW, Ko JS, Kim NH, Park YM, Lee JM, Yoon NS, Kim SS, Kim JH, Kim DM. Standard-Intensity Versus Low-Intensity Anticoagulation with Warfarin in Asian Patients with Atrial Fibrillation: A Multi-Center, Randomized Controlled Trial. Clin Appl Thromb Hemost 2023; 29:10760296231171081. [PMID: 37082789 PMCID: PMC10126601 DOI: 10.1177/10760296231171081] [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: 04/22/2023] Open
Abstract
Anticoagulation with warfarin in Asian patients with atrial fibrillation (AF) often has been decreased as an international normalized ratio (INR) of prothrombin time 1.6-2.6 due to fear of bleeding, although universal criteria recommend an INR of 2.0-3.0. In this randomized, open-label trial, low-intensity anticoagulation (INR 1.6-2.6) was compared with standard-intensity anticoagulation (INR 2.0-3.0) with warfarin. A total 616 patients with AF and at least 1 risk factor for stroke were randomized to low-intensity anticoagulation (n = 308) and standard-intensity anticoagulation (n = 308) groups. The intention-to-treat analysis was performed to determine differences. The baseline characteristics of the two groups were comparable. New-onset stroke occurred in 2 patients (0.44% per year) in the low-intensity group and 5 patients (1.05% per year) in the standard-intensity group (HR 0.42, 95% CI 0.08-2.15). Major bleeding occurred in 4 patients (0.89% per year) in the low-intensity group and 5 patients (1.06% per year) in the standard-intensity group (HR 0.84, 95% CI 0.22-3.11). The rate of the net clinical outcome (composite of stroke, systemic embolism, major bleeding, and death) was 1.33% per year in the low-intensity group compared with 2.12% per year in the standard-intensity group (HR 0.63, 95% CI 0.23-1.72). In Asian patients with AF, clinical outcomes were not different between low-intensity and standard-intensity anticoagulation with warfarin.
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Affiliation(s)
- Jeong Gwan Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ki Hong Lee
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Yoo Ri Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Sunah Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jisoo Gwak
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Eunbit Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yourim Sin
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Seung Yong Shin
- Department of Cardiovascular Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyung Wook Park
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jum Suk Ko
- Department of Cardiovascular Medicine, Wonkwang University Hospital, Gwangju, Korea
| | - Nam Ho Kim
- Department of Cardiovascular Medicine, Wonkwang University Hospital, Gwangju, Korea
| | - Yae Min Park
- Department of Cardiovascular Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jung Myung Lee
- Department of Cardiovascular Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Nam Sik Yoon
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Sung Soo Kim
- Department of Cardiovascular Medicine, Chosun University Hospital, Gwangju, Korea
| | - Jun Hyung Kim
- Department of Cardiovascular Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Dong Min Kim
- Department of Cardiovascular Medicine, Dankook University Hospital, Cheonan, Korea
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Witt DM. Is It Time to Reevaluate Current International Normalized Ratio Targets for Asian Patients Following Mechanical Heart Valve Replacement? JAMA Netw Open 2022; 5:e2146034. [PMID: 35103796 DOI: 10.1001/jamanetworkopen.2021.46034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
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Zhu Z, Li C, Shen J, Wu K, Li Y, Liu K, Zhang F, Zhang Z, Li Y, Han J, Qin Y, Yang Y, Fan G, Zhang H, Ding Z, Xu D, Chen Y, Zheng Y, Zheng Z, Meng X, Zhang H. New Internet-Based Warfarin Anticoagulation Management Approach After Mechanical Heart Valve Replacement: Prospective, Multicenter, Randomized Controlled Trial. J Med Internet Res 2021; 23:e29529. [PMID: 34397393 PMCID: PMC8398748 DOI: 10.2196/29529] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/13/2021] [Accepted: 07/05/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Mechanical heart valve replacement (MHVR) is an effective method for the treatment of severe heart valve disease; however, it subjects patient to lifelong warfarin therapy after MHVR with the attendant risk of bleeding and thrombosis. Whether internet-based warfarin management reduces complications and improves patient quality of life remains unknown. OBJECTIVE This study aimed to compare the effects of internet-based warfarin management and the conventional approach in patients who received MHVR in order to provide evidence regarding alternative strategies for long-term anticoagulation. METHODS This was a prospective, multicenter, randomized, open-label, controlled clinical trial with a 1-year follow-up. Patients who needed long-term warfarin anticoagulation after MHVR were enrolled and then randomly divided into conventional and internet-based management groups. The percentage of time in the therapeutic range (TTR) was used as the primary outcome, while bleeding, thrombosis, and other events were the secondary outcomes. RESULTS A total of 721 patients were enrolled. The baseline characteristics did not reach statistical differences between the 2 groups, suggesting the random assignment was successful. As a result, the internet-based group showed a significantly higher TTR (mean 0.53, SD 0.24 vs mean 0.46, SD 0.21; P<.001) and fraction of time in the therapeutic range (mean 0.48, SD 0.22 vs mean 0.42, SD 0.19; P<.001) than did those in the conventional group. Furthermore, as expected, the anticoagulation complications, including the bleeding and embolic events had a lower frequency in the internet-based group than in the conventional group (6.94% vs 12.74%; P=.01). Logistic regression showed that internet-based management increased the TTR by 7% (odds ratio [OR] 1.07, 95% CI 1.05-1.09; P<.001) and reduced the bleeding and embolic risk by 6% (OR 0.94, 95% CI 0.92-0.96; P=.01). Moreover, low TTR was found to be a risk factor for bleeding and embolic events (OR 0.87, 95% CI 0.83-0.91; P=.005). CONCLUSIONS The internet-based warfarin management is superior to the conventional method, as it can reduce the anticoagulation complications in patients who receive long-term warfarin anticoagulation after MHVR. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1800016204; http://www.chictr.org.cn/showproj.aspx?proj=27518. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2019-032949.
