Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (From the TREAT-AF Study)
Abstract Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively), but can cause hemorrhage. The time in International Normalized Ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine...
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| Veröffentlicht in: | The American journal of cardiology 2017-01, Vol.119 (2), p.268-274 |
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| creator | Hellyer, Jessica A., MD Azarbal, Farnaz, MD Than, Claire T., MPH Fan, Jun, MS Schmitt, Susan K., PhD Yang, Felix, MD Frayne, Susan M., MD MPH Phibbs, Ciaran S., PhD Yong, Celina, MD MBA Heidenreich, Paul A., MD MS Turakhia, Mintu P., MD MAS |
| description | Abstract Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively), but can cause hemorrhage. The time in International Normalized Ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relationship between baseline stroke, bleeding risk and TTR. Using data from TREAT-AF retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003-2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2 DS2 -VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR as well as International Normalized Ratio (INR) monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2 DS2 -VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% was significantly associated with high CHA2 DS2 -VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin’s efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort. |
| doi_str_mv | 10.1016/j.amjcard.2016.09.045 |
| format | Article |
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The time in International Normalized Ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relationship between baseline stroke, bleeding risk and TTR. Using data from TREAT-AF retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003-2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2 DS2 -VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR as well as International Normalized Ratio (INR) monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2 DS2 -VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% was significantly associated with high CHA2 DS2 -VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin’s efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.</description><identifier>ISSN: 0002-9149</identifier><identifier>EISSN: 1879-1913</identifier><identifier>DOI: 10.1016/j.amjcard.2016.09.045</identifier><identifier>PMID: 27836133</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Ablation ; Age ; Aged ; Aged, 80 and over ; Algorithms ; Anticoagulants ; Anticoagulants - therapeutic use ; Atrial Fibrillation - complications ; Atrial Fibrillation - drug therapy ; Bleeding ; Cardiac arrhythmia ; Cardiovascular ; Circular dichroism ; Circulation ; Classification ; Comorbidity ; Computer programs ; Congestive heart failure ; Continuity (mathematics) ; Coronary artery disease ; Creatinine ; Criteria ; Cybersecurity ; Datasets ; Death ; Decision support systems ; Diabetes mellitus ; Diagnosis ; Disease prevention ; Dosage ; Effectiveness ; Female ; Fibrillation ; Flutter ; Glomerular filtration rate ; Health risk assessment ; Health risks ; Heart ; Hemorrhage ; Hemorrhage - etiology ; Humans ; Hypertension ; Hyperthyroidism ; International Normalized Ratio ; Interpolation ; Ischemia ; Male ; Middle Aged ; Patients ; Reduction ; Renal function ; Retrospective Studies ; Risk ; Risk Factors ; Safety ; Stroke ; Stroke - etiology ; Stroke - prevention & control ; Surgery ; Therapy ; Transient ischemic attack ; Warfarin ; Warfarin - therapeutic use</subject><ispartof>The American journal of cardiology, 2017-01, Vol.119 (2), p.268-274</ispartof><rights>2016</rights><rights>Published by Elsevier Inc.