Background: The intensive proliferation of guidelines and stratification scores for thromboembolic and hemorrhagic risk, such as CHA2DS2-VASC and HAS-BLED, focuses its interest on the proper management of oral anticoagulant therapy (OAT). In clinical practice, narrow therapeutic index of warfarin can be achieved through three cornerstones: (1) reliable laboratory (2) good medical expertise in OAT (3) Patients Compliance. In our Internal Medicine Department (IMD) atrial fibrillation (AF) is among the top 5 DRG by frequency. Driven by this reality, we prepared specific evidence-based protocols and pathways for AF management. Optimal OAT for 4 weeks is required before attempting sinus rhythm restoration, in order to reduce cardioembolic risk related to cardioversion (CV). Current guidelines confirm inverse relationship between time taken to proceed with CV and success of SR restoration. Many procedures still delay because at time of CV, patients (pts) were not in range. We can improve outcomes aiming at stable INR in the 5 weeks before the CV. A strict follow-up of these pts may reduce variations which lead to significant delays in CV. Our department routinely follows pts requiring OAT in preparation for CV. Aims: evaluate the effect of Patient Care Management by our IMD, from diagnosis to CV, especially on the stability of INR values in the 5 weeks preliminary to Electric Countershock (ECV), as indicator of a better outcome, in pts followed by our unit for AF. Methods: We followed 121 pts affected by persistent AF, who underwent ECV. 52 were excluded for AF recurrence, the other 60 were referred to our surveillance center for OAT before ECV. All pts were treated with the same pharmacologic protocol, including 4 weeks of therapy with oral anticoagulants, class III antiarrhythmic, angiotensin receptor blocker (irbesartan) and statin. After 4 weeks, pts underwent to ECV with standard protocol (first shock: 150 J, second shock: 200 J, third shock: 200 J). INR variations in this population of pts were evaluated. Multivariate GLM for repeated measures and Cronbach’s reliability analysis were performed with SPSS 13.0 for Windows systems. Results: The mean value of PT/INR in the 5 reading performed before ECV remained between 2.5 and 3.0 with a 95 %CI between 2.4 and 3.0 in each of the 5 measurements. The multivariate evaluation of intra-subject variation was not significant in the 5 measurements (p[0.05). This observation remained statistically non-significant also in direct comparison of the mean of single measurements, demonstrating a substantial homogeneity of the mean values of PT/INR. The internal reliability of the data was assessed using Cronbach’s test (alpha: 0.72), which confirmed the high intrasurvey validity of the INR in pts followed in our center (Figure 1). Conclusions: OAT management resulted highly reliable in our center: PT/INR controls remained substantially stable in the controls prior to ECV. We observed no major thrombotic nor hemorrhagic adverse events nor major complications in the selected sample. Most of pts are in range the day of ECV after 4 weeks of anticoagulation.With an efficient laboratory and a reliable center, as an IMD, it is possible to keep the dose of warfarin within the therapeutic range, optimizing resources. Undertaking this office, our IMD increases success chances of the procedure. However, the dark horse of pts, who must be reliable. It seems reasonable to argue that attending a reference center, compliance to OAT could be increase.
Effectiveness of integration hospital/territory in management of oral anticoagulant therapy of patients undergoing to Electric Countershock: an internal medicine department experience
L. FalsettiWriting – Original Draft Preparation
;
2012
Abstract
Background: The intensive proliferation of guidelines and stratification scores for thromboembolic and hemorrhagic risk, such as CHA2DS2-VASC and HAS-BLED, focuses its interest on the proper management of oral anticoagulant therapy (OAT). In clinical practice, narrow therapeutic index of warfarin can be achieved through three cornerstones: (1) reliable laboratory (2) good medical expertise in OAT (3) Patients Compliance. In our Internal Medicine Department (IMD) atrial fibrillation (AF) is among the top 5 DRG by frequency. Driven by this reality, we prepared specific evidence-based protocols and pathways for AF management. Optimal OAT for 4 weeks is required before attempting sinus rhythm restoration, in order to reduce cardioembolic risk related to cardioversion (CV). Current guidelines confirm inverse relationship between time taken to proceed with CV and success of SR restoration. Many procedures still delay because at time of CV, patients (pts) were not in range. We can improve outcomes aiming at stable INR in the 5 weeks before the CV. A strict follow-up of these pts may reduce variations which lead to significant delays in CV. Our department routinely follows pts requiring OAT in preparation for CV. Aims: evaluate the effect of Patient Care Management by our IMD, from diagnosis to CV, especially on the stability of INR values in the 5 weeks preliminary to Electric Countershock (ECV), as indicator of a better outcome, in pts followed by our unit for AF. Methods: We followed 121 pts affected by persistent AF, who underwent ECV. 52 were excluded for AF recurrence, the other 60 were referred to our surveillance center for OAT before ECV. All pts were treated with the same pharmacologic protocol, including 4 weeks of therapy with oral anticoagulants, class III antiarrhythmic, angiotensin receptor blocker (irbesartan) and statin. After 4 weeks, pts underwent to ECV with standard protocol (first shock: 150 J, second shock: 200 J, third shock: 200 J). INR variations in this population of pts were evaluated. Multivariate GLM for repeated measures and Cronbach’s reliability analysis were performed with SPSS 13.0 for Windows systems. Results: The mean value of PT/INR in the 5 reading performed before ECV remained between 2.5 and 3.0 with a 95 %CI between 2.4 and 3.0 in each of the 5 measurements. The multivariate evaluation of intra-subject variation was not significant in the 5 measurements (p[0.05). This observation remained statistically non-significant also in direct comparison of the mean of single measurements, demonstrating a substantial homogeneity of the mean values of PT/INR. The internal reliability of the data was assessed using Cronbach’s test (alpha: 0.72), which confirmed the high intrasurvey validity of the INR in pts followed in our center (Figure 1). Conclusions: OAT management resulted highly reliable in our center: PT/INR controls remained substantially stable in the controls prior to ECV. We observed no major thrombotic nor hemorrhagic adverse events nor major complications in the selected sample. Most of pts are in range the day of ECV after 4 weeks of anticoagulation.With an efficient laboratory and a reliable center, as an IMD, it is possible to keep the dose of warfarin within the therapeutic range, optimizing resources. Undertaking this office, our IMD increases success chances of the procedure. However, the dark horse of pts, who must be reliable. It seems reasonable to argue that attending a reference center, compliance to OAT could be increase.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
