Arendt Christopher J, Hong Joon Hwa, Daly Richard C, Scott Christopher, Mehta Ramila A, Bailey Kent, Pathak Jyotishman, Pereira Naveen L
Department of Pharmacy, Mayo Clinic, Rochester, MN.
Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Department of Thoracic and Cardiovascular Surgery, Heart Research Institute, Chung-Ang University College of Medicine, Seoul, Republic of Korea.
Am Heart J. 2017 May;187:70-77. doi: 10.1016/j.ahj.2017.02.011. Epub 2017 Feb 16.
Achieving a therapeutic international normalized ratio (INR) before hospital discharge is an important inpatient goal for patients undergoing mechanical cardiac valve replacement (MCVR). The use of clinical algorithms has reduced the time to achieve therapeutic INR (TTI) with warfarin therapy. Whether TTI prolongs length of stay (LOS) is unknown.
Patients who underwent MCVR over a consecutive 42-month period were included. Clinical data were obtained from the Society of Thoracic Surgeons Adult Cardiac Surgery database and electronic medical records. Therapeutic INR was defined as per standard guidelines. Warfarin dose was prescribed using an inpatient pharmacy-managed algorithm and computer-based dosing tool. International normalized ratio trajectory, procedural needs, and drug interactions were included in warfarin dose determination.
There were 708 patients who underwent MCVR, of which 159 were excluded for reasons that would preclude or interrupt warfarin use. Among the remainder of 549 patients, the average LOS was 6.4days and mean TTI was 3.5days. Landmark analysis showed that subjects in hospital on day 4 (n=542) who achieved therapeutic INR were more likely to be discharged by day 6 compared with those who did not achieve therapeutic INR (75% vs 59%, P<.001). Multivariable proportional hazards regression with TTI as a time-dependent effect showed a strong association with discharge (P=.0096, hazard ratio1.3) after adjustment for other significant clinical covariates.
Time to achieve therapeutic INR is an independent predictor of LOS in patients requiring anticoagulation with warfarin after MCVR surgery. Alternative dosing and anticoagulation strategies will need to be adopted to reduce LOS in these patients.
对于接受机械心脏瓣膜置换术（MCVR）的患者而言，在出院前达到治疗性国际标准化比值（INR）是一项重要的住院目标。临床算法的应用缩短了华法林治疗达到治疗性INR的时间（TTI）。TTI是否会延长住院时间（LOS）尚不清楚。
纳入连续42个月内接受MCVR的患者。临床数据来自胸外科医师协会成人心脏手术数据库和电子病历。治疗性INR按照标准指南定义。华法林剂量通过住院药房管理的算法和基于计算机的给药工具来确定。华法林剂量的确定纳入了国际标准化比值轨迹、手术需求和药物相互作用等因素。
共有708例患者接受了MCVR，其中159例因可能妨碍或中断华法林使用的原因被排除。在其余549例患者中，平均住院时间为6.4天，平均TTI为3.5天。标志性分析显示，与未达到治疗性INR的患者相比，在第4天仍住院（n = 542）且达到治疗性INR的患者在第6天出院的可能性更大（75%对59%，P <.001）。将TTI作为时间依赖性效应进行多变量比例风险回归分析，在对其他显著临床协变量进行调整后，显示与出院有强烈关联（P =.0096，风险比1.3）。
在MCVR手术后需要使用华法林进行抗凝治疗的患者中，达到治疗性INR的时间是住院时间的独立预测因素。需要采用替代给药和抗凝策略来缩短这些患者的住院时间。
