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Anticoagulation with warfarin for paediatric cardiac indications: a retrospective study
Stephen T O'Brien1, Sophie Duignan1, Kathleen Crumlish1
1Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland.
Insights
Warfarin anticoagulation in children with cardiac conditions often has international normalised ratio (INR) values outside the target range. This requires frequent blood draws and dose adjustments, impacting quality of life.
Area of Science:
- Pediatric Cardiology
- Pharmacology
- Hematology
Background:
- Warfarin is crucial for pediatric anticoagulation in cardiac conditions.
- Managing warfarin in children is complex due to narrow therapeutic windows and developmental factors.
- Dietary variations, illnesses, and immature metabolic/hemostatic systems complicate pediatric warfarin therapy.
Purpose of the Study:
- To evaluate warfarin use in pediatric cardiac patients.
- To assess international normalised ratio (INR) control, %ITR, and phlebotomy frequency.
- To identify challenges in maintaining therapeutic INR ranges in this population.
Main Methods:
- Retrospective review of pediatric patient medical records.
- Analysis of indications for warfarin therapy.
- Assessment of %ITR, phlebotomy frequency, and home INR monitoring (CoaguChek).
Main Results:
- 19 of 26 patients (73%) used warfarin post-total cavo-pulmonary connection.
- Median %ITR was 55.4%, with significant variability.
- Median phlebotomy frequency was every 10 days.
Conclusions:
- Pediatric cardiac patients frequently exhibit INR values outside the target range.
- Frequent phlebotomy and dose adjustments negatively affect patient and family quality of life.
- There is a critical need for quality improvement in pediatric cardiac anticoagulation management.
Abstract:
Warfarin is used as anticoagulation for children for a wide range of cardiac indications but carries the disadvantage of requiring international normalised ratio monitoring and dose adjustment. Management of warfarin therapy is challenging due to its narrow therapeutic window and is further complicated in children by dietary changes, frequent illnesses, and developing systems of metabolism and haemostasis.A retrospective review was performed of patients' medical records to assess the indication for warfarin use, percentage of international normalised ratio values in target range (%ITR), and frequency of phlebotomy.Twenty-six patients were identified. The most common indication for warfarin use was in patients post-total cavo-pulmonary connection (n = 19, 73%). We demonstrated a variability in duration of warfarin therapy following total cavo-pulmonary connection (median of 11.1 months). Nineteen (73%) patients had used the CoaguChek machine for home measurement of international normalised ratio. The median frequency of phlebotomy for all indications was once every 10 days, and the median %ITR was 55.4 % (29.7-86.4%). Of note, the percentage under target range in the patients with mechanical mitral (n = 2) and aortic valves (n = 1) was found to be 23% and 33%, respectively.These data demonstrate a high frequency of international normalised ratio values outside of the target range as seen in previous studies of warfarin in children. This necessitates frequent phlebotomy and dose changes, which can have a significant effect on the quality of life of these patients and their families highlighting the need to focus on quality improvement in the area of anticoagulation in paediatric cardiac patients.
