Time in therapeutic range is lower in women than in men and is not explained by differences in age or comorbidity

BACKGROUND

Time in therapeutic range (TTR) measures the stability of the international normalized ratio in patients on vitamin K antagonists (VKA). Low values are associated with poor outcomes. Women were shown to have lower TTR than men, but the causes are poorly defined. It was suggested that women on VKA are older and more morbid than men, and this could affect the stability of anticoagulation. We aimed to identify variables that affect TTR differently in women and men.

MATERIALS AND METHODS

This is a retrospective study in patients referred to a University hospital anticoagulant clinic. Age, sex, comorbidities, number of daily medications, indication and type of anticoagulant, weekly dosage and distribution, were derived from electronic records. Differences by sex and regression analysis to identify significant modulators of TTR were computed.

RESULTS

1182 women and 1281 men on VKA were studied. Women were older than men (81.5 yrs. ± 11.2 vs 78.4 yrs. ± 12.2), and had lower TTR (65% ± 20.3 vs 69% ± 19.8). Comorbidity was similar between sexes and negatively affected TTR in both. Mechanical valves as an indication to anticoagulation and acenocoumarol as an anticoagulant as opposed to warfarin had a strong negative influence on TTR, while age increased TTR. Being a man rather than a woman afforded more than three TTR points. Number of medications and average anticoagulant dose were equal between sexes.

DISCUSSION

Women have a lower TTR than men, on average below the safety threshold. They were indeed older, but age positively influenced TTR. Since women and men were equally comorbid, neither age nor disease explains differences in TTR. None of the other variables included in the study could explain the gender gap in TTR. Since women are at increased risk of cardioembolic stroke in atrial fibrillation, an effort at defining other causes for the observed differences, closer monitoring and switching to direct anticoagulants whenever possible is warranted.

[Congenital cytomegalovirus infection: current status and future perspectives]

In recent years, infection with cytomegalovirus (CMV) was the subject of numerous studies, one side being the most frequent congenital infection in newborns and one that determines the increased incidence of sequelae distance (about one third of childhood deafness is due to CMV), and the other one of the most frequent and serious opportunistic infections in immunocompromised individuals. Of newborns with congenital infection, approximately 10% are symptomatic at birth. Of the remaining 90%, asymptomatic at birth, 10-15% will develop sequelae from a distance. Regarding the possibility of vertical transmission of the disease from mother to fetus, the debate is still open on the usefulness or not to set a screening during pregnancy in order to prevent or limit the damage caused fetal infection. Despite detailed knowledge about the epidemiology and pathogenesis of CMV disease in pregnant women, this infection remains largely unknown to most women. The opportunity of a serological screening is important, however, since more than 90% of primary CMV infection in pregnancy are asymptomatic and may remain asymptomatic in the fetus. The education on methods to prevent transmission of CMV, particularly among young women of childbearing age, must continue until an effective vaccine becomes available. In this article we summarize the current concepts regarding the epidemiology, pathogenesis, symptoms and prevention of CMV disease, with particular focus on strategies to improve awareness of the risk of CMV infection in women of childbearing age.