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Huang Y, Xie Y, Huang L, Han Z. The Value of Anticoagulation Management Combining Telemedicine and Self-Testing in Cardiovascular Diseases: A Meta-Analysis of Randomized Controlled Trials. Ther Clin Risk Manag 2023; 19:279-290. [PMID: 36941980 PMCID: PMC10024473 DOI: 10.2147/tcrm.s395578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/02/2023] [Indexed: 03/15/2023] Open
Abstract
PURPOSE No consensus has been established on the safety and effectiveness of out-of-hospital management of Vitamin K antagonists (VKA) therapy combining portable coagulometers and telemedicine. The present meta-analysis investigated the safety and effectiveness of this hybrid anticoagulants management model. METHODS The PubMed, Embase, Cochrane, and Web of Science databases were searched for papers published before May 1, 2022. To reduce bias, only randomized controlled trials were included. RevMan 5.3 (Cochrane) software was used to evaluate and analyze clinical outcomes, including the effectiveness and safety of patient management approaches, determined by the time in the therapeutic range (TTR) and occurrence of thrombotic and bleeding events. RESULTS Eight studies, comprising 3853 patients, were selected. The meta-analysis showed that anticoagulant management combining portable coagulometers and telemedicine significantly improved frequency of testing (mean difference [MD]= 12.95 days; 95% CI, 8.77-17.12; I2= 92%; P< 0.01) and TTR (MD= 9.50%; 95% CI, 3.16-15.85; I2= 87%; P< 0.01). Thromboembolism events were reduced (RR= 0.72; 95% CI, 0.51-1.01; I2= 0%; P= 0.05), but the results were not statistically significant. And no significant differences in major bleeding events, rehospitalization rate, mortality, or overall treatment cost existed between the two groups. CONCLUSION Although the safety of remote cardiovascular disease management is not superior to that of conventional outpatient anticoagulant management, it provides a more stable monitoring of coagulation status.
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Affiliation(s)
- Yu Huang
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Guangdong, 518036, People’s Republic of China
- Anhui Medical University, Hefei, Anhui, 230032, People’s Republic of China
| | - Yilian Xie
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Guangdong, 518036, People’s Republic of China
- Shantou University Medical College, Shantou, Guangdong, 515041, People’s Republic of China
| | - Lei Huang
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Guangdong, 518036, People’s Republic of China
| | - Zhen Han
- Department of Cardiovascular Surgery, Peking University Shenzhen Hospital, Guangdong, 518036, People’s Republic of China
- Anhui Medical University, Hefei, Anhui, 230032, People’s Republic of China
- Correspondence: Zhen Han, Email
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Risk of recurrent venous thromboembolism and bleeding in patients with interstitial lung disease: a cohort study. J Thromb Thrombolysis 2021; 53:67-73. [PMID: 34232453 DOI: 10.1007/s11239-021-02518-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Abstract
Interstitial lung disease (ILD) encompasses various parenchymal lung disorders, which has the potential to increase the risk of venous thromboembolism (VTE). To evaluate, in patients with ILD and VTE, the risk of recurrent VTE during follow-up after stopping anticoagulation. This was a cohort of patients with a first VTE recruited between 1997 and 2015. The primary outcome was adjudicated fatal or nonfatal recurrent VTE after stopping anticoagulation. Main secondary outcomes were major or clinically relevant non-major bleeding under anticoagulation. Among 4314 patients with VTE, 50 had ILD diagnosed before VTE. Of these, anticoagulation was stopped in 30 patients after a median duration of 180 days and continued indefinitely in 20 patients. During a median follow-up of 27.8 months after anticoagulation discontinuation, recurrent VTE occurred in 15 on 30 patients (annual incidence of 19.2 events per 100-person-years [95%CI 12.0-29.3], case-fatality rate of 6.7% [95%CI 1.21-29.8]). The risk of recurrence was threefold higher when VTE was unprovoked and case-fatality rate of recurrence was increased by 3 when VTE index was PE. During the anticoagulant period, (median duration of 8.6 months), 6 patients had a major or clinically relevant bleeding (annual incidence of 7.3 events per 100-person-years [95%CI 3.4-15.1], case-fatality rate of 16.7% [95%CI 3.0-56.4]). In patients with ILD, the risk of recurrent VTE after stopping anticoagulation and the risk of bleeding under anticoagulation were very high. Our results suggest that anticoagulation should not be prolonged beyond 3-6 months of anticoagulation in most of cases.
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Impact of Valve Type (Ross vs. Mechanical) on Health-Related Quality of Life in Children and Young Adults with Surgical Aortic Valve Replacement. Pediatr Cardiol 2021; 42:1119-1125. [PMID: 33825913 DOI: 10.1007/s00246-021-02589-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/18/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND The impact of aortic valve replacement (AVR) type on health-related quality of life (HRQOL) in adolescents and young adults is unclear, but may vary depending on need for anticoagulation or re-intervention. We sought to determine the differences in HRQOL following AVR with either the Ross procedure or mechanical AVR in this young population. METHODS Patients 14-35 years old and at least 1 year post-AVR were included. HRQOL was assessed using the Short Form-36 (SF-36). Valve-specific concerns regarding anticoagulation and reoperation were also assessed. Clinical outcome data were obtained by chart review. RESULTS A total of 51 patients were enrolled: 24 (47%) Ross and 27 (53%) mechanical AVR. Ross patients were younger at time of AVR (16 vs. 22 years, p < 0.01) and study enrollment (23.7 vs 29.5 years, p < 0.01). Median follow-up from AVR to study enrollment was similar (5.4 years for Ross vs. 5.6 years for mechanical, p = 0.62). At last follow-up, clinical outcomes including cardiac function, functional class, and aortic valve re-intervention rates were similar between groups, although mechanical valve patients had more bleeding events (p = 0.012). SF-36 scores were generally high for the entire cohort, with no significant difference between groups in any domain. Mechanical AVR patients reported more concern about frequency of blood draws (p < 0.01). Concern for reoperation was similar between both groups. CONCLUSION Despite more bleeding events and concern about the frequency of blood draws, adolescents and young adults with mechanical AVR reported similarly high levels of HRQOL compared to those following Ross AVR.
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Teo YN, Teo YH, Syn NL, Goh MW, Yoong CSY, Lee CH, Chan MYY, Chai P, Yeo TC, Sia CH. Effects of Colchicine on Cardiovascular Outcomes in Patients with Coronary Artery Disease: A Systematic Review and One-Stage and Two-Stage Meta-Analysis of Randomized-Controlled Trials. High Blood Press Cardiovasc Prev 2021; 28:343-354. [PMID: 34003455 DOI: 10.1007/s40292-021-00460-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022] Open
Abstract
AIM Colchicine has received emerging interest due to its cardiovascular benefits in patients with coronary artery disease (CAD). We conducted a one-stage meta-analysis of reconstructed individual patient data (IPD) from randomized-controlled trials to summarize the effects of colchicine on cardiovascular outcomes in patients with CAD. METHODS Four databases (PubMed, Embase, Cochrane, SCOPUS) were searched for articles published from inception to 30th September 2020, examining the effect of colchicine on cardiovascular outcomes in patients with CAD, yielding 10 randomized-controlled trials with a combined cohort of 12,781 patients. IPD was reconstructed from Kaplan-Meier curves published in 3 studies and analysed using the shared-frailty Cox model. Aggregate data meta-analysis of all 10 studies was performed for outcomes unsuitable for IPD reconstruction. RESULTS In patients receiving colchicine compared to placebo, one-stage meta-analysis demonstrated a hazard ratio of 0.70 (95% CI 0.61-0.80) for the composite outcome of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and urgent hospitalization for angina requiring coronary revascularization. Aggregate data meta-analysis demonstrated a significant reduction in hazard rate for stroke (HR 0.45; 95% CI 0.27-0.75) and urgent revascularization (HR 0.59; 95% CI 0.38-0.91); and a relative risk reduction for myocardial infarction (RR 0.72; 95% CI of 0.52-1.00) and post-operative atrial fibrillation (RR 0.64; 95% CI 0.48-0.86). CONCLUSION Given the significant benefits of colchicine demonstrated on IPD, and its consistent benefits when analyzed using aggregate data meta-analysis, we propose that colchicine may be considered as an additional pharmacological adjunct to the first line therapy for patients with coronary artery disease.
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Affiliation(s)
- Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas L Syn
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ming Wei Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Celine Shuen Yin Yoong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chi-Hang Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Mark Yan-Yee Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore.
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Kim J, Jang I. Predictors of bleeding event among elderly patients with mechanical valve replacement using random forest model: A retrospective study. Medicine (Baltimore) 2021; 100:e25875. [PMID: 34106641 PMCID: PMC8133181 DOI: 10.1097/md.0000000000025875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 12/25/2020] [Indexed: 11/25/2022] Open
Abstract
Available classification tools and risk factors predicting bleeding events in elderly patients after mechanical valve replacement may not be suitable in Asian populations. Thus, we aimed to identify an accurate model for predicting bleeding in elderly patients receiving warfarin after mechanical valve replacement in a Korean population. In this retrospective cohort study, a random forest model was used to determine factors predicting bleeding events among 598 participants. Twenty-two descriptors were selected as predictors for bleeding. Steroid use was the most important predictor of bleeding events, followed by labile international normalized ratio, history of stroke, history of myocardial infarction, and cancer. The random forest model was sensitive (80.77%), specific (87.67%), and accurate (85.86%), with an area under the curve of 0.87, suggesting fair prediction. In the elderly, drug interactions with steroids and overall physical condition had a significant effect on bleeding. Elderly patients taking warfarin for life require lifelong management.
