Anders Nissen Bonde1, Laila Staerk2, Christina J-Y Lee3, Naja Emborg Vinding4, Casper N Bang5, Christian Torp-Pedersen3, Gunnar Gislason6, Gregory Y H Lip7, Jonas Bjerring Olesen2. 1. Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark. Electronic address: Andersnissenbonde@gmail.com. 2. Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark. 3. Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Health Science and Technology, Aalborg University, Aalborg University Hospital, Aalborg, Denmark. 4. Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. 5. Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark; Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark. 6. Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark. 7. Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark.
Abstract
BACKGROUND: Atrial fibrillation (AF) patients on a vitamin K antagonist (VKA) with time in therapeutic range (TTR) ≥70% are not recommended to switch to a direct oral anticoagulant according to guidelines. OBJECTIVES: This study sought to assess future TTR and risk of stroke/thromboembolism and major bleeding among AF patients on VKA with TTR ≥70%. METHODS: The authors used Danish nationwide registries to identify AF patients on VKA from 1997 to 2011 with available international normalized ratio values. Patients were included 6 months after VKA initiation, divided according to TTR, and followed for 12 months after inclusion. Cox proportional hazard models estimated hazard ratios (HRs). TTR was examined both as a baseline variable and as a time-dependent covariate in the Cox models. RESULTS: Of the 4,772 included AF patients still on VKA 6 months after initiation, 1,691 (35.4%) had a TTR ≥70%, and 3,081 (65.6%) had a TTR <70%. Among patients with prior TTR ≥70% still on treatment 12 months after inclusion, only 513 (55.7%) still had a TTR ≥70%. Compared with prior TTR ≥70%, prior TTR <70% was not associated with a higher risk of stroke/thromboembolism (HR: 1.14; 95% confidence interval [CI]: 0.77 to 1.70) or major bleeding (HR: 1.12; 95% CI: 0.84 to 1.49). When the authors estimated TTR time-dependently during follow-up, TTR <70% was associated with an increased risk of stroke/thromboembolism (HR: 1.91; 95% CI: 1.30 to 2.82) and major bleeding (HR: 1.34; 95% CI: 1.02 to 1.76). CONCLUSIONS: Among AF patients on VKA, almost one-half of patients with prior TTR ≥70% had TTR <70% during the following year. Prior TTR ≥70% per se had limited long-term prognostic value.
BACKGROUND:Atrial fibrillation (AF) patients on a vitamin K antagonist (VKA) with time in therapeutic range (TTR) ≥70% are not recommended to switch to a direct oral anticoagulant according to guidelines. OBJECTIVES: This study sought to assess future TTR and risk of stroke/thromboembolism and major bleeding among AFpatients on VKA with TTR ≥70%. METHODS: The authors used Danish nationwide registries to identify AFpatients on VKA from 1997 to 2011 with available international normalized ratio values. Patients were included 6 months after VKA initiation, divided according to TTR, and followed for 12 months after inclusion. Cox proportional hazard models estimated hazard ratios (HRs). TTR was examined both as a baseline variable and as a time-dependent covariate in the Cox models. RESULTS: Of the 4,772 included AFpatients still on VKA 6 months after initiation, 1,691 (35.4%) had a TTR ≥70%, and 3,081 (65.6%) had a TTR <70%. Among patients with prior TTR ≥70% still on treatment 12 months after inclusion, only 513 (55.7%) still had a TTR ≥70%. Compared with prior TTR ≥70%, prior TTR <70% was not associated with a higher risk of stroke/thromboembolism (HR: 1.14; 95% confidence interval [CI]: 0.77 to 1.70) or major bleeding (HR: 1.12; 95% CI: 0.84 to 1.49). When the authors estimated TTR time-dependently during follow-up, TTR <70% was associated with an increased risk of stroke/thromboembolism (HR: 1.91; 95% CI: 1.30 to 2.82) and major bleeding (HR: 1.34; 95% CI: 1.02 to 1.76). CONCLUSIONS: Among AFpatients on VKA, almost one-half of patients with prior TTR ≥70% had TTR <70% during the following year. Prior TTR ≥70% per se had limited long-term prognostic value.
Authors: Christopher T Sciria; Thomas M Maddox; Lucas Marzec; Benjamin Rodwin; Salim S Virani; Amarnath Annapureddy; James V Freeman; Ali O'Hare; Yuyin Liu; Yang Song; Gheorghe Doros; Yue Zheng; Jane J Lee; Ramesh Daggubati; Lina Vadlamani; Christopher Cannon; Nihar R Desai Journal: Clin Cardiol Date: 2020-05-06 Impact factor: 3.287