</rights><rights>Copyright Elsevier Sequoia S.A. Jan 15, 2017</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c514t-6759b70819f85264da08eba9de43fd313de0a86bcb74ef5d6564cbb9d384d7fb3</citedby><cites>FETCH-LOGICAL-c514t-6759b70819f85264da08eba9de43fd313de0a86bcb74ef5d6564cbb9d384d7fb3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.proquest.com/docview/1898070732?pq-origsite=primo$$EHTML$$P50$$Gproquest$$H</linktohtml><link.rule.ids>314,778,782,3539,27907,27908,45978,64366,64368,64370,72220</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/27836133$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Hellyer, Jessica A., MD</creatorcontrib><creatorcontrib>Azarbal, Farnaz, MD</creatorcontrib><creatorcontrib>Than, Claire T., MPH</creatorcontrib><creatorcontrib>Fan, Jun, MS</creatorcontrib><creatorcontrib>Schmitt, Susan K., PhD</creatorcontrib><creatorcontrib>Yang, Felix, MD</creatorcontrib><creatorcontrib>Frayne, Susan M., MD MPH</creatorcontrib><creatorcontrib>Phibbs, Ciaran S., PhD</creatorcontrib><creatorcontrib>Yong, Celina, MD MBA</creatorcontrib><creatorcontrib>Heidenreich, Paul A., MD MS</creatorcontrib><creatorcontrib>Turakhia, Mintu P., MD MAS</creatorcontrib><title>Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (From the TREAT-AF Study)</title><title>The American journal of cardiology</title><addtitle>Am J Cardiol</addtitle><description>Abstract Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively), but can cause hemorrhage. The time in International Normalized Ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relationship between baseline stroke, bleeding risk and TTR. Using data from TREAT-AF retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003-2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2 DS2 -VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR as well as International Normalized Ratio (INR) monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2 DS2 -VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% was significantly associated with high CHA2 DS2 -VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin’s efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.</description><subject>Ablation</subject><subject>Age</subject><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Algorithms</subject><subject>Anticoagulants</subject><subject>Anticoagulants - therapeutic use</subject><subject>Atrial Fibrillation - complications</subject><subject>Atrial Fibrillation - drug therapy</subject><subject>Bleeding</subject><subject>Cardiac arrhythmia</subject><subject>Cardiovascular</subject><subject>Circular dichroism</subject><subject>Circulation</subject><subject>Classification</subject><subject>Comorbidity</subject><subject>Computer programs</subject><subject>Congestive heart failure</subject><subject>Continuity (mathematics)</subject><subject>Coronary artery disease</subject><subject>Creatinine</subject><subject>Criteria</subject><subject>Cybersecurity</subject><subject>Datasets</subject><subject>Death</subject><subject>Decision support systems</subject><subject>Diabetes mellitus</subject><subject>Diagnosis</subject><subject>Disease prevention</subject><subject>Dosage</subject><subject>Effectiveness</subject><subject>Female</subject><subject>Fibrillation</subject><subject>Flutter</subject><subject>Glomerular filtration rate</subject><subject>Health risk assessment</subject><subject>Health risks</subject><subject>Heart</subject><subject>Hemorrhage</subject><subject>Hemorrhage - etiology</subject><subject>Humans</subject><subject>Hypertension</subject><subject>Hyperthyroidism</subject><subject>International Normalized Ratio</subject><subject>Interpolation</subject><subject>Ischemia</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Patients</subject><subject>Reduction</subject><subject>Renal function</subject><subject>Retrospective Studies</subject><subject>Risk</subject><subject>Risk Factors</subject><subject>Safety</subject><subject>Stroke</subject><subject>Stroke - etiology</subject><subject>Stroke - prevention & control</subject><subject>Surgery</subject><subject>Therapy</subject><subject>Transient ischemic attack</subject><subject>Warfarin</subject><subject>Warfarin - therapeutic