Scientific letter
Anticoagulation quality control in Primary Care with vitamin K antagonists
GRado de control de la ANticoagulación con Antagonistas De la vitamina K en Atención primaria. Estudio GRANADA
Juan Carlos Aguirre Rodriguez
, Manuel Jimenez de la Cruz, Abraham Hidalgo Rodríguez
Corresponding author
Centro de Salud Casería de Montijo, Servicio Andaluz de Salud, Granada, Spain
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Estudio GRANADA" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "571" "paginaFinal" => "572" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Anticoagulation quality control in Primary Care with vitamin K antagonists" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1036 "Ancho" => 2917 "Tamanyo" => 108865 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Grado de control de anticoagulación según los diferentes métodos empleados (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>252).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El Rosendaal global fue de un 64,30%. El porcentaje de pacientes con TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>50% supone el 79,68%; con TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>55%, el 67,86%, y con un TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>65%, el 49,60%. El porcentaje de pacientes con un mínimo del 60% de los INR en rango terapéutico es del 41,27%; el porcentaje con valor medio del INR en rango es del 89,68%, y el porcentaje de pacientes con el último valor del INR en rango es del 67,86%.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan Carlos Aguirre Rodriguez, Manuel Jimenez de la Cruz, Abraham Hidalgo Rodríguez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Juan Carlos" "apellidos" => "Aguirre Rodriguez" ] 1 => array:2 [ "nombre" => "Manuel" "apellidos" => "Jimenez de la Cruz" ] 2 => array:2 [ "nombre" => "Abraham" "apellidos" => "Hidalgo Rodríguez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020617303662" "doi" => "10.1016/j.medcle.2017.05.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303662?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317301483?idApp=UINPBA00004N" "url" => "/00257753/0000014800000012/v1_201706010052/S0025775317301483/v1_201706010052/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020617303674" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.05.014" "estado" => "S300" "fechaPublicacion" => "2017-06-21" "aid" => "3984" "copyright" => "Elsevier España, S.L.U." 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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" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Degree of anticoagulation control according to the different methods used (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>252). The overall Rosendaal was 64.30%. The percentage of patients with TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>50% represents 79.68%; with TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>55%, 67.86%, and with an TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>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%.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">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).</p><p id="par0010" class="elsevierStylePara elsevierViewall">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).</p><p id="par0015" class="elsevierStylePara elsevierViewall">We obtained an advanced middle age: 73.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>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%).</p><p id="par0020" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">INR time in therapeutic range according to the Rosendaal method (TRT); we obtained an overall TRT of 64.30%. If we consider a TRT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>50% as optimal, good control is achieved in 79.68% of the cases, whereas if we consider a TRT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>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"><span class="elsevierStyleSup">1</span></a> However, because of its complexity, it is not normally used in routine PC clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Average value of INR in range during the previous year: 89.68%.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Last value of INR in range<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>: 67.86%. The last two overestimate the degree of control.</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">5</span></a>).</p><p id="par0050" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">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.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">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.</p>" ] ] "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" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Degree of anticoagulation control according to the different methods used (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>252). The overall Rosendaal was 64.30%. The percentage of patients with TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>50% represents 79.68%; with TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>55%, 67.86%, and with an TRT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>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%.</p>" ] ] ] "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]. 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