Anticoagulation quality control in Primary Care with vitamin K antagonists

Aguirre Rodriguez, Juan Carlos; Jimenez de la Cruz, Manuel; Hidalgo Rodríguez, Abraham

doi:10.1016/j.medcle.2017.05.013

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Estudio GRANADA" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1036 "Ancho" => 2917 "Tamanyo" => 107781 ] ] "descripcion" => array:1 [ "en" => "Degree of anticoagulation control according to the different methods used (n=252). The overall Rosendaal was 64.30%. The percentage of patients with TRT≥50% represents 79.68%; with TRT≥55%, 67.86%, and with an TRT≥65%, 49.60%. The percentage of patients with a minimum of 60% of INR in therapeutic range is 41.27%; the percentage with an INR mean value in range is 89.68%, and the percentage of patients with the last INR value in range is 67.86%." ] ] ] "textoCompleto" => "Currently, more than 72% of patients receiving vitamin K antagonist's anticoagulation (OAC) are monitored in Primary Care (PC). The effectiveness and safety of anticoagulant therapy is determined by the time the patient remains within therapeutic range (below its effectiveness range is low or null, and in a higher range the risk of bleeding increases considerably).In order to know the degree of control in patients receiving oral anticoagulation (OAC) therapy and to determine the most appropriate method to define it, we selected a population of 307 people, of whom 252 met the selection criteria (exclusive control in PC, more than 3 determinations of INR and less than 90 days between 2 determinations).We obtained an advanced middle age: 73.4±11.8 years, 57.14% of women and a high frequency of chronic disease: HBP (61.9%), diabetes mellitus (25.4%) and dyslipidaemia (24.21%), with 10.32% of the cases having the previous 3 together. Although to a lesser extent, they also had kidney failure (14.68%), COPD (11.11%), heart failure (9.13%), dementia (4.76%), depression, hypothyroidism (4.36%) and ischemic heart disease (3.57%). The main reason for anticoagulation in the studied population was atrial fibrillation (66.27%), followed by valvular prosthesis (17.06%), deep vein thrombosis (9.52%) and pulmonary thromboembolism (3.97%).In order to evaluate the effectiveness of the treatment, we took as reference the INR value for each subject according to its indication, so that when we included patients with different diseases, our optimal INR range varied from 2 to 3.5. In order to assess the degree of control and to estimate the percentage of patients who were correctly anticoagulated, we used different methods described in the medical literature, obtaining the following results (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-INR time in therapeutic range according to the Rosendaal method (TRT); we obtained an overall TRT of 64.30%. If we consider a TRT>50% as optimal, good control is achieved in 79.68% of the cases, whereas if we consider a TRT>65%, the result would be 49.60%. This method is considered the most accurate, since other control formulas offer very different and little individualized results.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> However, because of its complexity, it is not normally used in routine PC clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0035">2–4</a></li><li class="elsevierStyleListItem" id="lsti0010">-Percentage of INR within range (≥60%): 41.27%. Based on our results, it is the value that comes closest to the TRT, so it could be used instead, having to take into account that it will underestimate the degree of control.<a class="elsevierStyleCrossRef" href="#bib0040">3</a></li><li class="elsevierStyleListItem" id="lsti0015">-Average value of INR in range during the previous year: 89.68%.</li><li class="elsevierStyleListItem" id="lsti0020">-Last value of INR in range<a class="elsevierStyleCrossRef" href="#bib0035">2</a>: 67.86%. The last two overestimate the degree of control.</li></ul><elsevierMultimedia ident="fig0005"></elsevierMultimedia>The present work shows control data in line with those of multicentre studies from different European countries, reinforcing the idea of the quality of OAC control in PC in Spain (questioned in the year 2013<a class="elsevierStyleCrossRef" href="#bib0050">5</a>).In order to improve these results, we ask ourselves what else could be done, because our attitude toward these patients completely follows standardized algorithms and it is possible that, despite a correct compliance, there is always an important number of patients in whom an optimal control is not achieved. According to our results, between 50.4 and 58.73% of the patients studied are not controlled based on TRT or according to the percentage of INR in range, respectively; in other words, one in 2 patients treated with OAC in our area has a suboptimal control of his/her INR, so they may be candidates to replace their treatment with the “new” direct oral anticoagulants. If this were so, both the benefit and the economic impact of such a change would have to be considered, and it would be advisable to have an analysis that identifies which groups of patients are priorities for these new treatments and which would allow to establish a rational strategy for its use in the National Health System in the approved indications.<a class="elsevierStyleCrossRef" href="#bib0030">1</a>In conclusion, half of our anticoagulated patients do not have an INR under control and, what is worse, we do not exactly know what we can do to improve it." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Aguirre Rodriguez JC, Jimenez de la Cruz M, Hidalgo Rodríguez A. GRado de control de la ANticoagulación con Antagonistas De la vitamina K en Atención primaria. Estudio GRANADA. Med Clin (Barc). 2017;148:571–572." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1036 "Ancho" => 2917 "Tamanyo" => 107781 ] ] "descripcion" => array:1 [ "en" => "Degree of anticoagulation control according to the different methods used (n=252). The overall Rosendaal was 64.30%. The percentage of patients with TRT≥50% represents 79.68%; with TRT≥55%, 67.86%, and with an TRT≥65%, 49.60%. The percentage of patients with a minimum of 60% of INR in therapeutic range is 41.27%; the percentage with an INR mean value in range is 89.68%, and the percentage of patients with the last INR value in range is 67.86%." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[consulted 29 Jan 2017]. Available in https://www.aemps.gob.es/medicamentosUsoHumano/informesPublicos/docs/criterios-anticoagulantes-orales.pdf" "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Criterios y recomendaciones generales para el uso de los anticoagulantes orales directos (ACOD) en la prevención del ictus y la embolia sistémica en pacientes con fibrilación auricular no valvular. 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Llisterri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.semerg.2015.08.004" "Revista" => array:6 [ "tituloSerie" => "Semergen" "fecha" => "2016" "volumen" => "42" "paginaInicial" => "363" "paginaFinal" => "369" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26602939" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fibrilación auricular en la práctica clínica: todavía faltan respuestas, pero ¿interpretamos bien las que tenemos?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Alonso-Roca" 1 => "E. Barrera-Linares" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2014" "volumen" => "142" "paginaInicial" => "43" "paginaFinal" => "44" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack288345" "titulo" => "Acknowledgements" "texto" => "Our sincere thanks to all the doctors and residents of the Casería de Montijo Health Center, in Granada, for their help in data collection, and to Celia Aguirre Muñoz and Carlos Aguirre Muñoz for their collaboration in the recording of the same." 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Vol. 148. Issue 12.

Pages 571-572 (June 2017)

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