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Affiliation(s)
- Zhihui Zhu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Ludwig Maximilian University of Munich, Munich, Germany
| | - Chenyu Li
- Renal Division, Department of Medicine IV, Ludwig Maximilian University of Munich, Munich, Germany
| | - Jinglun Shen
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kaisheng Wu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuehuan Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kun Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fan Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhenhua Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Department of Cardiovascular Surgery, Beijing Luhe Hospital,, Capital Medical University, Beijing, China
| | - Yan Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Han
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ying Qin
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yu Yang
- Department of Cardiovascular Surgery, Beijing Xuanwu Hospital, Beijing, China
| | - Guangpu Fan
- Department of Cardiovascular Surgery, Peking University People's Hospital, Beijing, China
| | - Huajun Zhang
- Department of Cardiovascular Surgery, PLA General Hospital, Beijing, China
| | - Zheng Ding
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Xu
- Department of Cardiovascular Surgery, Beijing Xuanwu Hospital, Beijing, China
| | - Yu Chen
- Department of Cardiovascular Surgery, Peking University People's Hospital, Beijing, China
| | - Yingli Zheng
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Meng
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haibo Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Long term CentriMag biventricular support using hybrid cannulation as a bridge to transplant in a pediatric patient. J Artif Organs 2020; 23:374-377. [PMID: 32436156 DOI: 10.1007/s10047-020-01177-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/12/2020] [Indexed: 10/24/2022]
Abstract
Paracorporeal continuous-flow ventricular assist devices designed for short-term support can also potentially provide long-term circulatory support as bridges to transplantation in children. We describe the long-term use of the CentriMag biventricular assist device with multiple pump changes in a 9-year-old boy with idiopathic-dilated cardiomyopathy. The initially implanted Berlin Heart EXCOR pumps were replaced by CentriMag due to thromboembolic complications. The CentriMag pumps were exchanged 15 times due to clot and fibrin formation or when the pumps reached their expiration dates. Connecting CentriMag to Berlin Heart EXCOR cannulae effectively served as an alternative long-term hybrid bridge to transplantation for 235 days. The patient successfully underwent a transplant after 284 days. Judicious pump monitoring and timely pump exchanges can potentially overcome device-related complications and extend the duration on support.
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Liang JB, Lao CK, Tian L, Yang YY, Wu HM, Tong HHY, Chan A. Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 28:97-106. [PMID: 31576625 DOI: 10.1111/ijpp.12584] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 08/21/2019] [Accepted: 08/26/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES This study was designed to evaluate the impact of a pharmacist-led anticoagulation service on international normalised ratio (INR) control and other outcomes among patients receiving warfarin therapy at a tertiary hospital in Zhuhai, China. METHODS In this randomised controlled trial, adult patients who were newly initiated on warfarin with intended treatment duration of at least 3 months were recruited. Participants were randomly allocated to receive the pharmacist-led education and follow-up service (PEFS) or usual care (UC). Anticoagulation control was calculated as the proportions of time within the target INR range (TTR) and time within the expanded target range (TER). KEY FINDINGS A total of 152 participants (77 in the PEFS group and 75 in the UC group) were included. Within 180 days after hospital discharge, the PEFS group spent more TER than the UC group (54.4% versus 42.0%; P = 0.024), whereas the difference in TTR did not reach statistical significance (35.9% versus 29.5%; P = 0.203). No major bleeding events were observed, and the cumulative incidences of major thromboembolic events (6.5% versus 9.3%) and mortality (1.3% versus 1.3%) were similar between the two groups (P> 0.05). At 30 days postdischarge, the PEFS group had better warfarin knowledge by answering 57.5% of questions correctly, compared with the UC group (43.0%) (P = 0.003). CONCLUSIONS The PEFS markedly enhanced anticoagulation control and warfarin knowledge but there was room for improvement. The expansion of pharmacists' clinical role and the development of more effective education and follow-up strategies are warranted to optimise anticoagulation management services in China.