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Rosman L, Armbruster T, Kyazimzade S, Tugaoen Z, Mazzella AJ, Deyo Z, Walker J, Machineni S, Gehi A. Effect of a virtual self-management intervention for atrial fibrillation during the outbreak of COVID-19. Pacing Clin Electrophysiol 2021; 44:451-461. [PMID: 33565642 PMCID: PMC8014277 DOI: 10.1111/pace.14188] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/05/2021] [Accepted: 01/31/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND As the pandemic continues to unfold, effective, technology-based solutions are needed to help patients with atrial fibrillation (AF) maintain their health and well-being during the outbreak of COVID-19. METHODS This single-center, pilot study investigated the effects of a 4-week (eight sessions) virtual AF self-management program. Questionnaires were completed at baseline and 1 week after the intervention, and assessed AF knowledge, adherence to self-management behaviors, mental health, physical function, and disease-specific quality of life in patients with AF. Secondary outcomes included knowledge of COVID-19, intervention, acceptability, and satisfaction. RESULTS Of 68 patients who completed baseline questionnaires, 57 participated in the intervention and were included in the analysis (mean age of 73.4 ± 10.0 years, 60% male). Adherence to AF self-monitoring behaviors, including monitoring their heart rate (p < .001), heart rhythm (p = .003), and blood pressure (p = .013) were significantly improved at the end of the intervention compared with baseline. Symptom identification (p = .007) and management (p < .001) also improved. Reductions in sleep disturbance (p < .001), anxiety (p = .014), and depression (p = .046) were also observed. Misinformation and inaccurate beliefs about COVID-19 were significantly reduced at the end of the intervention compared with baseline. CONCLUSIONS This pilot study suggests that a virtual patient education program could have beneficial effects on adherence to guideline-recommend self-care of AF, emotional wellbeing, physical function, and knowledge of COVID-19 in patients with AF. Future randomized studies in larger samples are needed to determine the clinical benefits of the intervention.
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Affiliation(s)
- Lindsey Rosman
- Department of MedicineDivision of CardiologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Tiffany Armbruster
- Department of MedicineDivision of CardiologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Sayyad Kyazimzade
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Zachary Tugaoen
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Anthony J. Mazzella
- Department of MedicineDivision of CardiologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Zack Deyo
- Department of PharmacyUniversity of North Carolina HospitalsChapel HillNorth CarolinaUSA
- Division of Practice Advancement and Clinical EducationUniversity of North Carolina Eshelman School of PharmacyChapel HillNorth CarolinaUSA
| | - Jennifer Walker
- Department of MedicineDivision of CardiologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Sriram Machineni
- Department of MedicineDivision of Endocrinology & MetabolismUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Anil Gehi
- Department of MedicineDivision of CardiologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Nopp S, Ay C. Bleeding Risk Assessment in Patients with Venous Thromboembolism. Hamostaseologie 2021; 41:267-274. [PMID: 33626580 DOI: 10.1055/a-1339-9987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The recommended treatment for patients with venous thromboembolism (VTE) is anticoagulation for at least 3 months. However, anticoagulant treatment increases the risk of bleeding, and patients at high risk for major bleeding might benefit from treatment discontinuation. In this review, we discuss strategies for assessing bleeding risk and compare different bleeding risk tools. Bleeding risk assessment is best viewed as a continuous approach with varying challenges throughout the acute and chronic phase. At diagnosis, bleeding risk factors must be identified and reversible risk factors treated or modified. After initial treatment, repeated bleeding risk assessment is crucial for the decision on extended/long-term anticoagulation. Current clinical prediction models (e.g., HAS-BLED, RIETE, or VTE-BLEED scores) are externally validated tools with relevant differences in specificity and sensitivity, which can aid in clinical decision-making. Unfortunately, none of the current bleeding risk assessment tools has been investigated in clinical trials and provides evidence to withhold anticoagulation treatment based on the score. Nevertheless, the HAS-BLED or RIETE score can be used to identify patients at high risk for major bleeding during the initial treatment phase, while the VTE-BLEED score might be used to identify patients at low risk for bleeding and, therefore, to safely administer extended/long-term anticoagulation for secondary thromboprophylaxis. As clinical prediction scores still lack predictive value, future research should focus on developing biomarker-based risk assessment models.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Kapoor A, Landyn V, Wagner J, Burgwinkle P, Huang W, Gore J, Spencer FA, Goldberg R, McManus DD, Darling C, Boudreaux E, Barton B, Mazor KM. Supplying Pharmacist Home Visit and Anticoagulation Professional Consultation During Transition of Care for Patients With Venous Thromboembolism. J Patient Saf 2020; 16:e367-e375. [PMID: 30702452 PMCID: PMC7678649 DOI: 10.1097/pts.0000000000000571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to assess the feasibility, satisfaction, and effectiveness of a care transition intervention with pharmacist home visit and subsequent anticoagulation expert consultation for patients with new episode of venous thromboembolism within a not-for-profit health care network. METHODS We randomized patients to the intervention or control. During the home visit, a clinical pharmacist assessed medication management proficiency, asked open-ended questions to discuss knowledge gaps, and distributed illustrated medication instructions. Subsequent consultation with anticoagulation expert further filled knowledge gaps. At 30 days, we assessed satisfaction with the intervention and also measured the quality of care transition, knowledge of anticoagulation and venous thromboembolism, and anticoagulant beliefs (level of agreement that anticoagulant is beneficial, is worrisome, and is confusing/difficult to take). RESULTS The mean ± SD time required to conduct home visits was 52.4 ± 20.5 minutes and most patients agreed that the intervention was helpful. In general, patients reported a high-quality care transition including having been advised of safety issues related to medications. Despite that, the mean percentage of knowledge items answered correctly among patients was low (51.5 versus 50.7 for intervention and controls, respectively). We did not find any significant difference between intervention and control patients for care transition quality, knowledge, or anticoagulant beliefs. CONCLUSIONS We executed a multicomponent intervention that was feasible and rated highly. Nevertheless, the intervention did not improve care transition quality, knowledge, or beliefs. Future research should examine whether alternate strategies potentially including some but not all components of our intervention would be more impactful.
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Affiliation(s)
- Alok Kapoor
- From the University of Massachusetts Memorial Health Care
- University of Massachusetts Medical School
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA
| | - Valentina Landyn
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA
| | - Joann Wagner
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA
| | | | - Wei Huang
- University of Massachusetts Medical School
| | - Joel Gore
- From the University of Massachusetts Memorial Health Care
- University of Massachusetts Medical School
| | | | | | - David D. McManus
- From the University of Massachusetts Memorial Health Care
- University of Massachusetts Medical School
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA
| | - Chad Darling
- From the University of Massachusetts Memorial Health Care
- University of Massachusetts Medical School
| | | | | | - Kathleen M. Mazor
- University of Massachusetts Medical School
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA
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Palm P, Qvist I, Rasmussen TB, Christensen SW, Håkonsen SJ, Risom SS. Educational interventions to improve outcomes in patients with atrial fibrillation-a systematic review. Int J Clin Pract 2020; 74:e13629. [PMID: 32726511 DOI: 10.1111/ijcp.13629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is an emerging epidemic associated with poor mental health and quality of life, as well as morbidity and mortality. Whilst other cardiovascular conditions have demonstrated positive outcomes from educational programmes, this approach is not well integrated in clinical practice in patients with AF. Though evidence in this area is mounting, a thorough overview seems to be lacking. AIM To assess benefits and harms of educational interventions compared with no intervention in adults with AF. METHOD A systematic review and meta-analysis were performed including the outcomes: Serious adverse events (mortality and readmission), mental health (anxiety and depression), physical capacity, quality of life and self-reported incidence of symptoms of AF. PubMed, Embase, CINAHL, Cochrane Library and PsycINFO were searched between June and august 2018. Data extraction and quality assessment were performed independently by two reviewers. The Cochrane Risk of Bias tool was applied for the randomised controlled trials and the Amstar Checklist for the systematic reviews. RESULTS Eight randomised controlled trials and one non-randomised interventional study were included, with a total of 2388 patients. Comparing with controls patient education was associated with a reduction in: Serious adverse events (Risk Ratio 0.78, CI 95% 0.63-0.97), anxiety with a mean difference of -0.62 (CI 95% -1.21, -0.04) and depression with a mean difference of -0.74 (CI 95% -1.34, -0.14). Health-related quality of life and physical capacity was found to increase after patient education, yet, only one study found statistically significant differences between groups. No differences were observed with regards to self-reported incidence of symptoms of AF. CONCLUSIONS Educational interventions significantly decrease the number of serious adverse events in patients with AF and seem to have a positive impact on mental health and self-reported quality of life. However, the evidence is limited, and more studies are warranted.
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Affiliation(s)
- Pernille Palm
- The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen O, Denmark
| | - Ina Qvist
- Department of Cardiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Trine Bernholdt Rasmussen
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen O, Denmark
| | | | - Sasja Jul Håkonsen
- Centre of Clinical Guidelines, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Signe Stelling Risom
- The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen O, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen O, Denmark
- Institute of Nursing and Nutrision, University College Copenhagen, Copenhagen N, Denmark
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Dai H, Zheng C, Lin C, Zhang Y, Zhang H, Chen F, Liu Y, Xiao J, Chen C. Technology-Based Interventions in Oral Anticoagulation Management: Meta-Analysis of Randomized Controlled Trials. J Med Internet Res 2020; 22:e18386. [PMID: 32673227 PMCID: PMC7391164 DOI: 10.2196/18386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/06/2020] [Accepted: 05/14/2020] [Indexed: 12/29/2022] Open
Abstract
Background An increasing number of patients have received prophylactic or therapeutic oral anticoagulants (OACs) for thromboembolic complications of diseases. The use of OACs is associated with both clinical benefits and risks. Considering the challenges imposed by this class of drugs, as well as the enormous progress made in portable device technology, it is possible that technology-based interventions may improve clinical benefits for patients and optimize anticoagulation management. Objective This study was designed to comprehensively evaluate the role of technology-based interventions in the management of OACs. Methods We searched 6 databases—PubMed, EMBASE, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Scopus, and PsycINFO—to retrieve relevant studies published as of November 1, 2019, to evaluate the effect of technology-based interventions on oral anticoagulation management. RevMan (version 5.3; Cochrane) software was used to evaluate and analyze clinical outcomes. The methodological quality of studies was assessed by the Cochrane risk of bias tool. Results A total of 15 randomized controlled trials (RCTs) were selected for analysis. They reported data for 2218 patients (1110 patients in the intervention groups and 1108 patients in the control groups). A meta-analysis was performed on the effectiveness and safety data reported in the RCTs. Technology-based interventions significantly improved the effectiveness of oral anticoagulation management (mean difference [MD]=6.07; 95% CI 0.84-11.30; I2=72%; P=.02). The safety of oral anticoagulation management was also improved, but the results were not statistically significant. Bleeding events were reduced (major bleeding events MD=1.02; 95% CI 0.78-1.32; I2=0%; P=.90; minor bleeding events MD=1.06, 95% CI 0.77-1.44; I2=41%; P=.73) and thromboembolism events were reduced (MD=0.71; 95% CI 0.49-1.01; I2=0%; P=.06). In general, patients were more satisfied with technology-based interventions, which could also improve their knowledge of anticoagulation management, improve their quality of life, and reduce mortality and hospitalization events. Conclusions Using technology to manage OACs can improve the effectiveness and safety of oral anticoagulation management, result in higher patient satisfaction, and allow greater understanding of anticoagulation.
