Objective To evaluate the quality of anticoagulant therapy in patients with mechanical prosthetic valve replacement during early period through time in therapeutic range(TTR) and fraction of time in therapeutic range(FTTR), and to provide an objective evidence for further improving quality of anticoagulant therapy. Methods All the patients were followed and registered in hospital and at outpatient clinic from July 2012 through April 2014, with a maximum of 6 months after surgery. Targeted international normalized rate (INR) was 1.60 to 2.20, acceptable INR was 1.50 to 2.30. And warfarin weekly dosage adjustment was used as the strategy of anticoagulation management. Adjusting the warfarin dosage when INR was beyond acceptable INR. Events of bleeding, thrombogenesis and thromboembolism, TTR and FTTR of these patients during the follow-up were collected to evaluate quality of anticoagulant therapy in these patients. Results A total 477 patients and 2 755 reports of INR values were included for data analysis. The follow-up time was 78 918 days. Values of INR varied from 0.92 to 7.72(1.83±0.64). Required weekly doses of warfarin in target INR and acceptable INR were 5.00–35.00(18.15±3.99) mg/week and 5.00–39.38(18.29±4.08) mg/week. TTR of target INR and acceptable INR was 36.85%(27 079.5 d/78 918.0 d) and 49.84% (39 331.5 d/78 918.0 d), respectively. FTTR of target INR and acceptable INR was 37.31% (1 028 times/2 755 times), 50.01% (1 378 times/2 755 times), respectively. TTR of target INR and acceptable INR was 46.04%(3 902.5 d/8 475.5 d), 59.49%(5 042 d/8 475.5 d) when the patients’ follow-up was up to six months and FTTR of target INR and acceptable INR value of these patients was 46.81%(206 times/440 times), 60.45%(266 times/440 times). During the follow-up, there were 3 thromboembolism events, 1 transient physical abnormal activity, and 1 thrombogenesis in the left atrium, and there was no bleeding and death events. Conclusion The strategy of anticoagulation management used in our study is reasonable. In order to further improve the patients’ quality of anticoagulant therapy, it is necessary to start anticoagulation after operation as soon as possible, to strengthen the education of patients with anticoagulant knowledge and to increase INR test frequency properly.
Objective Influence factors of the stable warfarin dose in the early period after mechanical prosthetic valve replacement were analyzed to guide the anticoagulation therapy for these patients. Methods A total of 288 patients within 6 months after mechanical prosthetic valve replacement in West China Hospital were followed up and registered at outpatient department from July 2012 to April 2014, including basic information (name, sex, age, height, weight, etc.), general clinical data (cardiac function, heart rate, surgery pattern, etc.) and related data about anticoagulation therapy. The target international standardized ratio (INR) range was 1.60 to 2.20 and the acceptable INR was 1.50 to 2.30. The sex, age, height, body weight, body mass index (BMI), body surface area (BSA) and related clinical factors were analyzed to find the relationship with the dose of warfarin. Results Sex was found to have a significant effect on the stable warfarin dose (P<0.05). Women needed a lower stable warfarin dose than men during the early anticoagulation therapy. There was no significant difference in the stable warfarin dose of patients with different ages, rhythms, NYHA classification, surgery pattern and diseases before operation; but the stable warfarin dose was lower in the patients with radiofrequency ablation during valve replacement procedures than the patients with single valve replacement (P<0.05). There was an association between age, height, weight, BMI, BSA and the stable warfarin dose withR2 of 1.2%, 3.2%, 3.5%, 1.1%, 4.2%, respectively and they could explain 6.1% of variability in warfarin dose. Conclusion During early anticoagulation therapy in patients with mechanical prosthetic valve replacement, it is necessary to consider the effects of various preoperative factors, drug factors and demographic factors on warfarin dose. Even though there is an association between age, height, weight, BMI, BSA and the stable warfarin dose, which can only explain 6.1% of variability in warfarin dose, thus cannot guide the postoperative anticoagulation of these patients.
The patients with mechanical prosthetic valve replacement need anticoagulant therapy for all their life. The incidence of thromboembolism and anticoagulation-related bleeding events still account for major postoperative complications after mechanical heart valve replacement. Most of the complications happen in the first half year after operation. Therefore, early anticoagulation therapy is very important. Of course, so far most guidelines focus stating their opinions on long-term anticoagulant therapy. However, there is no consensus about anticoagulant therapy in the early period of postoperation. In this review, we summarize early anticoagulant therapy of the patients with mechanical heart valve replacement through consulting domestic and abroad relevant research in recent years and give an overview of the present situations of early anticoagulant therapy.