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Affiliation(s)
- Jia-Bi Liang
- Department of Pharmacy, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, China
| | - Cheng-Kin Lao
- School of Health Sciences and Sports, Macao Polytechnic Institute, Macao S.A.R., China
| | - Lin Tian
- Department of Pharmacy, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, China
| | - Ying-Ying Yang
- Department of Pharmacy, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, China
| | - Hui-Min Wu
- Department of Pharmacy, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, China
| | - Henry Hoi-Yee Tong
- School of Health Sciences and Sports, Macao Polytechnic Institute, Macao S.A.R., China
| | - Alexandre Chan
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
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Lee KH, Cho JG, Lee N, Cho KH, Jeong HK, Park H, Kim Y, Cho JY, Kim MC, Sim DS, Yoon HJ, Yoon N, Kim KH, Hong YJ, Park HW, Ahn Y, Jeong MH, Park JC. Impact of Anticoagulation Intensity in Korean Patients with Atrial Fibrillation: Is It Different from Western Population? Korean Circ J 2019; 50:163-175. [PMID: 31642215 PMCID: PMC6974658 DOI: 10.4070/kcj.2019.0099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/30/2019] [Accepted: 09/11/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Although anticoagulation with warfarin is recommended as an international normalized ratio (INR) of prothrombin time between 2.0 and 3.0 and mean time in the therapeutic range (TTR) ≥70%, little has been proven that universal criteria might be suitable in Korean atrial fibrillation (AF) patients. METHODS We analyzed 710 patients with non-valvular AF who took warfarin. INR value and clinical outcomes were assessed during 2-year follow-up. Intensity of anticoagulation was assessed as mean INR value and TTR according to target INR range. Primary net-clinical outcome was defined as the composite of new-onset stroke and major bleeding. Secondary net-clinical outcome was defined as the composite of new-onset stroke, major bleeding and death. RESULTS Thromboembolism was significantly decreased when mean INR was over 1.6. Major bleeding was significantly decreased when TTR was over 70% and mean INR was less than 2.6. Mean INR 1.6-2.6 significantly reduced thromboembolism (adjusted hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.19-0.85), major bleeding (HR, 0.43; 95% CI, 0.23-0.81), primary (HR, 0.50; 95% CI, 0.29-0.84) and secondary (HR, 0.45; 95% CI, 0.28-0.74) net-clinical outcomes, whereas mean INR 2.0-3.0 did not. Simultaneous satisfaction of mean INR 1.6-2.6 and TTR ≥70% was associated with significant risk reduction of major bleeding, primary and secondary net-clinical outcomes. CONCLUSIONS Mean INR 1.6-2.6 was better than mean INR 2.0-3.0 for the prevention of thromboembolism and major bleeding. However, INR 1.6-2.6 and TTR ≥70% had similar clinical outcomes to INR 2.0-3.0 and TTR ≥70% in Korean patients with non-valvular AF.
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Affiliation(s)
- Ki Hong Lee
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea.
| | - Nuri Lee
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Hoon Cho
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Hyung Ki Jeong
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Hyukjin Park
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Yongcheol Kim
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Min Chul Kim
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Hyun Ju Yoon
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Namsik Yoon
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Kye Hun Kim
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Hyung Wook Park
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jong Chun Park
- Department of Cardiovascular Medicine, The Heart Center of Chonnam National University Hospital, Gwangju, Korea
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Zhou XM, Zhuang W, Hu JG, Li JM, Yu JF, Jiang L. Low-Dose Anticoagulation in Chinese Patients with Mechanical Heart Valves. Asian Cardiovasc Thorac Ann 2016; 13:341-4. [PMID: 16304222 DOI: 10.1177/021849230501300410] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to provide guidelines for optimal anticoagulation in Chinese patients after mechanical heart valve replacement. A Carbomedics valve was implanted in 178 patients between July 2000 and July 2003. During follow-up, 22 bleeding events and 1 thromboembolic complication occurred. The linearized rates of bleeding and thromboembolism were 5.83% and 0.26% per patient-year, respectively. The linearized mortality rate was 0.79% per patient-year. The final mean international normalized ratio (INR) was 1.68 ± 0.38, however there was a significant variation between the early and late periods of follow-up. For Chinese patients with mechanical heart valves, bleeding was the major complication rather than thromboembolism. Low-dose anticoagulation (international normalized ratio 1.4–2.0) could markedly decrease bleeding and effectively prevent thromboembolism. As the INR was most unstable in the first postoperative month, re-examination of patients in this period is critical.
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Affiliation(s)
- Xin-Min Zhou
- Department of Cardiovascular Surgery, The Second Xiang-Ya Hospital of Central South University, Changsha, Hunan 410011, China.
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Stack G, Maurice CB. Warfarin Pharmacogenetics Reevaluated: Subgroup Analysis Reveals a Likely Underestimation of the Maximum Pharmacogenetic Benefit by Clinical Trials. Am J Clin Pathol 2016; 145:671-86. [PMID: 27247371 DOI: 10.1093/ajcp/aqw049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Various patient subgroups were examined to determine which ones obtain the largest pharmacogenetic improvements in warfarin dose accuracy. Subgrouping schemes of recent clinical trials were analyzed for comparison. METHODS The accuracy of a pharmacogenetic dose algorithm was determined retrospectively in comparison to that of a clinical algorithm in subgroups of the International Warfarin Pharmacogenetics Consortium (IWPC) patient database (n = 2,274) and of newly studied clinic patients (n = 146). RESULTS White patients with low-dose genotypes (*1*3/AA, *2*2/AA, *2*3/GA, *2*3/AA, *3*3/GG, *3*3/GA, and *3*3/AA) achieved the largest pharmacogenetic improvements in warfarin dose accuracy. Mean absolute dosing error (MAE) in this subgroup of IWPC and newly studied patients was reduced 75.7% and 89.7%, respectively. White IWPC patients with >2 variants or ≥2 mg/day absolute difference between pharmacogenetic and clinical dose predictions obtained MAE reductions of 71.1% and 65.3%, respectively. By comparison, unstratified populations and subgroups of a major clinical trial, when replicated in IWPC patients, obtained smaller MAE reductions of 31.8% to 48.2%. Blacks and Asians obtained substantially smaller dose accuracy improvements overall than whites. CONCLUSIONS Patient subgroups were identified that obtained the largest pharmacogenetic improvements in warfarin dose accuracy. These subgroups have not been analyzed in clinical trials to date, likely resulting in underestimation of the pharmacogenetic benefit.