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Affiliation(s)
- Hengfen Dai
- Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | | | - Chun Lin
- School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Yan Zhang
- Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | - Hong Zhang
- Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | - Fan Chen
- Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | - Yunchun Liu
- Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | - Jingwen Xiao
- Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
| | - Chaoxin Chen
- School of Pharmacy, Fujian Medical University, Fuzhou, China
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11
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Yıldırım JG, Bayık Temel A. The Effect of Nurse Home-Support Program on Self-Management of Patients Receiving Oral Anticoagulation (Warfarin) Therapy. Florence Nightingale Hemsire Derg 2020; 28:13-22. [PMID: 34263181 PMCID: PMC7968461 DOI: 10.5152/fnjn.2020.19020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 09/12/2019] [Indexed: 11/22/2022] Open
Abstract
Aim Warfarin, which is widely used for preventing thromboembolic events, can cause major and minor side effects. The aim of this trial is to evaluate the effect of nurse home-support program on self-management of patients receiving warfarin therapy. Method A randomized, controlled trial was conducted using 36 selected and eligible patients who had 12-month home-visit follow-ups. The bleeding risk score, potential and preventable warfarin-related complications, patients' self-management behaviors, and anticoagulation satisfaction were examined. Data analyses were performed using parametric and nonparametric tests, split-plot analysis of variance, multiple regression analysis, and Bland and Altman plots test. Results The bleeding risk score was an effective variable for assessing patient satisfaction (p<0.05). The self-management group demonstrated decreased bleeding risk at the end of the trial. The Duke Anticoagulation Satisfaction Scale mean score represents a statistically significant improvement in the self-management group (p<0.05). Patients' self-management behaviors improved significantly in the self-management group compared to the control group (p<0.05). The number of international normalized ratio values within the target range was significantly higher in the self-management group (174/432) than in the control group (82/432). The self-management group showed significant reductions in both thromboembolic events. Conclusion This trial demonstrated evidence that use of nursing home care is effective in developing self-management behaviors, improving patient satisfaction, and preventing complications in patients receiving warfarin therapy. This model could be easily adopted and implemented by home care services and health organizations.
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Affiliation(s)
- Jülide Gülizar Yıldırım
- Department of Public Health Nursing, İzmir Katip Çelebi University Faculty of Health Sciences, İzmir, Turkey
| | - Ayla Bayık Temel
- Department of Public Health Nursing, Ege University Faculty of Nursing, İzmir, Turkey
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12
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Comparative efficacy and safety of warfarin care bundles and novel oral anticoagulants in patients with atrial fibrillation: a systematic review and network meta-analysis. Sci Rep 2020; 10:662. [PMID: 31959803 PMCID: PMC6971267 DOI: 10.1038/s41598-019-57370-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/18/2019] [Indexed: 01/04/2023] Open
Abstract
Warfarin care bundles (e.g. genotype-guided warfarin dosing, patient’s self-testing [PST] or patient’s self-management [PSM] and left atrial appendage closure) are based on the concept of combining several interventions to improve anticoagulation care. NOACs are also introduced for stroke prevention in atrial fibrillation (SPAF). However, these interventions have not been compared in head-to-head trials yet. We did a network meta-analysis based on a systematic review of randomized controlled trials comparing anticoagulant interventions for SPAF. Studies comparing these interventions in adults, whether administered alone or as care bundles were included in the analyses. The primary efficacy outcome was stroke and the primary safety outcome was major bleeding. Thirty-seven studies, involving 100,142 patients were assessed. Compared to usual care, PSM significantly reduced the risk of stroke (risk ratio [RR] 0.24, 95% CI 0.08–0.68). For major bleeding, edoxaban 60 mg (0.80, 0.71–0.90), edoxaban 30 mg (0.48, 0.42–0.56), and dabigatran 110 mg (0.81, 0.71–0.94) significantly reduced the risk of major bleeding compared with usual warfarin care. Cluster rank plot incorporating stroke and major bleeding outcomes indicates that some warfarin care bundles perform as well as NOACs. Both interventions are therefore viable options to be considered for SPAF. Additional studies including head-to-head trials and cost-effectiveness evaluation are still warranted.
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13
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Xia X, Fu J, Wu T, Chen W, Jinhua Z. Comparison of the outcomes of warfarin therapy and economics by online and offline anticoagulation management models: protocol for a randomised controlled trial. BMJ Open 2019; 9:e031730. [PMID: 31492796 PMCID: PMC6731806 DOI: 10.1136/bmjopen-2019-031730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Warfarin is widely used in the world as oral anticoagulant, but it is difficult to manage patients after medication due to its narrow treatment window and individualised differences. Therefore, every region uses network means to carry out online anticoagulant therapy services. The purpose of this paper is to compare monitoring results and randomised controlled studies of the complications of warfarin treated by offline or online management in a Chinese population. METHODS AND ANALYSIS This is a randomised controlled, multicentre clinical trial. Taking the Union Hospital Affiliated to Fujian Medical University as the main centre, a randomised controlled study of several subcentres around China produced a nationally representative sample. 496 participants who took warfarin will be recruited and then randomly divided into two groups at a ratio of 1:1. We will collect data on patient characteristics, diagnosis, treatment, hospitalisation results and later complications. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of the Union Hospital Affiliated to Fujian Medical University. All cooperative hospitals have been approved by the Central Ethics Committee. The results of the survey will be disseminated in future peer review documents and will provide the basis for a management model for patients in China taking warfarin. TRIAL REGISTRATION NUMBER ChiCTR1900021920.
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Affiliation(s)
- Xiaotong Xia
- College of Pharmacy, Fujian Medical University, Fuzhou, China
- Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jinglan Fu
- College of Pharmacy, Fujian Medical University, Fuzhou, China
- Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Tingting Wu
- College of Pharmacy, Fujian Medical University, Fuzhou, China
- Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wenjun Chen
- College of Pharmacy, Fujian Medical University, Fuzhou, China
- Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhang Jinhua
- College of Pharmacy, Fujian Medical University, Fuzhou, China
- Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
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14
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Yiu A, Bajorek B. Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review. Ther Adv Drug Saf 2019; 10:2042098619847423. [PMID: 31205676 PMCID: PMC6535713 DOI: 10.1177/2042098619847423] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 04/01/2019] [Indexed: 12/18/2022] Open
Abstract
The aim of this review was to identify patient-focused interventions that have been trialed to support vulnerable patient populations taking oral anticoagulants (warfarin and the direct-acting oral anticoagulants (DOACs)) such as older persons (65 years and over), those with limited health literacy, and those from culturally and linguistically diverse (CALD) backgrounds. This review also aimed to report on the effects of these interventions on outcomes relevant to the use of anticoagulant therapy. Original articles published between 1 January 1995 and 30 June 2017 were identified using several electronic databases such as Medline, Ovid, Embase, Scopus, Cochrane, and Google Scholar. The following terms were used for the three-tiered search: Tier 1, elderly, aged, older adult, geriatrics; Tier 2, health literacy, literacy, low health literacy, low English proficiency, patient literacy; and Tier 3, ethnicity, ethnic, ethnic groups, CALD, culturally and linguistically diverse, NESB, non-English speaking background, race, racial groups, religion, religious groups, and minority groups. The terms for each tier were combined with the following terms: anticoagulants, anticoagulation, warfarin, apixaban, dabigatran, rivaroxaban, DOACS, new oral anticoagulants, novel oral anticoagulants, patient care, patient knowledge, comprehension, patient education, patient participation, and communication. A total of 41 studies were identified. Most of the interventions identified included older persons taking warfarin who were monitored using the international normalized ratio (INR) and who received patient education. Many interventions reported a significant positive impact on patients' knowledge, reduction in the number of adverse events caused by hemorrhage, and better INR control. More research on patient-focused interventions is needed that includes patients with limited health literacy, those from CALD backgrounds, and family members and caregivers of patients taking oral anticoagulants.
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Affiliation(s)
- Angela Yiu
- Graduate School of Health – Pharmacy, University Technology of Sydney, Level 4, Building 7, 67 Thomas Street, Ultimo, NSW 2007, Australia
| | - Beata Bajorek
- Graduate School of Health – Pharmacy, University of Technology Sydney and Pharmacy Department, Royal North Shore Hospital, Australia
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15
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Modelo de costos asociados al ataque cerebrovascular y los eventos adversos en pacientes con fibrilación auricular no valvular tratados con warfarina. REVISTA COLOMBIANA DE CARDIOLOGÍA 2019. [DOI: 10.1016/j.rccar.2018.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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16
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Pourafkari L, Baghbani-Oskouei A, Savadi-Oskouei S, Ghaffari S, Parizad R, Tajlil A, Nader ND. Prediction Model for Significant Bleeding in Patients with Supratherapeutic International Normalized Ratio After Oral Administration of Warfarin. Clin Drug Investig 2019; 39:533-542. [PMID: 30887419 DOI: 10.1007/s40261-019-00774-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE The use and range of indications for anticoagulation therapy are steadily growing. The objective of this study was to develop a scoring model to predict the occurrence of significant bleeding in patients taking warfarin with a supra-therapeutic international normalized ratio. METHODS Data were collected from the medical records of patients taking warfarin with an international normalized ratio > 3.5. The characteristics of bleeding episodes and the need for transfusion of blood products were recorded. Regression models were constructed to predict the occurrence of significant bleeding (requiring a transfusion of more than 2 units of packed red blood cells, intrapericardial or intracranial hemorrhage). The predictive values of previously published scores (ATRIA: anemia, hypertension, severe renal disease, age ≥ 75 years, or prior bleeding history; and ORBIT: old, reduced hemoglobin, bleeding history, kidney insufficiency or antiplatelet treatment) were compared with our New Bleeding Score (NBLDSCOR); the areas under the curve for the receiver-operating characteristic plots were compared using a non-parametric DeLong test. RESULTS Significant bleeding was reported in 87 out of 389 admitted patients. With an area under the curve of 0.736 ± 0.032, NBLDSCOR was the best predictor of significant bleeding in this population. Neither ATRIA nor ORBIT was a good predictor of significant bleeding, where the area under the curve for the receiver-operating characteristic plot for ATRIA was 0.654 ± 0.034 and for ORBIT was 0.604 ± 0.033. The predictive power of NBLDSCOR was superior to ATRIA and ORBIT (p < 0.001), while there was no meaningful difference in the predictive powers of ATRIA and ORBIT. CONCLUSION The NBLDSCOR including age, negative Rhesus factor, low hemoglobin, renal impairment, and concomitant peptic ulcer and disseminated cancer is a good predictor of significant bleeding in this patient population.