Objective To investigate whether the individualized anticoagulation therapy based on CYP2C9 and VKORC1 gene is superior to empirical anticoagulation therapy after artificial heart valve replacement surgery in Uygur patients. Methods From December 2012 to December 2015, 210 Uygur patients who underwent artificial heart valve replacement surgery at the First Affiliated Hospital of Xinjiang Medical University were randomly assigned to a genetic anticoagulation therapy group (group A, n=106, 41 females and 65 males, aged 44.7±10.02 years) or an empirical anticoagulation therapy group (group B, n=104, 47 females and 57 males, aged 45.62±10.01 years) according to the random number table. CYP2C9 and VKORC1 genotypes were tested in the group A and then wafarin of administration in anticoagulation therapy was recommended. Patients in the group B were treated with conventional anticoagulation. Patients in both groups were followed up for 1 month and coagulation function was regularly tested. Results The percentage of patients with INR values of 1.8-2.5 after 4 weeks warfarin anticoagulation treatment in the group A was higher than that in the group B (47.1% vs. 32.7%, P=0.038). The rate of INR≥3.0 in the warfarin anticoagulation therapy period in the group A was lower than that in the group B (21.6% vs. 26.5%, P=0.411). The time to reach the standard INR value and the time to get maintenance dose were shorter in the group A compared with the group B (8.80±3.07 d vs. 9.26±2.09 d, P=0.031; 14.25±4.55 d vs. 15.33±1.85 d, P=0.032). Bleeding occured in one patient in the group A and three patients in the group B (P=0.293). Embolic events occured in three patients in the group A and five patients in the group B (P=0.436). Conclusion Compared with the empirical anticoagulation, the genetic anticoagulation based on wafarin dosing model can spend less time and make more patients to reach the standard INR value. However there is no significant difference between the two groups in the ratio of INR≥3.0, bleeding and embolic events in the warfarin anticoagulation therapy.
The management of women with mechanical heart valves during pregnancy remains difficult and controversial. The selection of prosthetic heart valve, management during pregnancy and delivery period, guidelines and anticoagulation strategy used in patients with a mechanical heart valve in China are summarized in this review.
ObjectiveTo evaluate the quality of warfarin anticoagulant therapy in patients with stable stage after mechanical valve replacement surgery, to observe the effect of compound salvia miltiorrhiza tablet on the anticoagulant effect of warfarin in patients after mechanical valve replacement, and to understand the impact of genetic polymorphisms of VKORC1, CYP2C9 and CYP4F2 on warfarin resistance in patients with mechanical valve replacement in the stable period.MethodsFrom July 2011 to February 2014, 1 831 patients who had ≥ 6 months after mechanical valve replacement surgery were enrolled at the outpatient follow-up. The basic clinical data were recorded. Anticoagulant therapy uses a target international normalized ratio（INR, 1.60–2.20) and a weekly warfarin dose adjustment strategy. Forty-six patients who needed compound salvia miltiorrhiza tablet were screened and the INR values. Before and after taking tablets were recorded and compared. The patients were divided into three groups according to the percentile of warfarin dosage including a warfarin sensitive patients group, a control patients group, and a warfarin resistance patients group. And 101 of them were selected. TIANGEN blood DNA Kit blood genomic DNA extraction kit was used to extract samples and polymerase chain restriction fragment length polymorphism (PCR-RELP) was used to determine the genotypes of patients. The detected gene loci included CYP4F2: rs2108622C>T locus; VKORC1:1639G>A locus; VKORC1:1173C>T locus; CYP2C9*2: rs1799853C>T locus; CYP2C9*3:1061A>C locus.ResultsThe time in therapeutic range (TTR) and fraction of time in therapeutic range (FTTR) in the target INR range of the patients included in the study period was 27.2% and 49.4%, respectively, and the TTR and FTTR in the acceptable INR range was 34.25% and 63.36%, respectively. Before and after the addition of compound salvia miltiorrhiza tablets, the INR value was 1.55±0.03 and 1.69±0.30, respectively, and the difference was statistically different (P<0.05). A total of 101 patients with genetic testing, in which the C/T composition of the VKORC1: 1173C>T locus increased in the warfarin sensitivity, contrast and warfarin resistance patients, while the ratio of allelic loci of C/T in CYP2C9*3: 1061A>C loci decreased in turn. There was no difference in the CYP4F2 gene, VKORC1639 gene, and CYP2C9*2 locus. The IWPC model predicts that warfarin dose is only consistent with the actual warfarin dose in warfarin sensitive patients.ConclusionRelatively low TTR and FTTR are acceptable in patients with stable stage after mechanical valve replacement. It is beneficial to the patients with compound salvia miltiorrhiza tablets in terms of some appropriate patients. VKORC1: 1173C>T site and CYP2C9*3: 1061A>C site mutation is the main pharmacological gene factor of warfarin dose sensitivity and warfarin resistance in stable period after mechanical valve replacement. The IWPC dose prediction model is only consistent with the actual dose of warfarin sensitive patients.
