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Luo A, Liu J, Zhang Y, Long Y, Chen X. Assessment of Knowledge and Training Needs for the Clinical Management of Warfarin Anticoagulation Among Physicians in China. Risk Manag Healthc Policy 2025; 18:537-546. [PMID: 39990617 PMCID: PMC11844193 DOI: 10.2147/rmhp.s489195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Accepted: 01/31/2025] [Indexed: 02/25/2025] Open
Abstract
Objective To assess the knowledge level of physicians on anticoagulation management and identify their training needs to ensure the safety and efficacy of warfarin therapy among patients. Methods This project adopted convenient sampling and collected survey questionnaires online to investigate physicians' management level in aspects such as basic anticoagulation knowledge, routine adjustment of warfarin dosage, and management of warfarin complications and special situations after mechanical valve replacement. Results Among the 232 participants in this survey, 158 were male (68.10%), and 74 were female (31.90%); Grade III hospitals accounted for 61.21%; cardiovascular medicine department accounted for 65.09%; primary, intermediate, and advanced title holders each accounted for about one-third. The respondents had a good foundation in warfarin anticoagulation knowledge, and most physicians could guide patients in anticoagulation treatment. However, there were still many respondents who answered incorrectly on some basic questions. Using the chi-square test, the analysis of the impact of gender, age, hospital level, department, education, and title on the knowledge level of warfarin anticoagulation found that gender had no statistical significance in all items; age, department, and title had statistically significant differences in the impact on the knowledge level of anticoagulation in the respondent (P < 0.05). Conclusion The respondents have good anticoagulation knowledge on basic items, but some healthcare professionals have insufficient understanding of some items, such as the approximate time required for INR to reach a stable value and the use of warfarin in pregnant women, posing significant risks in clinical work. Relevant healthcare professional training should be strengthened on extended knowledge on warfarin.
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Affiliation(s)
- Aijing Luo
- Second Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
- Clinical Research Center For Cardiovascular Intelligent Healthcare in Hunan Province, Changsha, Hunan, People’s Republic of China
- Key Laboratory of Medical Information Research (Central South University), College of Hunan Province, Changsha, Hunan, People’s Republic of China
- Xiangya School of Public Health, Central South University, Changsha, Hunan, People’s Republic of China
| | - Juan Liu
- Second Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
- Clinical Research Center For Cardiovascular Intelligent Healthcare in Hunan Province, Changsha, Hunan, People’s Republic of China
- Key Laboratory of Medical Information Research (Central South University), College of Hunan Province, Changsha, Hunan, People’s Republic of China
- Xiangya School of Public Health, Central South University, Changsha, Hunan, People’s Republic of China
| | - Yuzi Zhang
- School of Life Sciences, Central South University, Changsha, Hunan, People’s Republic of China
| | - Yijia Long
- Xiangya School of Medicine, Central South University, Changsha, Hunan, People’s Republic of China
| | - Xuliang Chen
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
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Liang Y, Yang G, Li H, Ding N, Zhang L, Chen J. Anticoagulation decision-making before non-cardiac surgery in patients with mechanical heart valve: A retrospective study. Heliyon 2023; 9:e16858. [PMID: 37484263 PMCID: PMC10360928 DOI: 10.1016/j.heliyon.2023.e16858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023] Open
Abstract
Objective To clarify the timing of warfarin discontinuation at different ranges of INR. Improve anticoagulation management in non-cardiac surgical patients with MHV. Design This is a single-center retrospective observational study. Setting and participants This study used data from the Hospital Information System, and the Surgery and Anesthesia Information System of the Second Affiliated Hospital of Army Military Medical University. Participants included 121 adult patients with MHV who underwent non-cardiac surgery from 2012 to 2021. Results Overall, 121 patients with MHV (15 aortic valve only, 56 mitral valve only, and 50 with multiple valves) underwent non-cardiac surgery. When the duration of warfarin discontinuation was ≤ 3 days, 3-5 days, and≥5 days, the INR was 1.45, 1.15, and 1.09, respectively. Bleeding between INR ≤1.2 and INR >1.2 groups was not statistically significant using Student's t-test (95% CI -0.57, 0.14 P = 0.24). Multivariate regression analysis revealed that Intraoperative bleeding volume correlated with preoperative albumin levels (OR = 0.68，95% CI 0.49, 0.89). Conclusions When need preoperative INR is less than 1.5 in patients with MHV undergoing non-cardiac surgery, preoperative warfarin discontinuation for 3 days is sufficient. If INR less than 1.2, preoperative warfarin discontinuation for 3-5 days is appropriate. And in patients with MHV underwent abdominal surgery, intraoperative bleeding is not significant reduced by lower INR after preoperative warfarin discontinuation. Furthermore, the effect of albumin levels on coagulation function cannot be ignored in patients with MHV. Strengths and limitations This study was derived from real-world clinical data. It's a retrospectively study to describe the INR changed according to the duration of warfarin discontinuation in patients with MHV and compared intraoperation of bleeding volume between INR>1.2 and INR ≤ 1.2after warfarin discontinuation. To clarify the timing of warfarin discontinuation at different ranges of INR. Improve anticoagulation management in non-cardiac surgical patients with MHV, while providing clinicians with a reference for preoperative warfarin adjustment. This study does have a few limitations. The number of cases is small because patients undergoing repeat noncardiac surgery after heart valve surgery are a special case population. And the patients were not followed up after non-cardiac surgery. The impact of changes in INR on postoperative complications could not be assessed in patients with MHV.