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Affiliation(s)
- Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Anesthesiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 77 Goodell Street, Suite 550, Buffalo, NY, 14203, USA
| | | | - Safa Savadi-Oskouei
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Raziye Parizad
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arezou Tajlil
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nader D Nader
- Department of Anesthesiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 77 Goodell Street, Suite 550, Buffalo, NY, 14203, USA.
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17
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Abstract
OBJECTIVES To identify and examine individual characteristics and socioeconomic factors that contribute to the knowledge of patients who receive warfarin anticoagulation. METHODS All patients treated using warfarin for anticoagulation were enrolled during a 6-month period at a university-affiliated cardiac clinic. All relevant demographic and clinical information were collected and the Anticoagulation Knowledge Assessment (AKA) questionnaire consisting of 29 questions was administered. After completion, the questionnaires were scored and the percent correct answers were analyzed for overall scores, as well as the following categories: drug/food interactions, pharmacological knowledge, recognition of complications, and patient compliance. Multiple linear regression analysis was used to identify the contributing factors to the knowledge level of the patients in each category. RESULTS One hundred fifty patients (79 men and 71 women) with a median age of 61.5 years completed the AKA questionnaire. The average overall score was 29.3%. Living alone (P = 0.008), higher levels of education (P = 0.001), and durations of ≥3 years of warfarin therapy (P = 0.018) positively impacted overall AKA scores. CONCLUSIONS Socioeconomic factors and level of general education remain the most important elements determining the patient awareness of therapeutic goals, possible drug/food interaction, recognition of adverse effects, and compliance of warfarin treatment.
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18
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Wool GD. Benefits and Pitfalls of Point-of-Care Coagulation Testing for Anticoagulation Management: An ACLPS Critical Review. Am J Clin Pathol 2019; 151:1-17. [PMID: 30215666 DOI: 10.1093/ajcp/aqy087] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objectives Point-of-care (POC) testing is generally less precise and has higher reagent costs per test than laboratory-based assays. However, POC hemostasis testing can offer significant advantages in particular situations: patient-managed warfarin therapy as well as rapid turnaround time heparin management for intraoperative patients. Of note, POC hemostasis testing is generally approved for the purposes of anticoagulation monitoring and is inferior to laboratory coagulation testing for the diagnosis of congenital or acquired coagulopathy. Methods The frequently used POC coagulation instruments for POC international normalized ratio and activated clotting time are reviewed, as well as their typical performance relative to central laboratory testing (where available). Results Several cases are discussed that highlight the benefits, as well as pitfalls, of POC coagulation testing. Conclusions POC coagulation testing for anticoagulation monitoring offers advantages in particular situations. Clear policies and protocols must be developed to guide proper use of POC versus central laboratory hemostasis testing.
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Affiliation(s)
- Geoffrey D Wool
- The Department of Pathology, University of Chicago, Chicago, IL
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19
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Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA, Agarwal A, Bhatt M, Khatib R, Riva JJ, Zhang Y, Guyatt G. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257-3291. [PMID: 30482765 PMCID: PMC6258922 DOI: 10.1182/bloodadvances.2018024893] [Citation(s) in RCA: 284] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO
| | - Jack Ansell
- School of Medicine, Hofstra Northwell, Hempstead, NY
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane Skov
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; and
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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20
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Bhatt S, McCurdy CE, Liew D, Russell DM. Effect of warfarin education on patient knowledge and anticoagulation control: a randomised controlled trial. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Shireen Bhatt
- Department of General Medicine, The Royal Melbourne Hospital Melbourne Australia
| | | | - Danny Liew
- Monash Centre of Cardiovascular Research and Education in Therapeutics Monash University Melbourne Australia
| | - David M. Russell
- Department of General Medicine, The Royal Melbourne Hospital Melbourne Australia
- Department of Medicine University of Melbourne Melbourne Australia
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21
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Yazdchi F, Kaneko T, Aranki S. Bioprosthesis in young patients: A reality or a fantasy. J Thorac Cardiovasc Surg 2018; 157:894-895. [PMID: 30297087 DOI: 10.1016/j.jtcvs.2018.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/20/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Farhang Yazdchi
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sary Aranki
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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22
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Menichetti J, Graffigna G, Steinsbekk A. What are the contents of patient engagement interventions for older adults? A systematic review of randomized controlled trials. PATIENT EDUCATION AND COUNSELING 2018; 101:995-1005. [PMID: 29246493 DOI: 10.1016/j.pec.2017.12.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/07/2017] [Accepted: 12/09/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To describe the contents of interventions reported in RCTs focusing on patient engagement of older adults. METHODS A systematic literature review based on a search for "patient engagement/activation/empowerment/involvement/participation". Interventions were classified according to: (i) specific components (micro level), (ii) single/multiple dimensions (educational, behavioral, affective) (meso level), and (iii) the studies' main educational, behavioral or affective dimension (macro level). RESULTS After screening 2749 articles, 35 were included. 20 unique components were identified, mostly behavioral or educational (45.5% each) (e.g., goal setting or written informational materials). Most interventions with a single-focus were classified as educational (31%), one was solely affective (3%). Half of the interventions covered more than one dimension, with four (11%) combining all three dimensions. Studies mainly focusing on the affective dimension included older participants (72 vs. 67 years), had a higher proportion of females (71% vs. 44%), and included other dimensions more frequently (67% vs. 31%) than did studies with a main focus on the educational dimension. CONCLUSION The contents of the interventions that focused on patient engagement of older adults tend to focus more on behavioral and educational dimensions than the affective dimension. PRACTICE IMPLICATIONS The possibility of adding the affective dimension into behavioral and/or educational interventions should be explored.
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Affiliation(s)
- Julia Menichetti
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy.
| | | | - Aslak Steinsbekk
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
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23
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Kantito S, Saokaew S, Yamwong S, Vathesatogkit P, Katekao W, Sritara P, Chaiyakunapruk N. Cost-effectiveness analysis of patient self-testing therapy of oral anticoagulation. J Thromb Thrombolysis 2017; 45:281-290. [PMID: 29181693 DOI: 10.1007/s11239-017-1588-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient Self-testing (PST) could be an option for present anticoagulation therapy monitoring, but current evidence on its cost-effectiveness is limited. This study aims to estimate the cost-effectiveness of PST to other different care approaches for anticoagulation therapy in Thailand, a low-to-middle income country (LMIC). A Markov model was used to compare lifetime costs and quality-adjusted life years (QALYs) accrued to patients receiving warfarin through PST or either anticoagulation clinic (AC) or usual care (UC). The model was populated with relevant information from literature, network meta-analysis, and database analyses. Incremental cost-effectiveness ratios (ICERs) were presented as the year 2015 values. A base-case analysis was performed for patients at age 45-year-old. Sensitivity analyses including one-way and probabilistic sensitivity analyses (PSA) were constructed to determine the robustness of the findings. From societal perspective, PST increased QALY by 0.87 and costs by 112,461 THB compared with UC. Compared with AC, PST increased QALY by 0.161 and costs by 21,019 THB. The ICER with PST was 128,697 (3625 USD) and 130,493 THB (3676 USD) per QALY gained compared with UC and AC, respectively. The probability of PST being cost-effective is 74.1% and 51.9%, compared to UC and AC, respectively, in Thai context. Results were sensitive to the efficacy of PST, age and frequency of hospital visit or self-testing. This analysis suggested that PST is highly cost-effective compared with usual care and less cost-effective against anticoagulation clinic. Patient self-testing strategy appears to be economically valuable to include into healthcare system within the LMIC context.
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Affiliation(s)
- Sutat Kantito
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, Malaysia
| | - Sukit Yamwong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prin Vathesatogkit
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wisuit Katekao
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piyamitr Sritara
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia.
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, Malaysia.
- School of Pharmacy, University of Wisconsin, Madison, USA.
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Kaneko T, Aranki SF. No rat poison for me. J Thorac Cardiovasc Surg 2017; 154:1542-1543. [DOI: 10.1016/j.jtcvs.2017.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 07/06/2017] [Indexed: 11/26/2022]
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Kelcey B, Shen Z. Planning community-based assessments of HIV educational intervention programs in sub-Saharan Africa. HEALTH EDUCATION RESEARCH 2017; 32:353-363. [PMID: 28854572 DOI: 10.1093/her/cyx046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/05/2017] [Indexed: 06/07/2023]
Abstract
A key consideration in planning studies of community-based HIV education programs is identifying a sample size large enough to ensure a reasonable probability of detecting program effects if they exist. Sufficient sample sizes for community- or group-based designs are proportional to the correlation or similarity of individuals within communities. As a result, efficient and effective design requires reasonable a priori estimates of the correlational structure among individuals within communities. In this study, we investigate the degree of correlation among individuals within communities and regions using samples of sixth-grade adolescents from 609 local area district communities and 122 regions in 15 sub-Saharan African nations. We develop nation-specific and international summaries of these correlations using variance partitioning coefficients from multilevel models and subsequently assess the extent to which different types of background variables delineate key sources of these correlations. The results suggest persistent differences among communities and regions and that the degree of correlation among individuals within communities varied considerably by nation. The findings underscore the importance of empirically derived values of design parameters that are anchored in evidence specific to the outcome, nation and context of the planned study.