ObjectiveTo systematically evaluate the effects of telemedicine on the management of warfarin therapy.MethodsWe searched PubMed, EMbase, Cochrane Library, Web of Science, CNKI, VIP, Wanfang Database (from inception to February 2020) and conducted retrospective literature searching to identify studies about the management of warfarin using telemedicine intervention techniques. R language software was used to evaluate the efficacy and safety of telemedicine on warfarin management.ResultsA total of 7 239 articles were retrieved, and 12 articles were finally included according to inclusion and exclusion criteria, totaling 8 112 patients, including 3 726 patients in the intervention group and 4 386 patients in the control group. The results of meta-analysis showed that there was a statistical difference in the accurate international normalized ratio (INR) treatment target range time ratio between the intervention group and the control group (MD=6.52, 95%CI 2.13 to 10.92, P<0.01, I2=89%). The incidence of bleeding events (RR=0.61, 95%CI 0.46 to 0.81, P=0.97, I2=0%) and the incidence of thromboembolic events (RR=0.50, 95%CI 0.29 to 0.85, P=0.63, I2=0%) were not statistically different between the two groups. ConclusionExisting evidence indicates that telemedicine management has a benefit in anticoagulant efficacy compared with conventional anticoagulant management in patients with thrombotic diseases, but there is no statistical difference in safety. Limited by the quantity and quality of the included studies, the above conclusion needs to be verified by more high-quality studies.
Objective To investigate the vaccination rate of Coronavirus Disease 2019 (COVID-19) vaccine in patients undergoing cardiac mechanical valve replacement and to evaluate its effect on international normalized ratio (INR) value. MethodsWe investigated 132 patients who had received cardiac mechanical valve replacement and followed up in the Department of Cardiovascular Surgery, West China Hospital of Sichuan University from May to October 2021. There were 51 males and 81 females aged 26-72 (53.01±9.51) years. ResultsThe vaccination coverage rate was 53.8%. Among the 61 unvaccinated patients, concerns about heart side-effects were the main reason. The average INR of the first review after vaccination was higher than that of the last review before vaccination, with a difference of 0.40±0.72 (P<0.001). ConclusionThe vaccination rate of patients after cardiac mechanical valve replacement is low. At the same time, COVID-19 vaccine may increase INR value, and it is suggested that patients should increase the frequency of review and adjust warfarin dosage after vaccination.
ObjectiveTo investigate the factors influencing international normalized ratio (INR)>3.0 in patients undergoing warfarin anticoagulation therapy after mechanical heart valve replacement. MethodsA retrospective analysis was performed on the clinical data of patients who underwent mechanical heart valve replacement surgery and received warfarin anticoagulation therapy at West China Hospital of Sichuan University from January 1, 2011 to June 30, 2022. The factors associated with INR>3.0 at the time of discharge were analyzed. ResultsA total of 8901 patients were enrolled, including 3409 males and 5492 females, with a median age of 49.3 (43.5, 55.6) years. Multivariate logistic regression analysis revealed that lower body mass index (BMI), preoperative prothrombin time (PT)>15 s, and mitral valve replacement were independent risk factors for INR>3.0 at discharge (P<0.05). ConclusionBMI, preoperative PT, and surgical site are factors influencing INR>3.0 at discharge in patients undergoing warfarin anticoagulation therapy after mechanical heart valve replacement. Special attention should be given to patients with lower BMI, longer preoperative PT, and mitral valve replacement to avoid excessive anticoagulation therapy.