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Affiliation(s)
- Yan Liang
- Department of Public Health, Chengdu Medical College, 783 Xindu Avenue, Xindu District, Chengdu, 610599, Sichuan Province, China
- Department of Anesthesiology, The Second Affiliated Hospital of the Army Medical University, 83 Xinqiao Street, Shapingba District, Chongqing, 400037, China
| | - Guiying Yang
- Department of Anesthesiology, The Second Affiliated Hospital of the Army Medical University, 83 Xinqiao Street, Shapingba District, Chongqing, 400037, China
| | - Hong Li
- Department of Anesthesiology, The Second Affiliated Hospital of the Army Medical University, 83 Xinqiao Street, Shapingba District, Chongqing, 400037, China
| | - Ning Ding
- Department of Anesthesiology, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250031, China
| | - Lin Zhang
- Department of Clinical Pharmacy, Shaoxing People's Hospital, Shaoxing Hospital, Zhejiang University School of Medicine, 568 Zhongxing North Road, Shaoxing, 312000, Zhejiang Province, China
| | - Jian Chen
- Department of Public Health, Chengdu Medical College, 783 Xindu Avenue, Xindu District, Chengdu, 610599, Sichuan Province, China
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Safety and efficacy of using portable coagulation monitor for INR examination after left-sided mechanical prosthetic valve replacement. J Cardiothorac Surg 2022; 17:297. [PMID: 36471365 PMCID: PMC9724327 DOI: 10.1186/s13019-022-02046-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Time in therapeutic range (TTR) is an index to assess the effectiveness of anticoagulation and is important to predict the risk of bleeding and thrombosis in patients taking warfarin. In recent years, the portable coagulation monitor, a point-of-care testing device for patients to perform self-management international normalized ratio (INR) examination, has provided an opportunity to improve the quality of oral warfarin treatment. In this study, we applied TTR to evaluate the safety and efficacy of the portable coagulation monitor for patients with oral anticoagulant warfarin after left-sided mechanical prosthetic valve (MPV) replacement. METHODS It is a single-centre cohort study. From September 2019 to June 2021, a total of 243 patients who returned to our institution for outpatient clinic revisit at 3 months after left-sided MPV replacement, met the inclusion criteria and agreed to be followed up were included. Self-management group used portable coagulation monitor for INR examination, and patients in the conventional group had their INR monitored in routine outpatient visits. Clinical data of the patients would be recorded for the next 12 months, and results were compared between the two groups to assess the effect of the coagulation monitor on TTR and complications related to bleeding and thrombosis in patients with left-sided MPV replacement. RESULTS A total of 212 individuals provided complete and validated INR data spanning of 1 year. Those who applied the portable coagulation monitor had higher TTR values and larger number of tests for INR. No significant differences were seen between the two groups in postoperative bleeding and thromboembolic complications, but portable coagulation monitor showed a trend toward fewer bleeding events. CONCLUSION Portable devices for coagulation monitoring are safe and can achieve a higher TTR. Patients who use the portable coagulation monitor for home INR self-management can achieve a safe and effective warfarin therapy.