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Affiliation(s)
- Ben Kelcey
- College of Education, Criminal Justice, and Human Services, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Zuchao Shen
- College of Education, Criminal Justice, and Human Services, University of Cincinnati, Cincinnati, OH 45221, USA
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Quel traitement anticoagulant au décours d’une embolie pulmonaire. Presse Med 2017; 46:728-738. [DOI: 10.1016/j.lpm.2017.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 06/27/2017] [Indexed: 01/22/2023] Open
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27
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Barnason S, White-Williams C, Rossi LP, Centeno M, Crabbe DL, Lee KS, McCabe N, Nauser J, Schulz P, Stamp K, Wood K. Evidence for Therapeutic Patient Education Interventions to Promote Cardiovascular Patient Self-Management: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/hcq.0000000000000025] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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28
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Singh P, Kalita J, Misra UK. Quality of anticoagulation therapy in neurological patients in a tertiary care hospital in north India. Indian J Med Res 2017; 143:428-33. [PMID: 27377498 PMCID: PMC4928548 DOI: 10.4103/0971-5916.184301] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND & OBJECTIVES There is paucity of studies on the quality of anticoagulation in neurological patients from India. This study evaluates the quality of oral anticoagulation therapy in neurology patients. METHODS Consecutive patients attending a tertiary care neurology service in north India who were prescribed oral anticoagulant (OAC), were included. Their international normalized ratio (INR) values were prospectively monitored and the earlier INR values of the patients who were already on OAC were retrospectively analyzed. The patients with multi-organ dysfunction, pregnancy and those below 18 yr of age were excluded. The therapeutic INR range was defined as per standard recommendations. The level of anticoagulation, factors interfering with OAC and complications were noted. RESULTS The results were based on 77 patients with median age 40 yr. Fifty one patients received OAC for secondary stroke prevention, 23 for cerebral venous sinus thrombosis (CVST) and three for deep vein thrombosis (DVT). A total 167.9 person-years of follow up was done with a median of 1.2 (0.3-9.3) years. of the 1287 INR reports, 505 (39.3%) reports were in the therapeutic range, 496 (38.5%) were below and 282 (21.91%) were above the therapeutic level. Stable INR was obtained in 33 (42.86%) patients only. INR level was improved by dose adjustment in 20 (26%), drug modification in two (2.6%), and dietary adjustment in six (7.8%) patients. Three patients were sensitive and five were resistant to OAC. Complications were noted in 28 instances; thromboembolic in 16 and haemorrhagic stroke in 12. The overall complication rate was 16.7 per 100 person-years. INTERPRETATION & CONCLUSIONS It may be concluded that stable therapeutic INR is difficult to maintain in neurological patients. Optimal modification of diet, drug and dose of oral anticoagulant may help in stabilization of INR.
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Affiliation(s)
- Prabhat Singh
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - J Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - U K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Clarkesmith DE, Pattison HM, Khaing PH, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev 2017; 4:CD008600. [PMID: 28378924 PMCID: PMC6478129 DOI: 10.1002/14651858.cd008600.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation (AF) with one or more risk factors for stroke; however, anticoagulation control (time in therapeutic range (TTR)) with vitamin K antagonists (VKAs) is dependent on many factors. Educational and behavioural interventions may impact patients' ability to maintain their international normalised ratio (INR) control. This is an updated version of the original review first published in 2013. OBJECTIVES To evaluate the effects of educational and behavioural interventions for oral anticoagulation therapy (OAT) on TTR in patients with AF. SEARCH METHODS We updated searches from the previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (January 2016, Issue 1), MEDLINE Ovid (1949 to February week 1 2016), EMBASE Classic + EMBASE Ovid (1980 to Week 7 2016), PsycINFO Ovid (1806 to Week 1 February 2016) and CINAHL Plus with Full Text EBSCO (1937 to 16/02/2016). We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials evaluating the effect of any educational and behavioural intervention compared with usual care, no intervention, or intervention in combination with other self-management techniques among adults with AF who were eligible for, or currently receiving, OAT. DATA COLLECTION AND ANALYSIS Two of the review authors independently selected studies and extracted data. Risk of bias was assessed using the Cochrane 'Risk of bias' tool. We included outcome data on TTR, decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), beliefs about medication, illness perceptions, and anxiety and depression. We pooled data for three outcomes - TTR, anxiety and depression, and decision conflict - and reported mean differences (MD). Where insufficient data were present to conduct a meta-analysis, we reported effect sizes and confidence intervals (CI) from the included studies. We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. MAIN RESULTS Eleven trials with a total of 2246 AF patients (ranging from 14 to 712 by study) were included within the review. Studies included education, decision aids, and self-monitoring plus education interventions. The effect of self-monitoring plus education on TTR was uncertain compared with usual care (MD 6.31, 95% CI -5.63 to 18.25, I2 = 0%, 2 trials, 69 participants, very low-quality evidence). We found small but positive effects of education on anxiety (MD -0.62, 95% CI -1.21 to -0.04, I2 = 0%, 2 trials, 587 participants, low-quality evidence) and depression (MD -0.74, 95% CI -1.34 to -0.14, I2 = 0%, 2 trials, 587 participants, low-quality evidence) compared with usual care. The effect of decision aids on decision conflict favoured usual care (MD -0.1, 95% CI -0.17 to -0.02, I2 = 0%, 2 trials, 721 participants, low-quality evidence). AUTHORS' CONCLUSIONS This review demonstrates that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
| | - Helen M Pattison
- Aston UniversitySchool of Life and Health SciencesAston TriangleBirminghamUKB4 7ET
| | - Phyo H Khaing
- University of BirminghamCollege of Medical and Dental Sciences8 Minnesota DriveGreat SankeyBirminghamCheshireUKWA5 3SY
| | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
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Suivi des patients traités par AVK : intérêt d’un relais pharmaceutique entre l’hôpital et la ville. ANNALES PHARMACEUTIQUES FRANÇAISES 2017; 75:45-53. [DOI: 10.1016/j.pharma.2016.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 11/19/2022]
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Mora-Pabón G. Utilidad de la automonitorización en el tratamiento de la terapia con warfarina. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Pozzi M, Mitchell J, Henaine AM, Hanna N, Safi O, Henaine R. International normalized ratio self-testing and self-management: improving patient outcomes. Vasc Health Risk Manag 2016; 12:387-392. [PMID: 27785043 PMCID: PMC5066985 DOI: 10.2147/vhrm.s85031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Long term oral anti-coagulation with vitamin K antagonists is a risk factor of hemorrhagic or thromebomlic complications. Periodic laboratory testing of international normalized ratio (INR) and a subsequent dose adjustment are therefore mandatory. The use of home testing devices to measure INR has been suggested as a potential way to improve the comfort and compliance of the patients and their families, the frequency of monitoring and, finally, the management and safety of long-term oral anticoagulation. In pediatric patients, increased doses to obtain and maintain the therapeutic target INR, more frequent adjustments and INR testing, multiple medication, inconstant nutritional intake, difficult venepunctures, and the need to go to the laboratory for testing (interruption of school and parents’ work attendance) highlight those difficulties. After reviewing the most relevant published studies of self-testing and self-management of INR for adult patients and children on oral anticoagulation, it seems that these are valuable and effective strategies of INR control. Despite an unclear relationship between INR control and clinical effects, these self-strategies provide a better control of the anticoagulant effect, improve patients and their family quality of life, and are an appealing solution in term of cost-effectiveness. Structured education and knowledge evaluation by trained health care professionals is required for children, to be able to adjust their dose treatment safely and accurately. However, further data are necessary in order to best define those patients who might better benefit from this multidisciplinary approach.
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Affiliation(s)
- Matteo Pozzi
- Department of Adult Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Julia Mitchell
- Department of Congenital Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | | | - Najib Hanna
- Pediatric Unit, "Hotel Dieu de France" Hospital, Saint Joseph University, Beirut, Lebanon
| | - Ola Safi
- Pediatric Unit, "Hotel Dieu de France" Hospital, Saint Joseph University, Beirut, Lebanon
| | - Roland Henaine
- Department of Congenital Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
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Allore HG, Tinetti ME, Gill TM, Peduzzi PN. Experimental designs for multicomponent interventions among persons with multifactorial geriatric syndromes. Clin Trials 2016; 2:13-21. [PMID: 16279575 DOI: 10.1191/1740774505cn067oa] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This paper discusses issues about the design of clinical trials to test multicomponent interventions for multifactorial health conditions, such as geriatric syndromes in which more than one risk factor is related to the outcome. The issues covered include: identification and selection of modifiable risk factors related to the outcome of interest, selection of intervention components to reduce the deleterious effects of the modifiable risk factors, assignment of components of the intervention, blinding, sample size requirements and estimation of component effects. Each of these issues is explored using examples from nine illustrative multicomponent intervention trials. Statistical and clinical concerns regarding the design of multicomponent interventions are addressed. We also propose elements of multicomponent interventions for multifactorial health conditions that should be reported in publications and areas where future research is needed.
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Affiliation(s)
- Heather G Allore
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
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Hyun G, Li J, Bass AR, Mohapatra A, Woller SC, Lin H, Eby C, McMillin GA, Gage BF. Use of signals and systems engineering to improve the safety of warfarin initiation. J Thromb Thrombolysis 2016; 42:529-33. [PMID: 27443162 DOI: 10.1007/s11239-016-1402-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Warfarin-dosing algorithms combine clinical factors and dosing history with the current international normalized ratio (INR) to estimate the therapeutic warfarin dose. Unfortunately, these approaches can result in an overdose if the INR is spuriously low. Our goal was to develop an alert mechanism based on prior INRs in addition to the current INR. Using data from the Genetics InFormatics Trial (GIFT) of Warfarin to Prevent DVT, we analyzed warfarin dose estimates for days 3 through 11 that were ≥10 % higher than an average of the previous two dose estimates. We fit a stepwise mixed model to current and prior dose estimates, and subsequently compared the root-mean-square-error (RMSE) in predicting the final therapeutic dose using the GIFT algorithm versus the mixed model. From 861 dosing records (obtain from 556 patients), 646 dosing records (75 %) were randomly selected for the derivation cohort and 215 dosing records (25 %) for the validation cohort. Using one prior dose estimate improved the accuracy of the warfarin dose estimate. Compared to a dose estimate based on current INR (GIFT algorithm), the mixed model reduced the RMSE in the derivation cohort by 0.0015 mg/day (RMSE 0.2079 vs. 0.2094; p = 0.039). In the validation cohort, the RMSE reduction was not significant. A mixed model of dose estimates based on the current and most recent INRs shows potential to improve the safety of warfarin dosing. Clinicians should be cautious about aggressively escalating the warfarin dose after an INR that is lower than expected.
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Affiliation(s)
- G Hyun
- Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8005, St. Louis, MO, 63110, USA
| | - J Li
- Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8005, St. Louis, MO, 63110, USA
| | - A R Bass
- Hospital for Special Surgery, Weill Cornell Medical College, 535 E 70th Street, New York, NY, 10021, USA
| | - A Mohapatra
- Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8005, St. Louis, MO, 63110, USA
| | - S C Woller
- Intermountain Medical Center, 5121 Cottonwood St, Murray, UT, 84157, USA
| | - H Lin
- Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8005, St. Louis, MO, 63110, USA
| | - C Eby
- Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8005, St. Louis, MO, 63110, USA
| | - G A McMillin
- Department of Pathology and ARUP Laboratories, University of Utah, 500 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - B F Gage
- Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8005, St. Louis, MO, 63110, USA.
