Elizabeth S Mearns1, Christine G Kohn2, Ju-Sung Song3, Jessica Hawthorne4, Joy Meng5, C Michael White6, Monika K Raut7, Jeff R Schein8, Craig I Coleman9. 1. University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69N Eagleville Road, Storrs, CT, 06269-3092, USA; Hartford Hospital Division of Cardiology, 80 Seymour Street, Hartford, CT, 06102-5037, USA. Electronic address: Elizabeth.Mearns@hhchealth.org. 2. University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69N Eagleville Road, Storrs, CT, 06269-3092, USA; Hartford Hospital Division of Cardiology, 80 Seymour Street, Hartford, CT, 06102-5037, USA. Electronic address: Christine.Kohn@hhchealth.org. 3. University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69N Eagleville Road, Storrs, CT, 06269-3092, USA. Electronic address: Ju-Sung.Song@uconn.edu. 4. University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69N Eagleville Road, Storrs, CT, 06269-3092, USA. Electronic address: Jessica.Hawthorne@uconn.edu. 5. University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69N Eagleville Road, Storrs, CT, 06269-3092, USA. Electronic address: Joy.Meng@uconn.edu. 6. University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69N Eagleville Road, Storrs, CT, 06269-3092, USA; Hartford Hospital Division of Cardiology, 80 Seymour Street, Hartford, CT, 06102-5037, USA. 7. Janssen Scientific Affairs, LLC, Raritan, NJ, USA. Electronic address: MRaut1@its.jnj.com. 8. Janssen Scientific Affairs, LLC, Raritan, NJ, USA. Electronic address: JSchein@its.jnj.com. 9. University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69N Eagleville Road, Storrs, CT, 06269-3092, USA; Hartford Hospital Division of Cardiology, 80 Seymour Street, Hartford, CT, 06102-5037, USA. Electronic address: Craig.Coleman@hhchealth.org.
Abstract
INTRODUCTION: Patients with venous thromboembolism (VTE) frequently require vitamin K antagonists (VKAs) to prevent recurrent events, but their use increases hemorrhage risk. We performed a meta-analysis to assess the quality of international normalized ratio (INR) control, identify study-level predictors of poor control and to examine the relationship between INR control and adverse outcomes in VTE patients. MATERIALS AND METHODS: We searched bibliographic databases (1990-June 2013) for studies of VTE patients receiving adjusted-dose VKAs that reported time in range (2.0-3.0) or proportion of INRs in range and/or reported INR measurements coinciding with thromboembolic or hemorrhagic events. Meta-analysis and meta-regression analysis was performed. RESULTS: Upon meta-analysis, studies found 59% (95%CI: 54-64%) of INRs measured and 61% (95%CI: 59-63%) of the time patients were treated were spent outside the target range of 2.0-3.0; with a tendency for under- versus over-anticoagulation. Moreover, this poor INR control resulted in a greater chance of recurrent VTE (beta-coefficient=-0.46, p=0.01) and major bleeding (beta-coefficient=-0.30, p=0.02). Patients with an INR<2.0 made up 58% (95%CI: 39-77%) of VTE cases, while those with an INR>3.0 made up 48% (95%CI: 34-61%) of major hemorrhage cases. Upon meta-regression, being VKA-naïve (-14%, p=0.04) and treated in the community (-7%, p<0.001) were associated with less time in range, while being treated in Europe/United Kingdom (compared to North America) was associated with (11%, p=0.003) greater time. CONCLUSIONS: Strategies to improve INR control or alternative anticoagulants, including the newer oral agents, should be widely implemented in VTE patients to reduce the rate of recurrent events and bleeding.
INTRODUCTION:Patients with venous thromboembolism (VTE) frequently require vitamin K antagonists (VKAs) to prevent recurrent events, but their use increases hemorrhage risk. We performed a meta-analysis to assess the quality of international normalized ratio (INR) control, identify study-level predictors of poor control and to examine the relationship between INR control and adverse outcomes in VTEpatients. MATERIALS AND METHODS: We searched bibliographic databases (1990-June 2013) for studies of VTEpatients receiving adjusted-dose VKAs that reported time in range (2.0-3.0) or proportion of INRs in range and/or reported INR measurements coinciding with thromboembolic or hemorrhagic events. Meta-analysis and meta-regression analysis was performed. RESULTS: Upon meta-analysis, studies found 59% (95%CI: 54-64%) of INRs measured and 61% (95%CI: 59-63%) of the time patients were treated were spent outside the target range of 2.0-3.0; with a tendency for under- versus over-anticoagulation. Moreover, this poor INR control resulted in a greater chance of recurrent VTE (beta-coefficient=-0.46, p=0.01) and major bleeding (beta-coefficient=-0.30, p=0.02). Patients with an INR<2.0 made up 58% (95%CI: 39-77%) of VTE cases, while those with an INR>3.0 made up 48% (95%CI: 34-61%) of major hemorrhage cases. Upon meta-regression, being VKA-naïve (-14%, p=0.04) and treated in the community (-7%, p<0.001) were associated with less time in range, while being treated in Europe/United Kingdom (compared to North America) was associated with (11%, p=0.003) greater time. CONCLUSIONS: Strategies to improve INR control or alternative anticoagulants, including the newer oral agents, should be widely implemented in VTEpatients to reduce the rate of recurrent events and bleeding.
Authors: Maria Rikala; Helena Kastarinen; Pekka Tiittanen; Risto Huupponen; Maarit Jaana Korhonen Journal: Clin Epidemiol Date: 2016-02-05 Impact factor: 4.790
Authors: Victoria Speed; Vivian Auyeung; Jignesh P Patel; Derek Cooper; Stephen Miller; Lara N Roberts; Raj K Patel; Roopen Arya Journal: Res Pract Thromb Haemost Date: 2021-11-21
Authors: Pascale Notten; Jorinde H H van Laanen; Pieter Eijgenraam; Mark A F de Wolf; Ralph L M Kurstjens; Hugo Ten Cate; Arina J Ten Cate-Hoek Journal: Res Pract Thromb Haemost Date: 2020-04-08