Poor warfarin anticoagulation in long-term thromboprophylaxis: a survey in a southern Croatian county
Aleksandar Knežević, Marijana Nadinić, Irena Užović Frakin
1Vladimir Trkulja, Department of Pharmacology, Zagreb University School of Medicine, Šalata 11, 10000 Zagreb, Croatia, vtrkulja@mef.hr.
Insights
Real-world warfarin anticoagulation quality for thromboprophylaxis is suboptimal. Most patients on warfarin had international normalized ratio (INR) levels outside the therapeutic range, indicating a need for improved management.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- Warfarin is a crucial anticoagulant for chronic thromboprophylaxis.
- Effective anticoagulation management is essential to prevent thromboembolic events.
- Assessing real-world anticoagulation quality is vital for patient outcomes.
Purpose of the Study:
- To evaluate the quality of warfarin anticoagulation in patients needing long-term thromboprophylaxis.
- To identify the proportion of international normalized ratio (INR) values within and outside the target range.
- To determine the percentage of patients achieving adequate anticoagulation control.
Main Methods:
- Retrospective analysis of international normalized ratio (INR) values from Zadar County General Hospital (2016-2017).
- Inclusion of warfarin-treated patients requiring chronic thromboprophylaxis.
- Analysis of 31,162 INR values from 3,697 patients, representing a significant county-wide data capture.
Main Results:
- Only 50.1% of INR values were within the target range (2.0-3.5); 43.6% were below 2.0.
- A mere 23.0% of patients achieved ≥70% of their INR values within the target range.
- Inadequate anticoagulation was prevalent, with 66.5% of patients having ≥33.3% of INRs below 2.0.
Conclusions:
- The quality of warfarin anticoagulation in this real-world setting is significantly below optimal levels for effective thromboprophylaxis.
- A substantial proportion of patients experience suboptimal anticoagulation, increasing the risk of thrombotic or bleeding complications.
- There is a clear need for enhanced strategies to improve warfarin management and patient outcomes in clinical practice.
Aim:
To assess the quality of real-life warfarin anticoagulation in patients requiring chronic thromboprophylaxis in a southern Croatian county.
Methods:
We retrospectively analyzed international normalized ratio (INR) values determined over one year (2016-2017) at the Zadar County General Hospital in warfarin-treated patients requiring chronic thromboprophylaxis. The values represent 83.0% of all INRs and were determined in 84.0% of all warfarin-treated patients in the county during the observed period.
Results:
Overall 31162 INRs were taken from 3697 patients, 2240 of whom (20 851 INRs, 3-56 per patient, median 9) were referred with diagnoses requiring chronic thromboprophylaxis: mainly atrial fibrillation/flutter (n=1508, 14902 INRs) but also cardiac implants, valvular disease, severe heart failure, and cerebrovascular disease ("other", n=732, 5949 INRs). Only 50.1% of all INRs were within the target range, 2.0-3.5, while 43.6% were <2.0, and 6.3% were >3.5. Median crude individual proportion of INRs within the range was 50.0%, while it was 42.0% for INRs <2.0. Only 23.0% of the patients had ≥70% of the INRs within the target range (adequately anticoagulated), while 35.5% had ≤33.3% of the INRs within the range. Conversely, 66.5% of the patients had ≥33.3% INRs <2.0. Adjusted probability of adequate anticoagulation in atrial fibrillation/flutter patients was consistently 25.5% to 27.7%, regardless of the number of determined INRs, while in patients with other conditions it increased from 9.5% to 25.2% with a higher number of INRs.
Conclusion:
The achieved level of warfarin anticoagulation in this real-life setting is far below what is needed for effective long-term thromboprophylaxis.
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