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Heneghan CJ, Garcia-Alamino JM, Spencer EA, Ward AM, Perera R, Bankhead C, Alonso-Coello P, Fitzmaurice D, Mahtani KR, Onakpoya IJ. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev 2016; 7:CD003839. [PMID: 27378324 PMCID: PMC8078378 DOI: 10.1002/14651858.cd003839.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The introduction of point-of-care devices for the management of patients on oral anticoagulation allows self-testing by the patient at home. Patients who self-test can either adjust their medication according to a pre-determined dose-INR (international normalized ratio) schedule (self-management), or they can call a clinic to be told the appropriate dose adjustment (self-monitoring). Increasing evidence suggests self-testing of oral anticoagulant therapy is equal to or better than standard monitoring. This is an updated version of the original review published in 2010. OBJECTIVES To evaluate the effects on thrombotic events, major haemorrhages, and all-cause mortality of self-monitoring or self-management of oral anticoagulant therapy compared to standard monitoring. SEARCH METHODS For this review update, we re-ran the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), 2015, Issue 6, the Cochrane Library, MEDLINE (Ovid, 1946 to June week 4 2015), Embase (Ovid, 1980 to 2015 week 27) on 1 July 2015. We checked bibliographies and contacted manufacturers and authors of relevant studies. We did not apply any language restrictions . SELECTION CRITERIA Outcomes analysed were thromboembolic events, mortality, major haemorrhage, minor haemorrhage, tests in therapeutic range, frequency of testing, and feasibility of self-monitoring and self-management. DATA COLLECTION AND ANALYSIS Review authors independently extracted data and we used a fixed-effect model with the Mantzel-Haenzel method to calculate the pooled risk ratio (RR) and Peto's method to verify the results for uncommon outcomes. We examined heterogeneity amongst studies with the Chi(2) and I(2) statistics and used GRADE methodology to assess the quality of evidence. MAIN RESULTS We identified 28 randomised trials including 8950 participants (newly incorporated in this update: 10 trials including 4227 participants). The overall quality of the evidence was generally low to moderate. Pooled estimates showed a reduction in thromboembolic events (RR 0.58, 95% CI 0.45 to 0.75; participants = 7594; studies = 18; moderate quality of evidence). Both, trials of self-management or self-monitoring showed reductions in thromboembolic events (RR 0.47, 95% CI 0.31 to 0.70; participants = 3497; studies = 11) and (RR 0.69, 95% CI 0.49 to 0.97; participants = 4097; studies = 7), respectively; the quality of evidence for both interventions was moderate. No reduction in all-cause mortality was found (RR 0.85, 95% CI 0.71 to 1.01; participants = 6358; studies = 11; moderate quality of evidence). While self-management caused a reduction in all-cause mortality (RR 0.55, 95% CI 0.36 to 0.84; participants = 3058; studies = 8); self-monitoring did not (RR 0.94, 95% CI 0.78 to 1.15; participants = 3300; studies = 3); the quality of evidence for both interventions was moderate. In 20 trials (8018 participants) self-monitoring or self-management did not reduce major haemorrhage (RR 0.95, 95% CI, 0.80 to 1.12; moderate quality of evidence). There was no significant difference found for minor haemorrhage (RR 0.97, 95% CI 0.67 to 1.41; participants = 5365; studies = 13). The quality of evidence was graded as low because of serious risk of bias and substantial heterogeneity (I(2) = 82%). AUTHORS' CONCLUSIONS Participants who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy. Thromboembolic events were reduced, for both those self-monitoring or self-managing oral anticoagulation therapy. A reduction in all-cause mortality was observed in trials of self-management but not in self-monitoring, with no effects on major haemorrhage.
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Affiliation(s)
- Carl J Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Oxford, Oxfordshire, UK, OX2 6GG
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Parker K, Aasebø W, Haslemo T, Stavem K. Relationship between cytochrome P450 polymorphisms and prescribed medication in elderly haemodialysis patients. SPRINGERPLUS 2016; 5:350. [PMID: 27066364 PMCID: PMC4801827 DOI: 10.1186/s40064-016-1986-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/09/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Elderly patients on haemodialysis have a high prevalence of polypharmacy and are at risk of drug-related complications. More than 80 % of all prescribed drugs are metabolized by the cytochrome P450 (CYP) enzyme system. The aims of this study were to describe the prevalence of polymorphism in three CYP isoenzymes and the relationship between CYP polymorphism and prescribed drugs. METHODS Fifty-one elderly haemodialysis patients aged ≥65 years were included. CYP-genotyping was carried out in whole blood by a real-time PCR method for detecting common variant alleles in CYP2C9, CYP2C19 and CYP2D6. The allele frequencies were calculated using the Hardy-Weinberg equation. RESULTS The overall prevalence of CYP polymorphisms (heterozygous and homozygous) was 77 %. The prevalence of heterozygous carriers of variant alleles coding for defective CYP2D6, CYP2C9 and CYP2C19 was 64, 22 and 55 %, respectively; the prevalence of homozygous carriers was 6 % for each of the CYP2D6, CYP2C9 and CYP2C19 enzymes. The prevalence of the CYP2D6*6, CYP2D6*9 and CYP2D6*41 variant alleles did not differ (p = 0.31) from that in a European Caucasian reference population. Twenty-three patients (45 %) had at least one CYP mutation and used drugs that are metabolized by the CYP isoenzymes. Metoprolol and proton-pump inhibitors were the most commonly used drugs that could be affected by a heterozygous or homozygous mutation. CONCLUSIONS Polymorphisms of CYP2C9, CYP2C19 and CYP2D6 are common in elderly haemodialysis patients. Many of these patients have a phenotype with altered CYP enzyme activity and could benefit from close drug monitoring or a drug switch.
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Affiliation(s)
- Krystina Parker
- Medical Division, Department of Nephrology, Akershus University Hospital, 1478 Lørenskog, Norway ; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Willy Aasebø
- Medical Division, Department of Nephrology, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Tore Haslemo
- Department of Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway ; Medical Division, Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway ; HØKH, Department of Health Services Research, Akershus University Hospital, Lørenskog, Norway
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Discrepancies between Patients' Preferences and Educational Programs on Oral Anticoagulant Therapy: A Survey in Community Pharmacies and Hospital Consultations. PLoS One 2016; 11:e0146927. [PMID: 26765105 PMCID: PMC4713069 DOI: 10.1371/journal.pone.0146927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 12/23/2015] [Indexed: 11/29/2022] Open
Abstract
Background Oral anticoagulation therapy is increasingly used for the prevention and treatment of thromboembolic complications in various clinical situations. Nowadays, education programs for patients treated with anticoagulants constitute an integrated component of their management. However, such programs are usually based on the healthcare providers’ perceptions of what patients should know, rather than on patients’ preferences. Objective To investigate patients’ viewpoints on educational needs and preferred modalities of information delivery. Methods We conducted an observational study based on a self-administered questionnaire. To explore several profiles of patients, the study was designed for enrolling patients in two settings: during outpatient consultations in a cardiology department (Saint Antoine Hospital, Paris, France) and in community pharmacies throughout France. Results Of the 371 patients who completed the questionnaire, 187 (50.4%) were recruited during an outpatient consultation and 184 (49.6%) were recruited in community pharmacies. 84.1% of patients were receiving a vitamin K antagonist and 15.6% a direct oral anticoagulant. Patients ranked 16 of 21 (76.2%) questionnaire items on information about their treatment as important or essential; information on adverse effects of treatment was the highest ranked domain (mean score 2.38, 95% CI 2.30–2.46). Pharmacists (1.69, 1.58–1.80), nurses (1.05, 0.95–1.16), and patient associations (0.36, 0.29–0.44), along with group sessions (0.85, 0.75–0.95), the internet (0.77, 0.67–0.88), and delivery of material at the patient’s home (1.26, 1.14–1.38), were ranked poorly in terms of delivering educational material. Conclusion This study revealed substantial discrepancies between patient preferences and current educational programs. These findings should be useful for tailoring future educational programs that are better adapted to patients, with a potential associated enhancement of their effectiveness.
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Shrestha S, Sapkota B, Kumpakha A, Acharya U, Sharma R. Evaluation of patients' knowledge on warfarin in outpatient pharmacy of a tertiary care cardiac center. BMC Res Notes 2015; 8:429. [PMID: 26358332 PMCID: PMC4566289 DOI: 10.1186/s13104-015-1416-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 09/07/2015] [Indexed: 11/22/2022] Open
Abstract
Background Warfarin is widely used for the prevention and treatment of cardiac, thromboembolic and hypercoagulable diseases. Since warfarin is a narrow therapeutic index medicine, it requires close monitoring when used in the outpatient setting and on long term basis. Warfarin has been found to be associated with a number of complications especially bleeding. Patients’ knowledge on warfarin can improve anticoagulation control with decrease in adverse drug reaction and other associated complications. The objective was to assess knowledge level of warfarin therapy among its users and to provide adequate education and counseling to the patients. Methods In the present cross sectional study, 34 patients on warfarin were interviewed. Patients’ knowledge on warfarin was assessed using a validated Anticoagulation Knowledge Assessment (AKA) questionnaire comprising 29 questions. Each correct answer scored 3.45 points whereas an incorrect answer scored zero point. Patient who answered at least 21 questions correctly or scored (21 × 3.45 = 72.4 %) was considered to have adequate level of knowledge or have obtained a passing score. Association between independent variables and AKA score was assessed using Pearson Chi square test or Fisher’s exact test for categorical variables. Patients were counseled regarding proper warfarin use by the researcher pharmacists at the end of each data collection schedule. Results Of the 34 patients, only 5.8 % (n = 2) achieved a passing score whereas 94.1 % (n = 32) failed to achieve the passing score. 67.6 % of the patients (n = 23) achieved a score below 50 %. More than 50 % of the patients incorrectly answered 15 questions in the questionnaire. None of the patients scored 100 %. No significant association was found between age, gender of patients and total warfarin score. A significant association (p < 0.05) was found between duration of warfarin therapy and total warfarin score. Conclusions Warfarin knowledge was poor among the patients. Hence, regular counseling with timely assessment of their understanding was felt necessary.