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Affiliation(s)
- Gary Stack
- From the Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven; Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT.
| | - Carleta B Maurice
- From the Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven
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Lin SW, Kang WY, Lin DT, Lee J, Wu FL, Chen CL, Tseng YJ. Comparison of warfarin therapy clinical outcomes following implementation of an automated mobile phone-based critical laboratory value text alert system. BMC Med Genomics 2014; 7 Suppl 1:S13. [PMID: 25079609 PMCID: PMC4101312 DOI: 10.1186/1755-8794-7-s1-s13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Computerized alert and reminder systems have been widely accepted and applied to various patient care settings, with increasing numbers of clinical laboratories communicating critical laboratory test values to professionals via either manual notification or automated alerting systems/computerized reminders. Warfarin, an oral anticoagulant, exhibits narrow therapeutic range between treatment response and adverse events. It requires close monitoring of prothrombin time (PT)/international normalized ratio (INR) to ensure patient safety. This study was aimed to evaluate clinical outcomes of patients on warfarin therapy following implementation of a Personal Handy-phone System-based (PHS) alert system capable of generating and delivering text messages to communicate critical PT/INR laboratory results to practitioners' mobile phones in a large tertiary teaching hospital. METHODS A retrospective analysis was performed comparing patient clinical outcomes and physician prescribing behavior following conversion from a manual laboratory result alert system to an automated system. Clinical outcomes and practitioner responses to both alert systems were compared. Complications to warfarin therapy, warfarin utilization, and PT/INR results were evaluated for both systems, as well as clinician time to read alert messages, time to warfarin therapy modification, and monitoring frequency. RESULTS No significant differences were detected in major hemorrhage and thromboembolism, warfarin prescribing patterns, PT/INR results, warfarin therapy modification, or monitoring frequency following implementation of the PHS text alert system. In both study periods, approximately 80% of critical results led to warfarin discontinuation or dose reduction. Senior physicians' follow-up response time to critical results was significantly decreased in the PHS alert study period (46.3% responded within 1 day) compared to the manual notification study period (24.7%; P = 0.015). No difference in follow-up response time was detected for junior physicians. CONCLUSIONS Implementation of an automated PHS-based text alert system did not adversely impact clinical or safety outcomes of patients on warfarin therapy. Approximately 80% immediate recognition of text alerts was achieved. The potential benefits of an automated PHS alert for senior physicians were demonstrated.
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Wang Y, Wang C, Chen Z, Zhang J, Liu Z, Jin B, Ying K, Liu C, Shao Y, Jing Z, Meng IL, Prins MH, Pap AF, Müller K, Lensing AW. Rivaroxaban for the treatment of symptomatic deep-vein thrombosis and pulmonary embolism in Chinese patients: a subgroup analysis of the EINSTEIN DVT and PE studies. Thromb J 2013; 11:25. [PMID: 24341332 PMCID: PMC3896794 DOI: 10.1186/1477-9560-11-25] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 11/08/2013] [Indexed: 11/30/2022] Open
Abstract
Background The worldwide EINSTEIN DVT and EINSTEIN PE studies randomized 8282 patients with acute symptomatic deep-vein thrombosis (DVT) and/or pulmonary embolism (PE) and, for the first time in trials in this setting, included patients in China. This analysis evaluates the results of these studies in this subgroup of patients. Methods A total of 439 Chinese patients who had acute symptomatic DVT (n=211), or PE with or without DVT (n=228), were randomized to receive rivaroxaban (15 mg twice daily for 21 days, followed by 20 mg once daily) or standard therapy of enoxaparin overlapping with and followed by an adjusted-dose vitamin K antagonist, for 3, 6, or 12 months. The primary efficacy outcome was symptomatic recurrent venous thromboembolism. The principal safety outcome was major or non-major clinically relevant bleeding. Results The primary efficacy outcome occurred in seven (3.2%) of the 220 patients in the rivaroxaban group and in seven (3.2%) of the 219 patients in the standard-therapy group (hazard ratio, 1.04; 95% confidence interval 0.36–3.0; p=0.94). The principal safety outcome occurred in 13 (5.9%) patients in the rivaroxaban group and in 20 (9.2%) patients in the standard-therapy group (hazard ratio, 0.63; 95% confidence interval 0.31–1.26; p=0.19). Major bleeding was observed in no patients in the rivaroxaban group and in five (2.3%) patients in the standard-therapy group. In fragile patients (defined as age >75 years, creatinine clearance <50 mL/min, and/or body weight ≤50 kg), the principal safety outcome occurred in four (8.9%) of the 45 patients who received rivaroxaban compared with seven (15.2%) of the 46 patients who received standard therapy. Conclusions In Chinese patients with acute symptomatic DVT and/or PE, rivaroxaban was as efficacious as enoxaparin followed by vitamin K antagonist therapy, with a similar safety profile. The relative efficacy and safety of rivaroxaban compared with enoxaparin/vitamin K antagonist were consistent with that found in the rest of the world. Trial registration number EINSTEIN PE, ClinicalTrials.gov
NCT00439777; EINSTEIN DVT, ClinicalTrials.gov
NCT00440193
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Abstract
With the increasing globalization of clinical research and evidence, clinical-practice guidelines (CPGs) developed by the European Union (EU) and the USA are also becoming increasingly international. However, these CPGs can encounter barriers to their practical application. In this Perspectives article, we analyze the main obstacles to the application of EU and US CPGs for cardiovascular diseases from the unique perspective of China, and highlight some potential problems in the globalization of CPGs. Currently, China and other countries with limited independent evidence for CPG development must localize or adapt the CPGs developed by the EU, the USA, or international medical organizations, with systematic consideration of cost-effectiveness and alternative strategies on the basis of the available evidence from the native populations. At the same time, comprehensive capabilities to collect and review clinical evidence to produce population-specific CPGs should be developed.