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Huang Y, Huang L, Han Z. Combining portable coagulometers with the Internet: A new model of warfarin anticoagulation in patients following mechanical heart valve replacement. Front Surg 2022; 9:1016278. [PMID: 36311931 PMCID: PMC9608170 DOI: 10.3389/fsurg.2022.1016278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
Heart valve replacement, as a safe and effective treatment for severe valvular heart disease, can significantly improve hemodynamics in patients. However, such patients then require lifelong anticoagulant therapy. Warfarin, a cheap and highly effective vitamin K antagonist, remains the major anticoagulant recommended for lifelong use following mechanical heart valve replacement. However, the effect of warfarin anticoagulant therapy is complicated by physiological differences among patients and non-compliance with treatment at different degrees. Effective management of warfarin therapy after heart valve replacement is currently an important issue. Portable coagulometers and the emergence of the Internet have provided new opportunities for long-term management of anticoagulation therapy, but the safety and affordability of this approach remain to be fully evaluated. This paper reviews recent progress on the use of portable coagulometers and the Internet in the management of warfarin anticoagulation therapy following mechanical heart valve replacement, which offers opportunities for reducing complications during postoperative anticoagulation and for facilitating patient compliance during follow-up.
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Pandey AK, Xu K, Zhang L, Gupta S, Eikelboom J, Lopes RD, Crowther M, Belley-Côté EP, Whitlock RP. Efficacy and safety of low intensity vitamin K antagonists in Western and East-Asian patients with left-sided mechanical heart valves. J Thromb Thrombolysis 2021; 53:697-707. [PMID: 34622377 DOI: 10.1007/s11239-021-02568-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2021] [Indexed: 11/24/2022]
Abstract
The optimal INR target in patients with mechanical heart valves is unclear. Higher INR targets are often used in Western compared with East Asian countries. The objective of this systematic review and meta-analysis was to summarize the evidence for the efficacy and safety of lower versus higher INR targets in Western and East Asian left-sided mechanical heart valve patients. We searched Western databases including Cochrane CENTRAL, Medline, and Embase as well as Chinese databases including SinoMed, CNKI, and Wanfang Data in addition to grey literature for Randomized Controlled Trials (RCTs) and observational studies. We pooled risk ratios (RRs) using random-effects model. Low and high INR targets were defined by the individual studies. We identified nine RCTs, including six Western (n = 5496) and three East Asian (n = 209) trials, and 17 observational studies, including two Western (n = 3199) and 15 East Asian (n = 5485) studies. In the RCTs, lower compared with higher targets were associated with similar rates of thromboembolism (2.4 vs. 2.3%; RR: 1.14, 95% CI 0.82, 1.60, I2 = 0%) and lower rates of both total bleeding (21.9 vs. 40.9%, RR: 0.46, 95% CI 0.28, 0.78, I2 = 88%) and major bleeding. RCT data showed no statistical heterogeneity by region. These effects were consistent in the observational data. We downgraded the quality of evidence due to serious risk of bias and imprecision. In patients with left-sided contemporary mechanical heart valves, low quality evidence suggests lower INR targets are associated with similar rates of thromboembolism and moderate quality evidence suggests lower rates of bleeding.
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Affiliation(s)
- Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Ke Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Li Zhang
- Banner University Medical Center, Tucson, USA
| | - Saurabh Gupta
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada.,Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, USA.,Duke University School of Medicine, Durham, USA
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Canada.,Division of Hematology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Richard P Whitlock
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Canada. .,Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
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Hu YN, Zhou BT, Yang HR, Peng QL, Gu XR, Sun SS. Effect of rifampicin on anticoagulation of warfarin: A case report. World J Clin Cases 2021; 9:1087-1095. [PMID: 33644171 PMCID: PMC7896655 DOI: 10.12998/wjcc.v9.i5.1087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The drug interaction between warfarin and rifampicin is widely known, but there are still some difficulties in managing the combination of the two drugs.
CASE SUMMARY A patient with brucellosis received strict monitoring from a Chinese pharmacist team during combination of warfarin and rifampicin. The dose of warfarin was increased to 350% in 3 mo before reaching the lower international normalized ratio treatment window. No obvious adverse reaction occurred during the drug-adjustment period. This is the first case report of long-term combined use of rifampicin and warfarin in patients with brucellosis and valve replacement in China based on the Chinese lower warfarin dose and international normalized ratio range.