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Affiliation(s)
- Sweta Shrestha
- Kathmandu University School of Science Department of Pharmacy, Kathmandu, Nepal.
| | - Binaya Sapkota
- Government of Nepal Civil Service Hospital, Minbhawan, Kathmandu, Nepal.
| | | | - Upasana Acharya
- Kathmandu University School of Science Department of Pharmacy, Kathmandu, Nepal.
| | - Rashmi Sharma
- Kathmandu University School of Science Department of Pharmacy, Kathmandu, Nepal.
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Tromeur C, Couturaud F. [Optimal duration of anticoagulant treatment after venous thromboembolic disease]. Presse Med 2015; 44:779-90. [PMID: 26276297 DOI: 10.1016/j.lpm.2015.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Determination of the optimal duration of anticoagulant treatment for venous thromboembolic disease (VTED) is a major step in the management of patients with this disease. The assessment depends on the identification of two sets of risk factors: those for recurrence after anticoagulant treatment is stopped and those for hemorrhage in cases of prolonged treatment. Nonetheless, the determination of the optimal duration remains controversial. Recent data finally make it possible to clarify this decision. Recent treatment trials demonstrate that patients at high risk of recurrence receive no sustained benefit from a prolonged but limited anticoagulant treatment. In other words, the choice is simplified: either the risk is low, and treatment for 3months is sufficient, or the risk is high, and treatment must be envisioned for an unlimited duration. Adequate identification of patients eligible for short or unlimited treatment is more crucial than ever and depends on the presence of determinant clinical variables, as the information from laboratory or morphologic tests is generally marginal. The risk of thromboembolic recurrence is low when the initial episode is triggered by a major reversible factor, and a short treatment of 3months is thus indicated. These inducing factors are mainly surgery, lower limb injuries, immobilization for a medical condition, pregnancy, or use of combined estrogen-progestin contraceptives. Among patients with VTED not induced by these factors, the risk of recurrence is high and requires planning anticoagulant treatment for an unlimited duration. Nonetheless, the risk of hemorrhage is a major constraint to such unlimited treatment. Accordingly, the perspectives for secondary prevention that is equally effective but has a lower risk of hemorrhage are currently under evaluation. Finally, patients with cancer are in a separate category, with a very high risk of recurrence that justifies treatment for at least 6months.
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Affiliation(s)
- Cécile Tromeur
- CHU La Cavale-Blanche, département de médecine interne et pneumologie, EA 3878 (GETBO), IFR 148, CIC Inserm 1412, GIRC-Thrombose F-CRIN - INNOVTE, 29609 Brest cedex, France
| | - Francis Couturaud
- CHU La Cavale-Blanche, département de médecine interne et pneumologie, EA 3878 (GETBO), IFR 148, CIC Inserm 1412, GIRC-Thrombose F-CRIN - INNOVTE, 29609 Brest cedex, France.
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Kooiman J, van Hagen N, Iglesias del Sol A, Planken EV, Lip GYH, van der Meer FJM, Cannegieter SC, Klok FA, Huisman MV. The HAS-BLED Score Identifies Patients with Acute Venous Thromboembolism at High Risk of Major Bleeding Complications during the First Six Months of Anticoagulant Treatment. PLoS One 2015; 10:e0122520. [PMID: 25905638 PMCID: PMC4407886 DOI: 10.1371/journal.pone.0122520] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/12/2015] [Indexed: 12/29/2022] Open
Abstract
Objective The HAS-BLED score enables a risk estimate of major bleeds in patients with atrial fibrillation on vitamin K-antagonists (VKA) treatment, but has not been validated for patients with venous thromboembolism (VTE). We analyzed whether the HAS-BLED score accurately identifies patients at high risk of major bleeds during VKA treatment for acute VTE. Methods Medical records of 537 patients with acute VTE (primary diagnosis pulmonary embolism in 223, deep vein thrombosis in 314) starting VKA treatment between 2006-2007 were searched for items on the HAS-BLED score and the occurrence of major bleeds during the first 180 days of follow-up. The hazard ratio (HR) for the occurrence of major bleeds comparing non-high with high-risk patients as defined by a HAS-BLED score ≥ 3 points was calculated using Cox-regression analysis. Results Major bleeds occurred in 11/537 patients (2.0%, 5.2/100 person years, 95% CI 2.8-9.2). Cumulative incidences of major bleeds were 1.3% (95% CI 0.1-2.5) in the non-high (HAS-BLED < 3) and 9.6% (95%CI 2.2-17.0) in the high-risk group (HAS-BLED ≥ 3), (p <0.0001 by Log-Rank test), with a HR of 8.7 (95% CI 2.7-28.4). Of the items in the HAS-BLED score, abnormal renal function (HR 10.8, 95% CI 1.9-61.7) and a history of bleeding events (HR 10.4, 95% CI 2.5-42.5) were independent predictors of major bleeds during follow-up. Conclusion Acute VTE patients with a HAS-BLED score ≥ 3 points are at increased risk of major bleeding. These results warrant for correction of the potentially reversible risk factors for major bleeding and careful International Normalized Ratio monitoring in acute VTE patients with a high HAS-BLED score.
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Affiliation(s)
- Judith Kooiman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Nadja van Hagen
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Erwin V. Planken
- Department of Internal Medicine, Diaconessenhuis, Leiden, The Netherlands
| | - Gregory Y. H. Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
| | - Felix J. M. van der Meer
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C. Cannegieter
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Ferrando F, Mira Y. Effective and Safe Management of Oral Anticoagulation Therapy in Patients Who Use the Internet-Accessed Telecontrol Tool SintromacWeb. Interact J Med Res 2015; 4:e10. [PMID: 25900775 PMCID: PMC4420842 DOI: 10.2196/ijmr.3610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 11/24/2014] [Accepted: 02/19/2015] [Indexed: 01/04/2023] Open
Abstract
Background Despite the existing evidence that highlights the benefits of oral anticoagulation therapy (OAT) self-testing and self-management by patients in comparison with conventional control, significant progress is still needed in the implementation of computer-based, Internet-assisted systems for OAT within health care centers. The telecontrol tool “SintromacWeb” is a previously validated system for OAT management at home, which is currently operative and accessed by patients through a hospital Web portal. Objective The intent of the study was to assess the effectiveness and safety of OAT management in patients using the SintromacWeb telecontrol system in reference to control in patients using the conventional system (management at the hematology department), in terms of time in therapeutic range (TTR) of International Normalized Ratio (INR). Methods In this observational prospective study, patients were identified by their physician and divided in two groups according to the OAT management system that they were already using (conventional control or telecontrol with SintromacWeb). For 6 months, patients were required to visit the hematology department every time their physician considered it necessary according to usual clinical practice. Sociodemographic and clinical variables for the study were collected at first visit (baseline) and at those visits closest to 2, 4, and 6 months after first visit. Results A total of 173 patients were evaluated, 87 with conventional control and 86 with telecontrol. Follow-up time was a median of 6.3 (range 5.2-8.1) months. The average time of OAT treatment prior to enrollment was 9.2 (SD 6.4) years. Patients in the telecontrol group tested their INR a median of 21 (range 4-22) days versus a median of 35 (range 14-45) days in patients in the conventional control group (P<.001). TTR in the telecontrol group was 107 (SD 37) days versus 94 (SD 37) days in the conventional control group (an increase of 12.6%; P=.02). In all visits, the percentage of TTR was higher in the telecontrol group (at the third visit: 59% vs 48%; P=.01). Higher TTR (positive coefficient) was associated with patients under OAT telecontrol (P=.03). Under-anticoagulation (INR<1.5) and over-anticoagulation (INR>5) were observed in 34 (19.7%, 34/173) and 38 (22.0%, 38/173) patients, respectively (no differences between treatment groups). Seven thrombotic and/or bleeding events were serious, 12 were non-serious, and most of them (5 and 10, respectively) occurred in the conventional control group. Conclusions In clinical practice, OAT management with the Internet-based tool SintromacWeb is effective and safe for those patients who are eligible for OAT telecontrol.
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Affiliation(s)
- Fernando Ferrando
- Hospital Universitari i Politècnic La Fe, Unidad de Hemostasia y Trombosis, Valencia, Spain.
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Klok FA, Kooiman J, Huisman MV, Konstantinides S, Lankeit M. Predicting anticoagulant-related bleeding in patients with venous thromboembolism: a clinically oriented review. Eur Respir J 2014; 45:201-10. [PMID: 25102964 DOI: 10.1183/09031936.00040714] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Diagnosis of venous thromboembolism (VTE) requires prompt treatment with anticoagulants in therapeutic doses. Since these drugs are associated with the occurrence of haemorrhage, identification of patients at increased risk of major bleeding is of utmost clinical importance for defining the optimal treatment regimen and duration of anticoagulation. Current suggested prediction scores for bleeding risk in VTE patients have been derived from observational studies of moderate quality, or from patients with various indications for therapeutic anticoagulation other than VTE. To date, none of the scores have been adequately validated in cohorts that underwent dedicated monitoring and independent adjudication of bleeding complications. In addition, while the scarce available evidence has focused on patients treated with heparins and/or vitamin K antagonists, risk stratification scores for bleeding complications in VTE patients treated with non-vitamin K dependent anticoagulants have not yet been developed. This clinically oriented review covers the incidence and risk factors of anticoagulation-related bleeding in VTE patients treated with different anticoagulant drugs as well as the available bleeding-prediction scores. Further, we attempt to provide guidance for bleeding-prevention in clinical practice and speculate on developments in the near future that may fundamentally change our current thinking on VTE management.