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Affiliation(s)
- Dong Zhao
- Department of Epidemiology, Capital Medical University Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No. 2 Anzhen Street, Chaoyang District, Beijing, 100029, China
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Sandanaraj E, Lal S, Cheung YB, Xiang X, Kong MC, Lee LH, Ooi LL, Chowbay B. VKORC1 diplotype-derived dosing model to explain variability in warfarin dose requirements in Asian patients. Drug Metab Pharmacokinet 2010; 24:365-75. [PMID: 19745563 DOI: 10.2133/dmpk.24.365] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
SUMMARY Warfarin-induced bleeding complications and high inter-patient variability are major hindrances to oral anticoagulant therapy. The present study identifies the influence of VKORC1 diplotypes, CYP2C9 and CYP2C19 variants on warfarin disposition and dose requirements in Chinese patients (n=107). The study subjects were genotyped for VKORC1, CYP2C9 and CYP2C19 polymorphic variants. Weekly warfarin dose requirements and S-warfarin clearance were stratified by VKORC1, CYP2C9 and CYP2C19 pharmacogenetics. The major VKORC1 diplotypes were H1-H1 (62%), H1-H7 (18%) and H1-H(*)(b) (10%). Warfarin dose requirements were significantly lower in patients with VKORC1 H1-H1 and H1-H(*)(a) diplotypes compared to patients harboring the H1-H7 and H1-H(*)(b) diplotypes (P<0.05). Hepatic tissues with H1-H1 diplotype had significantly lower expression of VKORC1 mRNA compared with liver tissues carrying the H1-H7 and H1-H(*)(b) diplotypes (P=0.006). The percent variability explained by VKORC1 diplotype status was 59.1% while the CYP2C9 genotype status accounted for 6.9% variability in warfarin dose requirements. Patient age and weight were significant covariates accounting for 29% and 8.6% of warfarin dose variability, respectively. The present study shows that VKORC1 diplotype status, CYP2C9 genotype, age and weight are significant covariates, accounting for 73.4% of interindividual variability in warfarin dose requirements among Chinese patients. Translation of these findings into clinical guidelines for warfarin dosing may be required to assess its impact on the safety and efficacy of warfarin.
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Affiliation(s)
- Edwin Sandanaraj
- Laboratory of Clinical Pharmacology, Division of Medical Sciences, Humphrey Oei Institute of Cancer Research, National Cancer Centre, Singapore
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Effect of CYP2C9 and VKORC1 genotypes on early-phase and steady-state warfarin dosing in Korean patients with mechanical heart valve replacement. Pharmacogenet Genomics 2009; 19:103-12. [PMID: 19077919 DOI: 10.1097/fpc.0b013e32831a9ae3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The effect of CYP2C9 and vitamin K epoxide reductase complex subunit 1 (VKORC1) genotypes was evaluated for the early-phase and steady-state warfarin dosing in Korean patients with mechanical heart valve replacement. METHODS The genotypes of CYP2C9 variants including CYP2C9*3, CYP2C9*13, and CYP2C9*14, and VKORC1 1173C>T were assessed for the association with warfarin dosing in 265 patients whose data were collected for warfarin dose; international normalized ratio (INR), comedication, comorbidity, and other clinical characteristics. RESULTS In the early phase of warfarin therapy, the combined genotypes of CYP2C9 and VKORC1 caused statistically significant difference in warfarin dose from day 7 of warfarin dosing and the subsequent time course of dose increase showed significant difference among the three different genotypes (P<0.001). Compared with patients with CYP2C9 wild type, the patients with heterozygous CYP2C9 variants have delayed time to reach stable dose [adjusted hazard ratio (HRadj): 0.48; 95% confidence interval (CI): 0.27-0.85] and tended to have high risk for the first INR greater than 3.5 (HRadj: 1.64; 95% CI: 0.98-2.75). The patients with the VKORC1 CT genotype showed no significant difference in the time to reach stable dose but statistically significant low HR for time to first INR greater than 3.5 compared with those with VKORC1 TT genotype (HRadj: 0.25; 95% CI: 0.13-0.51). The observed warfarin maintenance dose was best explained by a model including covariates of age, weight, concurrent congestive heart failure/cardiomyopathy, INR-increasing drugs, aspirin, dietary supplements, and CYP2C9 and VKORC1 genotypes (R=0.56). CONCLUSION The heterozygous CYP2C9 and VKORC1 genotypes influence warfarin dosing in an early phase as well as steady state of warfarin therapy in Korean patients with mechanical heart valve replacement.