use</subject><issn>0002-9149</issn><issn>1879-1913</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2017</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>8G5</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><sourceid>GUQSH</sourceid><sourceid>M2O</sourceid><recordid>eNqFks-O0zAQxiMEYsvCI4AscVkOCXacf76AutUWKq1A6hZxtBx7Ak4du9gJUnkOHhiHFpD2wsma0W--mfE3SfKc4IxgUr3uMzH0UniV5THMMMtwUT5IFqSpWUoYoQ-TBcY4Txkp2EXyJIQ-hoSU1ePkIq8bWhFKF8nPzXAQckSuQ9cigNEW0N3o3R7QVoc9ElahawOgtP1yyjiLPgvfCa8t2tgRvBWjdlYY9MH5QRj9AxTazjm0cjZKGRTJ5eh1RNa69dqY3xXoau3dgMavgHbbm-UuXa5j60kdXz1NHnXCBHh2fi-TT-ub3ep9evvx3Wa1vE1lSYoxreqStTVuCOuaMq8KJXADrWAKCtopSqgCLJqqlW1dQFeqqqwK2bZM0aZQddfSy-TqpHvw7tsEYeSDDhLifBbcFDhpKCMkL8sioi_vob2b4upmpliDa1zTPFLliZLeheCh4wevB-GPnGA-28Z7fraNz7ZxzHi0Lda9OKtP7QDqb9UfnyLw9gRA_I7vGjwPUoOV0RcPcuTK6f-2eHNPQUaztRRmD0cI_7bhIeeY3823M58OqSipSF3QX5otwEA</recordid><startdate>20170115</startdate><enddate>20170115</enddate><creator>Hellyer, Jessica A., MD</creator><creator>Azarbal, Farnaz, MD</creator><creator>Than, Claire T., MPH</creator><creator>Fan, Jun, MS</creator><creator>Schmitt, Susan K., PhD</creator><creator>Yang, Felix, MD</creator><creator>Frayne, Susan M., MD MPH</creator><creator>Phibbs, Ciaran S., PhD</creator><creator>Yong, Celina, MD MBA</creator><creator>Heidenreich, Paul A., MD MS</creator><creator>Turakhia, Mintu P., MD MAS</creator><general>Elsevier Inc</general><general>Elsevier Limited</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7RV</scope><scope>7TS</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FD</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M1P</scope><scope>M2O</scope><scope>M7Z</scope><scope>MBDVC</scope><scope>NAPCQ</scope><scope>P64</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>Q9U</scope><scope>7X8</scope></search><sort><creationdate>20170115</creationdate><title>Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (From the TREAT-AF Study)</title><author>Hellyer, Jessica A., MD ; Azarbal, Farnaz, MD ; Than, Claire T., MPH ; Fan, Jun, MS ; Schmitt, Susan K., PhD ; Yang, Felix, MD ; Frayne, Susan M., MD MPH ; Phibbs, Ciaran S., PhD ; Yong, Celina, MD MBA ; Heidenreich, Paul A., MD MS ; Turakhia, Mintu P., MD MAS</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c514t-6759b70819f85264da08eba9de43fd313de0a86bcb74ef5d6564cbb9d384d7fb3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2017</creationdate><topic>Ablation</topic><topic>Age</topic><topic>Aged</topic><topic>Aged, 80 and over</topic><topic>Algorithms</topic><topic>Anticoagulants</topic><topic>Anticoagulants - therapeutic use</topic><topic>Atrial Fibrillation - complications</topic><topic>Atrial Fibrillation - drug therapy</topic><topic>Bleeding</topic><topic>Cardiac arrhythmia</topic><topic>Cardiovascular</topic><topic>Circular dichroism</topic><topic>Circulation</topic><topic>Classification</topic><topic>Comorbidity</topic><topic>Computer programs</topic><topic>Congestive heart failure</topic><topic>Continuity (mathematics)</topic><topic>Coronary artery disease</topic><topic>Creatinine</topic><topic>Criteria</topic><topic>Cybersecurity</topic><topic>Datasets</topic><topic>Death</topic><topic>Decision support systems</topic><topic>Diabetes mellitus</topic><topic>Diagnosis</topic><topic>Disease prevention</topic><topic>Dosage</topic><topic>Effectiveness</topic><topic>Female</topic><topic>Fibrillation</topic><topic>Flutter</topic><topic>Glomerular filtration rate</topic><topic>Health risk assessment</topic><topic>Health risks</topic><topic>Heart</topic><topic>Hemorrhage</topic><topic>Hemorrhage - etiology</topic><topic>Humans</topic><topic>Hypertension</topic><topic>Hyperthyroidism</topic><topic>International Normalized Ratio</topic><topic>Interpolation</topic><topic>Ischemia</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Patients</topic><topic>Reduction</topic><topic>Renal function</topic><topic>Retrospective Studies</topic><topic>Risk</topic><topic>Risk Factors</topic><topic>Safety</topic><topic>Stroke</topic><topic>Stroke - etiology</topic><topic>Stroke - prevention & control</topic><topic>Surgery</topic><topic>Therapy</topic><topic>Transient ischemic attack</topic><topic>Warfarin</topic><topic>Warfarin - therapeutic use</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Hellyer, Jessica A., MD</creatorcontrib><creatorcontrib>Azarbal, Farnaz, MD</creatorcontrib><creatorcontrib>Than, Claire T., MPH</creatorcontrib><creatorcontrib>Fan, Jun, MS</creatorcontrib><creatorcontrib>Schmitt, Susan K., PhD</creatorcontrib><creatorcontrib>Yang, Felix, MD</creatorcontrib><creatorcontrib>Frayne, Susan M., MD MPH</creatorcontrib><creatorcontrib>Phibbs, Ciaran S., PhD</creatorcontrib><creatorcontrib>Yong, Celina, MD MBA</creatorcontrib><creatorcontrib>Heidenreich, Paul A., MD MS</creatorcontrib><creatorcontrib>Turakhia, Mintu P., MD MAS</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Nursing & Allied Health Database</collection><collection>Physical Education Index</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Technology Research Database</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Research Library</collection><collection>Biochemistry Abstracts 1</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central Basic</collection><collection>MEDLINE - Academic</collection><jtitle>The American journal of cardiology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Hellyer, Jessica A., MD</au><au>Azarbal, Farnaz, MD</au><au>Than, Claire T., MPH</au><au>Fan, Jun, MS</au><au>Schmitt, Susan K., PhD</au><au>Yang, Felix, MD</au><au>Frayne, Susan M., MD MPH</au><au>Phibbs, Ciaran S., PhD</au><au>Yong, Celina, MD MBA</au><au>Heidenreich, Paul A., MD MS</au><au>Turakhia, Mintu P., MD MAS</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (From the TREAT-AF Study)</atitle><jtitle>The American journal of cardiology</jtitle><addtitle>Am J Cardiol</addtitle><date>2017-01-15</date><risdate>2017</risdate><volume>119</volume><issue>2</issue><spage>268</spage><epage>274</epage><pages>268-274</pages><issn>0002-9149</issn><eissn>1879-1913</eissn><abstract>Abstract Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively), but can cause hemorrhage. The time in International Normalized Ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relationship between baseline stroke, bleeding risk and TTR. Using data from TREAT-AF retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003-2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2 DS2 -VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR as well as International Normalized Ratio (INR) monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2 DS2 -VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% was significantly associated with high CHA2 DS2 -VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin’s efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>27836133</pmid><doi>10.1016/j.amjcard.2016.09.045</doi><tpages>7</tpages></addata></record> |
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| subjects | Ablation Age Aged Aged, 80 and over Algorithms Anticoagulants Anticoagulants - therapeutic use Atrial Fibrillation - complications Atrial Fibrillation - drug therapy Bleeding Cardiac arrhythmia Cardiovascular Circular dichroism Circulation Classification Comorbidity Computer programs Congestive heart failure Continuity (mathematics) Coronary artery disease Creatinine Criteria Cybersecurity Datasets Death Decision support systems Diabetes mellitus Diagnosis Disease prevention Dosage Effectiveness Female Fibrillation Flutter Glomerular filtration rate Health risk assessment Health risks Heart Hemorrhage Hemorrhage - etiology Humans Hypertension Hyperthyroidism International Normalized Ratio Interpolation Ischemia Male Middle Aged Patients Reduction Renal function Retrospective Studies Risk Risk Factors Safety Stroke Stroke - etiology Stroke - prevention & control Surgery Therapy Transient ischemic attack Warfarin Warfarin - therapeutic use |
| title | Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (From the TREAT-AF Study) |
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