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Thromb Haemost 2015; 114(01): 70-77
DOI: 10.1160/TH14-09-0754
Coagulation and Fibrinolysis
Schattauer GmbH

Predicting outcomes among patients with atrial fibrillation and heart failure receiving anticoagulation with warfarin

Eun-Jeong Kim
1   Department of Medicine, Section of General Internal Medicine, Massachusetts General Hospital, Bedford, Massachusetts, USA
,
Al Ozonoff
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
4   Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts, USA
,
Elaine M. Hylek
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
3   Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
,
Dan R. Berlowitz
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
3   Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
5   Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
,
Arlene S. Ash
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
3   Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
6   Department of Quantitative Health Sciences, Division of Biostatistics and Health Services Research, University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
,
Donald R. Miller
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
5   Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
,
Shibei Zhao
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
,
Joel I. Reisman
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
,
Guneet K. Jasuja
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
5   Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
,
Adam J. Rose
2   Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
3   Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Publikationsverlauf

Received: 11. September 2014

Accepted after major revision: 20. Februar 2015

Publikationsdatum:
22. November 2017 (online)

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Summary

Among patients receiving oral anticoagulation for atrial fibrillation (AF), heart failure (HF) is associated with poor anticoagulation control. However, it is not known which patients with heart failure are at greatest risk of adverse outcomes. We evaluated 62,156 Veterans Health Administration (VA) patients receiving warfarin for AF between 10/1/06–9/30/08 using merged VA-Medicare dataset. We predicted time in therapeutic range (TTR) and rates of adverse events by categorising patients into those with 0, 1, 2, or 3+ of five putative markers of HF severity such as aspartate aminotransferase (AST)> 80 U/l, alkaline phosphatase> 150 U/l, serum sodium< 130 mEq/l, any receipt of metolazone, and any inpatient admission for HF exacerbation. These risk categories predicted TTR: patients without HF (referent) had a mean TTR of 65.0 %, while HF patients with 0, 1, 2, 3 or more markers had mean TTRs of 62.2 %, 57.2 %, 53.5 %, and 50.7 %, respectively (p< 0.001). These categories also discriminated for major haemorrhage well; compared to patients without HF, HF patients with increasing severity had hazard ratios of 1.84, 3.06, 3.52 and 5.14 respectively (p< 0.001). However, although patients with HF had an elevated hazard for bleeding compared to those without HF, these categories did not effectively discriminate risk of ischaemic stroke across HF. In conclusion, we developed a HF severity model using easily available clinical characteristics that performed well to risk-stratify patients with HF who are receiving anticoagulation for AF with regard to major haemorrhage.

Keywords

Anticoagulants - atrial fibrillation - heart failure - patient outcome assessment

 