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Schulman S, Beyth RJ, Kearon C, Levine MN. Hemorrhagic Complications of Anticoagulant and Thrombolytic Treatment. Chest 2008; 133:257S-298S. [PMID: 18574268 DOI: 10.1378/chest.08-0674] [Citation(s) in RCA: 482] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Sam Schulman
- From the Thrombosis Service, McMaster Clinic, HHS-General Hospital, Hamilton, ON, Canada.
| | - Rebecca J Beyth
- Rehabilitation Outcomes Research Center NF/SG Veterans Health System, Gainesville, FL
| | - Clive Kearon
- McMaster University Clinic, Henderson General Hospital, Hamilton, ON, Canada
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Chan FWH, Wong RSM, Lau WH, Chan TYK, Cheng G, You JHS. Management of Chinese patients on warfarin therapy in two models of anticoagulation service - a prospective randomized trial. Br J Clin Pharmacol 2007; 62:601-9. [PMID: 17061966 PMCID: PMC1885165 DOI: 10.1111/j.1365-2125.2006.02693.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIM To compare the treatment outcomes of a clinical pharmacist-managed anticoagulation service with physician-managed service in Chinese patients. METHODS A prospective, randomized clinical trial was conducted at the anticoagulation clinic of a teaching hospital in Hong Kong. Patients aged > or = 18 years who would required warfarin therapy for at least 3 months were recruited. Patients were randomized to the pharmacist-managed or physician-managed group. Primary clinical outcome was assessed by the percentage of patient time spent within the target international normalized ratio (INR) range. The incidence of major thromboembolic events (TEs) and major bleeding was assessed as secondary clinical outcomes. The cost per patient per month (cPPPM) was calculated and patient satisfaction was assessed by patient satisfaction questionnaire (PSQ)-18. RESULTS One hundred and forty-one patients were recruited at the anticoagulation clinic and 137 patients completed the study. Patients in the pharmacist-managed group (n = 68) were in the target INR 64% of patient time vs. 59% in the physician-managed group (n = 69) (P < 0.001). There was no significant difference in incidence of major TEs or bleeding. The cPPPM in the pharmacist-managed group (76 +/- 95 US dollar) (43 +/- 53 British pound) was lower than in the physician-managed group (98 +/- 158 US dollar) (55 +/- 89 British pound) (P < 0.001). The PSQ-18 score of the pharmacist-managed group (3.8 +/- 0.2) was higher than that of the physician-managed group (3.6 +/- 0.3) (P < 0.001). CONCLUSION The pharmacist-managed anticoagulation service was more effective and less costly than the physician-managed service in achieving target anticoagulation control for Chinese patients on warfarin therapy.
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Affiliation(s)
- Fredric W H Chan
- School of Pharmacy, Faculty of Medicine, The Prince of Wales Hospital, Hong Kong
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Marsh S, McLeod HL. Pharmacogenomics: from bedside to clinical practice. Hum Mol Genet 2006; 15 Spec No 1:R89-93. [PMID: 16651374 DOI: 10.1093/hmg/ddl087] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The field of pharmacogenomics has seen some exciting advances in the recent past. The Human Genome Project and International HapMap projects have uncovered a wealth of information for researchers. The discovery of clinically predictive genotypes (e.g. UGT1A1*28, TYMS TSER), haplotypes (e.g. VKORC1 Haplotype A) and somatic mutations (e.g. epidermal growth factor receptor), along with the introduction of FDA approved pharmacogenetic tests (UGT1A1*28) and the initiation of a genotype-guided clinical trial for cancer therapy (TYMS TSER in rectal cancer) have provided the first steps towards the integration of pharmacogenomics into clinical practice. This review describes some of the recent advances in pharmacogenomics research.
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Affiliation(s)
- Sharon Marsh
- Division of Oncology, Washington University School of Medicine, St Louis, MO 63110, USA
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Veenstra DL, You JHS, Rieder MJ, Farin FM, Wilkerson HW, Blough DK, Cheng G, Rettie AE. Association of Vitamin K epoxide reductase complex 1 (VKORC1) variants with warfarin dose in a Hong Kong Chinese patient population. Pharmacogenet Genomics 2005; 15:687-91. [PMID: 16141794 DOI: 10.1097/01.fpc.0000174789.77614.68] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the association of VKORC1 genetic variants with warfarin dose requirements in a Hong Kong Chinese patient population. METHODS A retrospective study of Hong Kong Chinese patients chronically maintained on warfarin was conducted. Single nucleotide polymorphisms (SNPs) in VKORC1 and CYP2C9 were genotyped. Stable warfarin dose data were retrieved from patient medical records. RESULTS Sixty-nine patients were included in the analysis. VKORC1 haplotypes H1 (group A) and H7 (group B) were most common, accounting for 86% and 13% of all haplotypic variation in this cohort. Patients carrying at least one copy of a VKORC1 group B haplotype (n = 16) required a significantly higher stable warfarin dose (5.17+/-1.53 mg/day) than patients that were homozygous for group A haplotypes (n = 53; 2.93+/-1.22 mg; P < 0.001). In the VKORC1 A/A group, four patients (5.8%) were heterozygous for CYP2C9*3 and had a lower dose requirement (1.94+/-0.43 mg) than patients that exhibited the CYP2C9 *1/*1 genotype (3.01+/-1.23 mg), P = 0.004. In multivariate analysis, VKORC1 and CYP2C9 explained 31% and 7.9% of the variability in warfarin dose, respectively. CONCLUSIONS VKORC1 genotype is the dominant genetic influence on inter-individual variability in warfarin dose in Hong Kong Chinese. The lower mean dose of warfarin in Chinese, relative to Europeans, appears to be a reflection of their preponderance of the 'low-dose' VKORC1 H1/H1 (homozygous group A) genotype.
