Sarawate Chaitanya, Sikirica Mirko V, Willey Vincent J, Bullano Michael F, Hauch Ole
HealthCore, 800 Delaware Ave. 5th Floor, Wilmington, DE 19801, USA.
J Thromb Thrombolysis. 2006 Apr;21(2):191-8. doi: 10.1007/s11239-006-4968-z.
Randomized control trials and observational studies show high-quality warfarin therapy leads to safe and effective stroke prophylaxis. In usual community practice, patient, physician and health care system factors are barriers to optimal anticoagulation. We examined the predictive relationship between inpatient and outpatient INR values in chronic non-valvular atrial fibrillation (AF) patients hospitalized for ischemic stroke (S), bleed (B) and control events (C) in usual community practice.
This nested case-control analysis identified AF patients hospitalized for S, B and C using medical and pharmacy claims spanning 4.5 years ('98-'03) and validating diagnosis with chart abstraction. AF was defined as 2 medical claims for AF >or= 42 days apart with a related prescription claim for warfarin. INRs from both outpatient and inpatient settings were used to yield a continuous history of coagulation status. Time-in-therapeutic-range (TTR) was calculated by Rosendaal's linear interpolation method. Correlation of inpatient and prognostic utility of last outpatient INRs was tested with S or B hospitalizations using univariate and multivariate logistic regression.
Overall, 614 hospitalizations (means: age 73.9, CHADS(2) = 3.24; 52% male) included S (n = 98), B (n = 101) and C (n = 415) events. Average TTR was 28.6% (49.4% at INR <2.0, 21.9% at INR >3.0). First INR on admission (INR <2.0 or >3.0) was associated with S and B hospitalizations (OR-adjusted [95%CI], 1.68 [1.04-2.73] and 1.72 [1.02-2.90]), respectively. Last outpatient INR <2.0 was not associated with S (OR-adjusted [95%CI], 1.12 [0.77-1.81]), and INR >3.0 was not associated with B (OR-adjusted [95%CI], 1.25 [0.67-2.32]). Last outpatient INR measurement occurred at 28, 22 and 24 days (median; S, B & C, respectively) before hospitalization.
Patients were observed within therapeutic range less than 30% of their time on warfarin. While inpatient INRs were clearly associated with both ischemic stroke and bleed events, last outpatient INR before event was not predictive.
随机对照试验和观察性研究表明，高质量的华法林治疗可安全有效地预防中风。在常规社区医疗实践中，患者、医生和医疗保健系统因素是实现最佳抗凝治疗的障碍。我们研究了在常规社区医疗实践中因缺血性中风（S）、出血（B）和对照事件（C）住院的慢性非瓣膜性心房颤动（AF）患者的住院和门诊国际标准化比值（INR）值之间的预测关系。
这项嵌套病例对照分析通过4.5年（1998 - 2003年）的医疗和药房索赔记录确定因S、B和C住院的AF患者，并通过病历摘要验证诊断。AF定义为相隔≥42天的2次AF医疗索赔以及相关的华法林处方索赔。使用门诊和住院环境中的INR来得出凝血状态的连续记录。通过罗森达尔线性插值法计算治疗范围内时间（TTR）。使用单变量和多变量逻辑回归测试住院INR与上次门诊INR对S或B住院的相关性及预后效用。
总体而言，614次住院（平均年龄73.9岁，CHADS(2)=3.24；52%为男性）包括S（n = 98）、B（n = 101）和C（n = 415）事件。平均TTR为28.6%（INR<2.0时为49.4%，INR>3.0时为21.9%）。入院时的首次INR（INR<2.0或>3.0）分别与S和B住院相关（校正比值比[95%置信区间]，1.68[1.04 - 2.73]和1.72[1.02 - 2.90]）。上次门诊INR<2.0与S无关（校正比值比[95%置信区间]，1.12[0.77 - 1.81]），INR>3.0与B无关（校正比值比[95%置信区间]，1.25[0.67 - 2.32]）。上次门诊INR测量分别在住院前28天、22天和24天（中位数；S、B和C）进行。
患者服用华法林期间处于治疗范围内的时间不到30%。虽然住院INR与缺血性中风和出血事件均明显相关，但事件发生前的上次门诊INR并无预测作用。