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Affiliation(s)
- Frederikus A Klok
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Judith Kooiman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
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Efficacy and safety of vitamin K-antagonists (VKA) for atrial fibrillation in non-dialysis dependent chronic kidney disease. PLoS One 2014; 9:e94420. [PMID: 24817475 PMCID: PMC4015895 DOI: 10.1371/journal.pone.0094420] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 03/16/2014] [Indexed: 11/19/2022] Open
Abstract
Background Essential information regarding efficacy and safety of vitamin K-antagonists (VKA) treatment for atrial fibrillation (AF) in non-dialysis dependent chronic kidney disease (CKD) is still lacking in current literature. The aim of our study was to compare the risks of stroke or transient ischemic attack (TIA) and major bleeds between patients without CKD (eGFR >60 ml/min), and those with moderate (eGFR 30–60 ml/min), or severe non-dialysis dependent CKD (eGFR <30 ml/min). Methods We included 300 patients without CKD, 294 with moderate, and 130 with severe non-dialysis dependent CKD, who were matched for age and sex. Uni- and multivariate Cox regression analyses were performed reporting hazard ratios (HRs) for the endpoint of stroke or TIA and the endpoint of major bleeds as crude values and adjusted for comorbidity and platelet-inhibitor use. Results Overall, 6.2% (45/724, 1.7/100 patient years) of patients developed stroke or TIA and 15.6% (113/724, 4.8/100 patient years) a major bleeding event. Patients with severe CKD were at high risk of stroke or TIA and major bleeds during VKA treatment compared with those without renal impairment, HR 2.75 (95%CI 1.25–6.05) and 1.66 (95%CI 0.97–2.86), or with moderate CKD, HR 3.93(1.71–9.00) and 1.86 (95%CI 1.08–3.21), respectively. These risks were similar for patients without and with moderate CKD. Importantly, both less time spent within therapeutic range and high INR-variability were associated with increased risks of stroke or TIA and major bleeds in severe CKD patients. Conclusions VKA treatment for AF in patients with severe CKD has a poor safety and efficacy profile, likely related to suboptimal anticoagulation control. Our study findings stress the need for better tailored individualised anticoagulant treatment approaches for patients with AF and severe CKD.
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Eischer L, Eichinger S, Kyrle PA. The risk of recurrence in women with venous thromboembolism while using estrogens: a prospective cohort study. J Thromb Haemost 2014; 12:635-40. [PMID: 24548536 DOI: 10.1111/jth.12528] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 02/08/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The optimal duration of anticoagulation for women who had venous thromboembolism (VTE) associated with estrogen use is unknown. OBJECTIVES To test the hypothesis that women who had a first VTE while using estrogens have a low risk of recurrence. METHODS A Prospective cohort study of 630 women (333 estrogen users, 297 non-users) with a first VTE, who were followed for an average of 69 months after anticoagulation withdrawal. Women with a previous or secondary VTE, coagulation inhibitor deficiency, lupus anticoagulant, cancer, pregnancy, requirement of long-term antithrombotic therapy or homozygosity or double heterozygosity for factor V Leiden and/or the G20210A prothrombin mutation were excluded. The endpoint was objectively documented symptomatic recurrent VTE. RESULTS VTE recurred in 22 (7%) estrogen users and in 49 (17%) non-users. After 1, 2 and 5 years, the cumulative probability of recurrence was 1% (95% confidence interval [CI], 0-2), 1% (95% CI, 0-2) and 6% (95% CI, 3-9) among estrogen users and 5% (95% CI, 2-7), 9% (95% CI, 6-13) and 17% (95% CI, 12-22) among non-users. Compared with non-users, estrogen users had an adjusted relative risk (RR) of recurrent VTE of 0.4 (95% CI, 0.2-0.8). Compared with non-users in the respective age groups, the RR of recurrence was 0.4 (95% CI, 0.2-0.8) among estrogen-containing-contraceptive users and 0.7 (95% CI, 0.3-1.5) among women using estrogen-containing menopausal hormone therapy. CONCLUSIONS Women who had their first VTE while using estrogens have a low risk of recurrent VTE. These women might not benefit from extended anticoagulant therapy.
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Affiliation(s)
- L Eischer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Okuyama Y, Matsuo M, Matsuo H, Sakaguchi Y, Takai H, Horiguchi Y, Ryomoto T, Adachi S, Amano T, Togawa M, Masuda M, Minamiguchi H, Nanto S, Komuro I, Sakata Y. Introduction of point-of-care testing in Japanese outpatient clinics is associated with improvement in time in therapeutic range in anticoagulant-treated patients. Circ J 2014; 78:1342-8. [PMID: 24717234 DOI: 10.1253/circj.cj-13-1256] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Warfarin reduces the risk of stroke in patients with atrial fibrillation, but requires a moderate-to-high time in therapeutic range (TTR). We hypothesized that point-of-care (POC) testing for prothrombin time-internationalized normalized ratio (PT-INR) could improve the TTR in patients receiving warfarin. METHODS AND RESULTS Eight outpatient clinics that introduced POC testing for PT-INR participated in this study. We identified 148 consecutive patients who received warfarin for at least 12 months before and after the introduction of POC testing. We compared the TTR before and after the introduction of POC testing for each patient. TTR after the introduction of POC testing was significantly higher than that beforehand (51.9%±33.0% vs. 69.3%±26.3%; P<0.0001). The improvement in TTR was statistically significant in patients who had low TTR (<70%) before the introduction of POC testing. After the introduction of POC, the time spent above the target INR showed no significant change (3.7%±10.6% vs. 3.3%±6.3%, P=0.7322), while that spent below the target INR improved significantly (44.4%±34.4% vs. 27.4%±27.6%, P<0.0001). CONCLUSIONS The introduction of POC testing was associated with an improvement in TTR, mainly through a reduction in the time spent below the target INR.
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Affiliation(s)
- Yuji Okuyama
- Advanced Cardiovascular Therapeutics and Department of Cardiology, Osaka University Graduate School of Medicine
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Pharmacist’s Counselling Improves Patient Knowledge Regarding Warfarin, Irrespective of Health Literacy Level. PHARMACY 2014. [DOI: 10.3390/pharmacy2010114] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Siebenhofer A, Jeitler K, Horvath K, Habacher W, Schmidt L, Semlitsch T. Self-management of oral anticoagulation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:83-91. [PMID: 24622604 PMCID: PMC3953995 DOI: 10.3238/arztebl.2014.0083] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 10/16/2013] [Accepted: 10/16/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Properly dosed oral anticoagulation effectively prevents thromboembolic events. It is unclear whether adult patients with an indication for long-term oral anticoagulation can benefit from self-management in terms of patient-oriented endpoints and improved coagulation values. METHOD We selectively searched the Medline database for high-quality systematic reviews based on randomized controlled trials of self-measurement or self-management of oral anticoagulation, compared to standard treatment. RESULTS We identified eight review articles based on overlapping sets of ran - domized clinical trials. In all of these systematic reviews, patients who performed self-measurement or self-management had a 40% to 50% lower rate of thromboembolic events; in six of them, the mortality was also significantly lower, by 30% to 50%. Subgroup analysis revealed that these effects were present exclusively in patients who performed self-management, and not in those who only performed self-measurement. None of the review articles revealed any difference in the frequency of severe hemorrhagic events. Quality of life and patient satisfaction were rated in five reviews, which, however, used different instruments, with the result that no clear conclusions could be drawn. All of the review articles documented an improvement in coagulation values, but information on statistical significance was mostly lacking. CONCLUSION Adults with an indication for long-term oral anticoagulation benefit from self-management, as compared to standard treatment with management of dosing by a physician. A limitation of this study is that the multiple review articles on which it is based were largely analyses of the same group of clinical trials.
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Affiliation(s)
- Andrea Siebenhofer
- Institute of General Practice, J. W. Goethe University, Frankfurt/Main
- EBM Review Center, Medical University of Graz
| | - Klaus Jeitler
- EBM Review Center, Medical University of Graz
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz
| | - Karl Horvath
- EBM Review Center, Medical University of Graz
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz
| | - Wolfgang Habacher
- Institute of Biomedicine and Health Sciences (HEALTH), JOANNEUM RESEARCH Forschungsgesellschaft mbh, Graz
| | - Louise Schmidt
- Institute of Biomedicine and Health Sciences (HEALTH), JOANNEUM RESEARCH Forschungsgesellschaft mbh, Graz
| | - Thomas Semlitsch
- EBM Review Center, Medical University of Graz
- Institute of Biomedicine and Health Sciences (HEALTH), JOANNEUM RESEARCH Forschungsgesellschaft mbh, Graz
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Newall F, Monagle P, Johnston L. Patient understanding of warfarin therapy: A review of education strategies. Hematology 2013; 10:437-42. [PMID: 16321807 DOI: 10.1080/10245330500276451] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Significant research has been directed into defining best-practice anticoagulant management of thromboembolic events and optimal strategies for determining the safety and efficacy of therapy. Similarly, improved patient outcomes have been realised through the development of novel management strategies such as self-monitoring and self-management. Considerably, less energy has been directed towards developing and evaluating the best mechanisms for delivery of patient education. This is in spite of the fact that numerous confounders to stable therapy confront warfarinised patients on a daily basis. That patients requiring warfarin therapy should be educated with respect to that therapy has never been questioned. However, relatively little attention appears to have been paid to the development of robust models of patient education in the setting of oral anticoagulant therapy. This paper reviews the current literature with respect to warfarin education interventions before recommending strategies that may facilitate determination of the impact educating patients about warfarin therapy has upon clinical outcomes.
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Affiliation(s)
- Fiona Newall
- Department of Haematology, Royal Children's Hospital, Parkville, 3053, Australia
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Eymin G, Jaffer AK. Evidence behind quality of care measures for venous thromboembolism and atrial fibrillation. J Thromb Thrombolysis 2013; 37:87-96. [DOI: 10.1007/s11239-013-0874-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Eichinger S. Anticoagulation after venous thromboembolism. Deciding on the optimal duration. Hamostaseologie 2013; 33:211-7. [PMID: 23719863 DOI: 10.5482/hamo-13-03-0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 05/27/2013] [Indexed: 01/13/2023] Open
Abstract
Deciding on the optimal duration of anticoagulation is based on the risk of recurrent venous thromboembolism (VTE) and of bleeding during anticoagulation. The duration of anticoagulation should be at least three months since shorter courses double the recurrence rates. At three months anticoagulation can be stopped in patients with a VTE provoked by a transient risk factor, as the recurrence risk is expected to be lower than the bleeding risk during anticoagulation. Patients with unprovoked VTE are at higher risk of recurrence and prolonged anticoagulation is currently recommended. However, attempts are made to stratify these patients according to their recurrence risk and to identify those with a low recurrence risk who would not benefit from extended anticoagulation. Novel approaches to optimize the management of patients with unprovoked VTE are the use of prediction models which link clinical patient characteristics with laboratory testing to discriminate between patients with a low risk (who may discontinue anticoagulation) and those with high risk (in whom long term anticoagulation is justified). Moreover, new antithrombotic concepts including new oral anticoagulants or aspirin both of which potentially confer a lower bleeding risk and are more convenient for the patients have been explored for extended thromboprophylaxis.
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Affiliation(s)
- S Eichinger
- Medical University of Vienna, Dept. of Medicine I, Austria.
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