CONCLUSION Anticoagulation for valve replacement in Chinese patients differs from that in other races. Establishment of a pharmacist clinic provides vital assistance in warfarin dose adjustment.
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Affiliation(s)
- Ya-Ni Hu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Bo-Ting Zhou
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
- The Institute of Hospital Pharmacy, Central South University, Changsha 410008, Hunan Province, China
| | - Hua-Rong Yang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Qi-Lin Peng
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Xu-Rui Gu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Shu-Sen Sun
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA 31329, United States
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Li YC, Wang R, Xu H, Ding LP, Ge WH. Anticoagulation Resumption in a Patient With Mechanical Heart Valves, Antithrombin Deficiency, and Hemorrhagic Transformation Following Thrombectomy After Ischemic Stroke. Front Pharmacol 2020; 11:549253. [PMID: 33390937 PMCID: PMC7772403 DOI: 10.3389/fphar.2020.549253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 10/16/2020] [Indexed: 11/26/2022] Open
Abstract
Anticoagulation is essential for patients undergoing mechanical heart valve replacement; however, the timing to reinitiate the anticoagulant could be a dilemma that imposes increased risk for bleeding events in patients suffering from the life-threatening hemorrhagic transformation (HT) after ischemic stroke. Such a situation was presented in this case report. A 71-year-old woman was transferred directly to the Neurocritical Care Unit because of a HT that occurred following the mechanical thrombectomy for ischemic stroke. Since she had a history of prosthetic metallic valve replacement, how the anticoagulating therapy could balance the hemorrhagic and thrombotic risks was carefully evaluated. On day 6 after the onset of hemorrhage transformation, the laboratory results of coagulation and fibrinolysis strongly suggested thrombosis as well as antithrombin deficiency. The short-acting and titratable anticoagulant argatroban was immediately initiated at low dose, and thrombosis was temporarily terminated. On day 3 of anticoagulation resumption, argatroban was discontinued for one dose when the prothrombin time and activated partial thromboplastin time significantly prolonged after argatroban infusion. Aortic valve thrombosis was detected the next day. The anticoagulation was then strengthened by dose adjustment to keep mitral valve intact, to stabilize the aortic valve thrombosis, and to decrease the aortic flow rate. The intravenous argatroban was transited to oral warfarin before the patient was discharged. This study is the first report of administering argatroban and titrating to its appropriate dose in the patient with valve thrombosis, antithrombin deficiency, and HT after mechanical thrombectomy for acute ischemic stroke. Notably, the fluctuations argatroban brings to the coagulation test results might not be interpreted as increased bleeding risk. This case also suggested that the reported timing (day 6 to day 14 after hemorrhage) of anticoagulant resumption in primary intracerebral hemorrhage with mechanical valves might be late for some patients with HT.
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Affiliation(s)
- Yi-Chen Li
- Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.,Department of Neurosurgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Rong Wang
- Department of Neurosurgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Hang Xu
- Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.,Department of Cardio-Thoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Lan-Ping Ding
- Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.,Department of Neurosurgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.,Department of Pharmacy, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei-Hong Ge
- Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
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Aikins J, Koomson A, Ladele M, Al-Nusair L, Ahmed A, Ashry A, Harky A. Anticoagulation and antiplatelet therapy in patients with prosthetic heart valves. J Card Surg 2020; 35:3521-3529. [PMID: 32939828 DOI: 10.1111/jocs.15034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The choice of antithrombotic therapy, anticoagulants or antiplatelets, after prosthetic heart valve replacement or repair, remains a disputed topic in the literature. Antithrombotic therapies are used after heart valve intervention to reduce the rates of thromboembolic events, therefore improving patient outcomes. Different interventions may require different therapeutic regimens to achieve the most efficacious clinical outcome for patients. METHODS AND DISCUSSION This review aims to summarize and critique the available literature concerning therapeutic agents used for bioprosthetic and mechanical valves as well as for valve repair, so as to assist clinicians and researchers in making decisions with regard to their patients and research endeavors.
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Affiliation(s)
- Joel Aikins
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Abeku Koomson
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Mofolaoluwami Ladele
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Lana Al-Nusair
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amna Ahmed
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amr Ashry
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Cardiothoracic Surgery, Assiut University Hospital, Assiut, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
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