Comparison of warfarin dosage fluctuation with time in therapeutic range for bleeding or thromboembolism rate in Chinese patients.

BACKGROUND/PURPOSE: Warfarin treatment benefits vary with the clinical skill of warfarin dosage adjustment. However, optimal dosage adjustment in response to the out-of-range international normalized ratio (INR) is not completely understood. METHODS: Data for 2014-2016 from an integrated health care information system of a single hospital were analyzed. Based on their warfarin dosage fluctuation (WDF), defined as the standard deviation of all prescribed warfarin dosages divided by the mean dosage, the patients were classified into Groups 1 (0-0.10), 2 (0.10-0.20), and 3 (>0.20). Target and in-range INRs were 2.0-2.5 and 1.5-3.0, respectively. Based on time in therapeutic range (TTR), patients were also categorized into Groups 1 (<0.6), 2 (0.6-0.9), and 3 (>0.9). The primary outcome was emergency department visits for bleeding or thromboembolism (TE) events. RESULTS: Eighty-three events were retrieved from 17,397 records (1834 patients). Annual incidence rates were 0.9%, 2.5%, and 4.5% for WDF Groups 1, 2, and 3, respectively (p < 0.05), and 2.3%, 1.7%, and 1.7% for TTR Groups 1, 2, and 3, respectively (p = 0.41). Area under the receiver operator characteristic curves for WDF and TTR were 0.686 and 0.519, respectively, indicating that WDF exhibited superior predictive performance than TTR. CONCLUSION: High WDF rather than low TTR was associated with increased bleeding and TE incidence rates.

Do Patients With High CHA2DS2-VASc Scores Need High Intensity of Anticoagulants After Valve Surgery?

BACKGROUND: Asian patients on warfarin therapy usually have lower international normalized ratio (INR) intensities than those recommended by Western clinical practice guidelines. This study evaluated whether a high INR reduces the incidence of thromboembolism (TE) or bleeding events in Asian patients with high CHA2DS2-VASc scores after valve surgery.Methods and Results:Data of adult patients after valve surgery were retrieved from an integrated healthcare information system of a single hospital between 2014 and 2016. The INR was derived from the closest laboratory data before the index outpatient-clinic visit date. The endpoint of every record was determined as emergency room visit or hospitalization because of TE or bleeding event. A total of 37 TE or bleeding events were retrieved from 8,207 records; the annual incidence rate were 1.2% and 2.8% for low (0-2) and high (3-8) CHA2DS2-VASc score groups, respectively (P=0.007). The incidence rates were lowest for both groups at an INR of 1.5-2.0. High INR intensities did not reduce TE or bleeding incidence. INR >3.0 was associated with increased TE or bleeding incidence in the high-score group (6.8%/year vs. 2.0%/year, P=0.079). CONCLUSIONS: The optimal INR is 1.5-2.5 for low- or high-score Asian patients after valve surgery. INR >3.0 was associated with increased TE or bleeding incidence in the high-score group.

Experience and result of extracorporeal membrane oxygenation in treating fulminant myocarditis with shock: what mechanical support should be considered first?

BACKGROUND: Extracorporeal membrane oxygenation (ECMO), instead of ventricular assist device (VAD), could work as the first-line treatment of choice for fulminant myocarditis (FM) with profound shock if intraaortic balloon pumping was inadequate. We reviewed our experience in treating FM with ECMO and compared it with the literature that described the use of VAD. METHODS: Fifteen consecutive patients (age 27.1 +/- 19.3 years) who had FM with profound shock were rescued with ECMO emergently. Hypotension, depressed left ventricular ejection fraction (19.1% +/- 6.1%), and oliguria occurred in all patients with high-dose catecholamine (inotropic equivalents: 69.0 +/- 37.7 microg/kg/min) and ventilator support. Before ECMO support, 6 patients received intraaortic balloon pumping support, 5 received external cardiac massage, 5 needed a temporary pacemaker, and 4 needed continuous hemofiltration. The pre-ECMO cardiac enzyme and liver enzyme levels were abnormally high. RESULTS: Fourteen patients (93.3%) could be weaned off mechanical support. Three of 14 successfully weaned patients died later as a result of complications. Survival to discharge was 73.3%, and none of survivors needed heart transplantation. The ECMO duration was 137.7 +/- 74.5 hours. The ECMO-related neurological complication (6.7%) and the reexploration rate for hemostasis (8.9%) were lower than the myocarditis group supported by VAD from the literature review. The 11 survivors exhibited no cardiac dysfunction during the follow-up period. CONCLUSIONS: Owning to advantages of fewer complications, easier application, and biventricular support, ECMO can be considered as the first-line treatment of mechanical support for FM with profound shock when intraaortic balloon pumping is inadequate or infeasible.