  • References

  • 1 Gage BF, Waterman AD, Shannon W. et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. J Am Med Assoc 2001; 285: 2864-2870.
    CrossrefPubMedSuche in Google Scholar
  • 2 Romanovsky A, Bagshaw S, Rosner MH. Hyponatremia and congestive heart failure: a marker of increased mortality and a target for therapy. Int J Nephrol 2011; 2011: 732746.
    PubMedSuche in Google Scholar
  • 3 Connolly SJ, Pogue J, Eikelboom J. et al. Benefit of oral anticoagulant over anti-platelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range. Circulation 2008; 118: 2029-2037.
    CrossrefPubMedSuche in Google Scholar
  • 4 De Caterina R, Husted S, Wallentin L. et al. Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis--Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2013; 110: 1087-1107.
    Thieme ConnectPubMedSuche in Google Scholar
  • 5 Gallego P, Roldan V, Marín F. et al. Cessation of oral anticoagulation in relation to mortality and the risk of thrombotic events in patients with atrial fibrillation. Thromb Haemost 2013; 110: 1189-1198.
    Thieme ConnectPubMedSuche in Google Scholar
  • 6 Rose AJ, Hylek EM, Ozonoff A. et al. Patient characteristics associated with oral anticoagulation control: results of the Veterans AffaiRs Study to Improve Anticoagulation (VARIA). J Thromb Haemost 2010; 08: 2182-2191.
    CrossrefPubMedSuche in Google Scholar
  • 7 Hylek EM, Regan S, Go AS. et al. Clinical predictors of prolonged delay in return of the international normalized ratio to within the therapeutic range after excessive anticoagulation with warfarin. Ann Intern Med 2001; 135: 393-400.
    CrossrefPubMedSuche in Google Scholar
  • 8 Rose A, Ozonoff A, Henault L. Warfarin for atrial fibrillation in community-based practise. J Thromb Haemost 2008; 06: 1647-1654.
    CrossrefPubMedSuche in Google Scholar
  • 9 White HD, Gruber M, Feyzi J. et al. Comparison of outcomes among patients randomized to warfarin therapy according to anticoagulant control: results from SPORTIF III and V. Arch Intern Med 2007; 167: 239-245.
    CrossrefPubMedSuche in Google Scholar
  • 10 Rosendaal F, Cannegieter S, van der Meer FJ, Briët E. A method to determine the optimal intensity of oral anticoagulant therapy. Thromb Res. 1993; 69: 236-239.
    PubMedSuche in Google Scholar
  • 11 Jasuja GK, Reisman JI, Miller DR. et al. Identifying Major Hemorrhage with Automated Data: Results of the Veterans Affairs Study to Improve Anticoagulation (VARIA). Thromb Res 2013; 131: 31-36.
    CrossrefPubMedSuche in Google Scholar
  • 12 Wan Y, Heneghan C, Perera R. et al. Anticoagulation control and prediction of adverse events in patients with atrial fibrillation: a systematic review. Circ Cardiovasc Qual Outcomes 2008; 01: 84-91.
    CrossrefPubMedSuche in Google Scholar
  • 13 Schulman S, Kearon C. Subcommittee on Control of Anticoagulation of the Scientific and Standardisation Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 2005; 03: 692-694.
    CrossrefPubMedSuche in Google Scholar
  • 14 Rothendler JA, Rose AJ, Reisman JI. et al. Choices in the use of ICD-9 codes to identify stroke risk factors can affect the apparent population-level risk factor prevalence and distribution of CHADS2 scores. Am J Cardiovasc Dis 2012; 02: 184-191.
    PubMedSuche in Google Scholar
  • 15 Kubo SH, Walter BA, John DHA. et al. Liver Function Abnormalities in Chronic Heart Failure: Influence of Systemic Hemodynamics. Arch Intern Med J Am Med Assoc 1987; 147: 1227.
    PubMedSuche in Google Scholar
  • 16 Van Deursen V, Damman K, Hillege H. et al. Abnormal Liver Function in Relation to Hemodynamic Profile in Heart Failure Patients. J Card Fail 2010; 16: 84-90.
    CrossrefPubMedSuche in Google Scholar
  • 17 Pitt B, Zannad F, Remme W. et al. The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe Heart Failure. N Eng J Med 1999; 341: 709-717.
    CrossrefPubMedSuche in Google Scholar
  • 18 Lee W, Packer M. Prognostic importance of serum sodium concentration and its modification by converting-enzyme. Circulation 1986; 73: 257-267.
    CrossrefPubMedSuche in Google Scholar
  • 19 Kiyingi A, Field MJ, Pawsey CC. et al. Metolazone in treatment of severe refractory congestive cardiac failure. Lancet 1990; 335: 29-31.
    CrossrefPubMedSuche in Google Scholar
  • 20 Rosenberg J, Gustafsson F, Galatius S. et al. Combination therapy with metola-zone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. Cardiovasc Drugs Ther 2005; 19: 301-306.
    CrossrefPubMedSuche in Google Scholar
  • 21 Pisters R, Lane DA, Nieuwlaat R. et al. A Novel User-Friendly Score (HAS-BLED) To Assess 1-Year Risk of Major Bleeding in Patients With Atrial Fibrillation. Chest American College of Chest Physicians; 2010; 138: 1093-1100.
    PubMedSuche in Google Scholar
  • 22 Visser LE, Bleumink GS, Trienekens PH. et al. The risk of overanticoagulation in patients with heart failure on coumarin anticoagulants. Br J Haematol 2004; 127: 85-89.
    CrossrefPubMedSuche in Google Scholar
  • 23 Gallego P, Roldan V, Marín F. et al. SAMe-TT2R2 Score, Time in Therapeutic Range, and Outcomes in Anticoagulated Patients with Atrial Fibrillation. Am J Med 2014; 127: 1083-1088.
    CrossrefPubMedSuche in Google Scholar
  • 24 Poli D, Antonucci E, Testa S. et al. A prospective validation of the SAME-TT2R 2 score: how to identify atrial fibrillation patients who will have good anticoagulation control on warfarin. Intern Emerg Med 2014; 09: 443-447.
    CrossrefPubMedSuche in Google Scholar
  • 25 Apostolakis S, Sullivan RM, Olshansky B. et al. Factors affecting quality of anticoagulation control among patients with atrial fibrillation on warfarin: the SAMe-TT [two. inferior]R[two.inferior] score. Chest 2013; 144: 1555-1563.
    CrossrefPubMedSuche in Google Scholar
  • 26 Jones M, McEwan P, Morgan CL. et al. Evaluation of the pattern of treatment, level of anticoagulation control, and outcome of treatment with warfarin in patients with non-valvar atrial fibrillation: a record linkage study in a large British population. Heart 2005; 91: 472-477.
    CrossrefPubMedSuche in Google Scholar
  • 27 Homma S, Thompson JLP, Pullicino PM. et al. Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm. N Engl J Med 2012; 366: 1859-1869.
    CrossrefPubMedSuche in Google Scholar
  • 28 Lee DS, Gona P, Vasan RS. et al. Relation of Disease Pathogenesis and Risk Factors to Heart Failure With Preserved or Reduced Ejection Fraction. Circulation 2009; 119: 3070-3077.
    CrossrefPubMedSuche in Google Scholar
  • 29 Boos CJ, Nam M, Camm AJ. Novel oral anticoagulants and stroke prevention in atrial fibrillation and chronic heart failure. Heart Fail Rev 2014; 19: 391-401.
    CrossrefPubMedSuche in Google Scholar
  • 30 Shantsila E, Lip GYH. Use of novel oral anticoagulants in patients with heart failure. Curr Treat Options Cardiovasc Med 2014; 16: 285.
    CrossrefPubMedSuche in Google Scholar
  • 31 Zannad F, McMurray JJV, Krum H. et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med 2011; 364: 11-21.
    CrossrefPubMedSuche in Google Scholar
  • 32 McMurray JJV, Packer M, Desai AS. et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med 2014; 371: 993-1004.
    CrossrefPubMedSuche in Google Scholar