Supra-therapeutic Anticoagulation with Warfarin: A Cross-sectional Study.

AIMS: To identify the extent and associated factors for patients with prolonged prothrombin time, international normalized ratio (PT-INR), and the dosage modifications were carried out with warfarin. BACKGROUND: Studies evaluating patients on warfarin with supratherapeutic anticoagulation are limited. It is vital to understand the management strategies for patients receiving warfarin who are bleeding and those with only supratherapeutic PT-INR. OBJECTIVE: To evaluate the factors associated with supratherapeutic anticoagulation without bleeding with warfarin. METHODS: A cross-sectional study was carried out on patients receiving long-term warfarin with at least one PT-INR value > 3.2. Percent time in therapeutic range (TTR) was calculated and National Institute for Health and Care Excellence (NICE) guidelines were adhered to defining anticoagulation control into good (> 65%) and poor (< 65%). RESULTS: One hundred and forty-four patients were recruited. Nearly half of the study population had PT-INR values between 3.2 and 3.9. On average, individuals had at least 4 times PT-INR values in the supratherapeutic range. Elderly patients were observed with a significant trend of supratherapeutic INR. Duration of therapy was significantly correlated with the risk of PT-INR > 4. Lower TTR was observed in patients with frequent PT-INR > 4 and those patients had significantly poor anticoagulation control. Duration of warfarin therapy and HAS-BLED scores were observed to be significant predictors of supratherapeutic INR. Large variations were observed in the modifications of warfarin dose carried out at various supratherapeutic INR values and consequently PTINR values. CONCLUSION: We observed that the majority of patients with supratherapeutic INR had their INR values between 3.2 and 3.9. Elderly patients, with higher HAS-BLED scores and prolonged duration of warfarin therapy, were observed with an increased risk of supratherapeutic anticoagulation. Careful dosage modifications are needed particularly in high-risk categories as mentioned above.

Implementation of Guideline-Recommended Therapies for Patients With Heart Failure and Reduced Ejection Fraction: A Regional Arab Middle East Experience.

We describe the characteristics of ambulatory patients with heart failure with reduced ejection fraction (HFrEF) in the Gulf region (Middle East) and the implementation of guideline-recommended treatments. We included 2427 HFrEF outpatients (mean age 59 ± 13 years, 75% males and median left ventricular ejection fraction [LVEF] of 30%). A high proportion of patients received guideline-recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blocker [ARB]/angiotensin receptor-neprilysin inhibitor [ARNI] 87%, ß-blocker 91%, mineralocorticoid antagonist [MRA] 64%). However, only a minority of patients received guideline-recommended target doses (ACEI/ARB/ARNI 13%, ß-blocker 27%, and MRA 4.4%). Old age was a significant independent predictor for not prescribing treatment (P < .001 for ACEI/ARB/ARNI and MRA; and P = .002 for ß-blockers). Other independent predictors were chronic kidney disease (for both ACEI/ARB/ARNI and MRA, P < .001) and higher LVEF (P = .014 for ß-blockers and P < .001 for MRA). Patients with HFrEF managed by heart failure specialists more often received recommended target doses of ACEI/ARB/ARNI (40% vs 11%, P < .001) and ß-blockers (56% vs 26%, P < .001) compared to those treated by general cardiologists. Although the majority of our patients with HFrEF received guideline-recommended medications, the doses they were prescribed were suboptimal. Understanding the reasons behind this is important for improved practice.