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Affiliation(s)
- David L Veenstra
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong
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Rieder MJ, Reiner AP, Gage BF, Nickerson DA, Eby CS, McLeod HL, Blough DK, Thummel KE, Veenstra DL, Rettie AE. Effect of VKORC1 haplotypes on transcriptional regulation and warfarin dose. N Engl J Med 2005; 352:2285-93. [PMID: 15930419 DOI: 10.1056/nejmoa044503] [Citation(s) in RCA: 947] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The management of warfarin therapy is complicated by a wide variation among patients in drug response. Variants in the gene encoding vitamin K epoxide reductase complex 1 (VKORC1) may affect the response to warfarin. METHODS We conducted a retrospective study of European-American patients receiving long-term warfarin maintenance therapy. Multiple linear-regression analysis was used to determine the effect of VKORC1 haplotypes on the warfarin dose. We determined VKORC1 haplotype frequencies in African-American, European-American, and Asian-American populations and VKORC1 messenger RNA (mRNA) expression in human liver samples. RESULTS We identified 10 common noncoding VKORC1 single-nucleotide polymorphisms and inferred five major haplotypes. We identified a low-dose haplotype group (A) and a high-dose haplotype group (B). The mean (+/-SE) maintenance dose of warfarin differed significantly among the three haplotype group combinations, at 2.7+/-0.2 mg per day for A/A, 4.9+/-0.2 mg per day for A/B, and 6.2+/-0.3 mg per day for B/B (P<0.001). VKORC1 haplotype groups A and B explained approximately 25 percent of the variance in dose. Asian Americans had a higher proportion of group A haplotypes and African Americans a higher proportion of group B haplotypes. VKORC1 mRNA levels varied according to the haplotype combination. CONCLUSIONS VKORC1 haplotypes can be used to stratify patients into low-, intermediate-, and high-dose warfarin groups and may explain differences in dose requirements among patients of different ancestries. The molecular mechanism of this warfarin dose response appears to be regulated at the transcriptional level.
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Affiliation(s)
- Mark J Rieder
- Department of Genome Sciences, University of Washington, Seattle, USA
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You JHS, Chan FWH, Wong RSM, Cheng G. Is INR between 2.0 and 3.0 the optimal level for Chinese patients on warfarin therapy for moderate-intensity anticoagulation? Br J Clin Pharmacol 2005; 59:582-7. [PMID: 15842557 PMCID: PMC1884850 DOI: 10.1111/j.1365-2125.2005.02361.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2004] [Indexed: 11/29/2022] Open
Abstract
AIM To examine the optimal range of International Normalized Ratio (INR) for Chinese patients receiving warfarin for moderate-intensity anticoagulation. METHODS This was a retrospective cohort study conducted at the ambulatory setting of a 1400-bed public teaching hospital in Hong Kong. The INR measurements and occurrence of serious or life-threatening haemorrhagic and thromboembolic events among patients newly started on warfarin from 1 January 1999 to 30 June 2001 for indications with target INR 2-3 were analysed. The INR-specific incidence of bleeding and thromboembolism were calculated. RESULTS A total of 491 patients were included, contributing to 453 patient-years of observation period. Forty-seven of the 491 patients experienced 25 haemorrhagic events (5.5 per 100 patient-years) and 27 thromboembolic events (6.0 per 100 patient-years). The percentage of patient-time spent within therapeutic INR range (2-3), INR <2 and INR >3 were 50, 44 and 6%, respectively. The incidence of either haemorrhagic or thromboembolic events was lowest (< or =4 events per 100 patient-years) at INR values between 1.8 and 2.4. CONCLUSIONS An INR of 1.8-2.4 appeared to be associated with the lowest incidence rate of major bleeding or thromboembolic events in a cohort of Hong Kong Chinese patients receiving warfarin therapy for moderate-intensity anticoagulation.
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Affiliation(s)
- J H S You
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong.
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Dang MTN, Hambleton J, Kayser SR. The influence of ethnicity on warfarin dosage requirement. Ann Pharmacother 2005; 39:1008-12. [PMID: 15855242 DOI: 10.1345/aph.1e566] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The optimal dose of warfarin varies among individuals, and the prediction of a maintenance dose is difficult. Ethnicity has been reported to influence warfarin dosing. OBJECTIVE To quantitate the influence of ethnicity on warfarin dose requirement. METHODS We conducted a retrospective cohort study at a university anticoagulation clinic to evaluate the influence of ethnicity on warfarin dose. Inclusion criteria included age > or = 18 years, target international normalized ratio (INR) 2-3, and warfarin management within the clinic for > or = 3 months with a minimum of 5 clinic visits. We collected clinical and demographic data including age, gender, weight, ethnicity, disease states, concomitant medications, indication, weekly warfarin dosage, and INR. To assess potential confounders, multivariate, repeated-measures regression analysis was used to identify and adjust for variables that may influence the maintenance dose of warfarin. RESULTS Of the 345 patients who met the inclusion criteria, 27% were Asian American, 6% Hispanic, 54% white, and 14% African American. The adjusted mean (95% CI) weekly warfarin doses for patients with an INR goal of 2 to 3 were Asian Americans 24 mg (21 to 27), Hispanics 31 mg (25 to 37), whites 36 mg (34 to 39), and African Americans 43 mg (39 to 47) (p < 0.001). Additional factors found to influence warfarin dose requirement included age, weight, concomitant use of amiodarone, and diagnosis of venous thromboembolism. CONCLUSIONS Warfarin dose requirements vary across ethnic groups even when adjusted for confounding factors, suggesting that genetic variation contributes to interpatient variability.
