Ambulatory Care Department, Virginia Garcia Memorial Health Center, Portland, OR, United States.
Clinical Pharmacy Research Team, Kaiser Permanente Colorado, Aurora, CO, United States; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States.
Thromb Res. 2018 Mar;163:54-59. doi: 10.1016/j.thromres.2018.01.024. Epub 2018 Feb 6.
Clinical pharmacy anticoagulation services have improved the quality of anticoagulant therapy and are associated with lower rates of bleeding and thromboembolism compared to usual care. Several studies have found that higher time-in-therapeutic range (TTR) during warfarin therapy is associated with better warfarin outcomes. However, whether increasing TTR over time within an established anticoagulation service is associated with further reduction in bleeding and thromboembolic outcomes is unknown.
This was a retrospective cohort study of patients with atrial fibrillation conducted at an integrated healthcare delivery system with a centralized, pharmacist-managed anticoagulation service. Clinical outcomes (clinically-relevant bleeding, ischemic stroke or systemic embolism, and all-cause mortality) and TTR were compared between two distinct time periods: 1/1/2006 through 12/31/2007 (control group) and 1/1/2012 through 12/31/2013 (observation group) with regression modeling to adjustment for potential confounders.
There were 3641 and 4764 patients in the control and observation groups, respectively. The mean age was 74.3 years and 54.4% of the cohort was female. Mean TTR was higher in the observation group (70.5% vs. 63.4%, p < 0.001). The composite outcome of clinically-relevant bleeding, thromboembolism and all-cause mortality occurred in 4.6% and 3.6% of the control and observation groups, respectively (adjusted odds ratio = 0.69; 95% confidence interval 0.54-0.87). Individual rates of stroke/systemic embolism and all-cause mortality were each lower in the observation group (both p < 0.05) while clinically-relevant bleeding was not significantly different (p = 0.256).
Increased TTR within a clinical pharmacy anticoagulation management service was associated with a lower risk of the composite outcomes of bleeding, thromboembolism and death in a large atrial fibrillation population receiving warfarin.
与常规护理相比，临床药学抗凝服务提高了抗凝治疗的质量，与较低的出血和血栓栓塞发生率相关。几项研究发现，华法林治疗期间时间治疗窗内（TTR）越高，华法林的效果越好。然而，在既定的抗凝服务中，随着时间的推移，TTR 是否持续增加与进一步降低出血和血栓栓塞结局相关尚不清楚。
这是一项在具有集中式、药师管理抗凝服务的综合医疗服务系统中进行的心房颤动患者回顾性队列研究。临床结局（临床相关出血、缺血性卒中和全身性栓塞以及全因死亡率）和 TTR 在两个不同时间段进行比较：2006 年 1 月 1 日至 2007 年 12 月 31 日（对照组）和 2012 年 1 月 1 日至 2013 年 12 月 31 日（观察组），使用回归模型进行潜在混杂因素的调整。
对照组和观察组分别有 3641 例和 4764 例患者。平均年龄为 74.3 岁，队列中有 54.4%为女性。观察组 TTR 较高（70.5%比 63.4%，p<0.001）。对照组和观察组的临床相关出血、血栓栓塞和全因死亡率的复合结局发生率分别为 4.6%和 3.6%（调整后的比值比=0.69；95%置信区间 0.54-0.87）。观察组的卒中/全身性栓塞和全因死亡率均较低（均 p<0.05），而临床相关出血无显著差异（p=0.256）。
在接受华法林治疗的大量心房颤动患者中，临床药学抗凝管理服务中 TTR 的增加与出血、血栓栓塞和死亡复合结局的风险降低相关。