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Affiliation(s)
- Mai-Trang N Dang
- Department of Clinical Pharmacy, University of California at San Francisco, San Francisco, CA 94143-0622, USA
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Rettie AE, Tai G, Veenstra DL, Farin FM, Srinouanprachan S, Lin YS, Thummel KE, Hines RN. CYP2C9 exon 4 mutations and warfarin dose phenotype in Asians. Blood 2003; 101:2896-7. [PMID: 12642346 DOI: 10.1182/blood-2002-11-3452] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Tang EOYL, Lai CSM, Lee KKC, Wong RSM, Cheng G, Chan TYK. Relationship between patients' warfarin knowledge and anticoagulation control. Ann Pharmacother 2003; 37:34-9. [PMID: 12503930 DOI: 10.1345/aph.1a198] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate patients' knowledge of warfarin and its relationship to anticoagulation control. METHODS From January to March 1999, 122 patients attending the warfarin clinic of the Prince of Wales Hospital in Hong Kong were interviewed. Their knowledge of warfarin therapy and adherence to medical advice were tested by 9 questions. A score (maximum 1.0) was calculated for each patient. The number of international normalized ratios (INRs) that was within the target range in the 4 most recent clinic visits was noted. RESULTS Fifty-six men and 66 women participated in the study (mean +/- SD age 58.0 +/- 13.0, duration of treatment 43.1 +/- 39.8 mo). Patients' warfarin knowledge was poor, with an overall score of 0.48 +/- 0.18. Participants generally knew the colors of their warfarin tablets and took them regularly. They almost always informed their physicians and dentists of their warfarin therapy. Only 40-45% of patients knew the strengths of their warfarin tablets, the reason for taking warfarin, and its effect on the body. Their deficiencies in knowledge were even more obvious with respect to the possible consequences of under- or over-anticoagulation, drugs and medicated oils that might interact with warfarin, and management of a missed dose. Knowledge was related to age (r -0.43; p < 0.001) and duration of therapy (r 0.18; p = 0.044). Sixty patients (49.2%) had read the information booklet on warfarin and had better knowledge than those who had not (0.53 +/- 0.20 vs. 0.42 +/- 0.20; p < 0.001). Illiteracy was the main reason for not reading the booklet. There was a positive correlation between patients' warfarin knowledge and the number of INR values that was within the target range in the 4 most recent clinic visits (r 0.20; p = 0.024). CONCLUSIONS Patients' warfarin knowledge, a determinant of anticoagulation control, was generally poor. More attention should be given to the education of elderly and illiterate patients.
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Fan K, Lee KL, Chow WH, Chau E, Lau CP. Internal cardioversion of chronic atrial fibrillation during percutaneous mitral commissurotomy: insight into reversal of chronic stretch-induced atrial remodeling. Circulation 2002; 105:2746-52. [PMID: 12057989 DOI: 10.1161/01.cir.0000018441.64861.de] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mechanoelectrical feedback caused by atrial dilatation plays an important role in atrial fibrillation (AF). To test the hypothesis that remodeling is reversible by reducing atrial stretch, we investigated electrophysiological changes after a reduction of left atrial (LA) pressure in patients undergoing percutaneous balloon mitral commissurotomy (PBMC). METHODS AND RESULTS In 22 patients with chronic AF who were undergoing PBMC for mitral stenosis, internal cardioversion was successful in 19 patients (86%). Twelve patients with sinus rhythm acted as controls. Mean LA pressure was significantly reduced after PBMC (18.5+/-5.9 mm Hg versus 10.2+/-4.1 mm Hg; P<0.001). The effective refractory period (ERP), conduction delay (CD), and the index of heterogeneity (CoV) of the ERP and CD were compared. Changes in LA pressure were only significantly correlated with AF vulnerability (r=0.7; P=0.02) and CoV of CD (r=0.3; P=0.03). There were no significant changes in ERP and CD immediately after PBMC in the AF group. However, the overall CoV of ERP was reduced in the AF group after PBMC. There were homogenous, although not significant, increases in regional ERP in the control group immediately after PBMC. Atrial CD and CoV of CD were significantly reduced after PBMC in the control group; this was most prominent within the regions of the LA. CONCLUSIONS AF vulnerability and CoV of CD correlated significantly with LA pressure. A homogenous increase in regional ERPs could be demonstrated in the control group after an immediate reduction of atrial stretch, whereas the recovery course of electrical remodeling was prolonged and heterogenous in the AF group. Regional conductions were irreversible in patients with preexisting AF.
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