Wang Na, Qiu Sha, Yang Ya, Zhang Chi, Gu Zhi-Chun, Qian Yan
Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Department of Infection Control, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
Front Pharmacol. 2021 Jun 9;12:673302. doi: 10.3389/fphar.2021.673302. eCollection 2021.
Poor time in therapeutic range (TTR) control is associated with an increased risk of stroke and bleeding in atrial fibrillation (AF) patients receiving warfarin. This study aimed to determine whether the physician-pharmacist collaborative clinic (PPCC) model could improve the anticoagulation quality as well as to create a nomogram for predicting anticoagulation quality in AF patients. This retrospective observational study enrolled AF patients who either initially received warfarin or returned to warfarin after withdrawal between January 1, 2016 and January 1, 2021, at our institution. The primary outcome was dynamic changes in TTRs (a TTR of ≥60% considered high anticoagulation quality). The secondary outcomes were thromboembolic and bleeding events during follow-up. We compared the dynamic changes in TTRs between the general clinic (GC) and PPCC groups in both the original and propensity score matching (PSM) cohorts. In addition, we explored the potential predictors of high anticoagulation quality and subsequently formulated a nomogram to predict anticoagulation quality. A total of 265 patients with AF were included, comprising 57 patients in the PPCC group and 208 patients in the GC group. During a median follow-up period of 203 days, the PPCC group had a shorter time (76 vs. 199 days, < 0.001) and more patients achieved a TTR ≥60% (73.7 vs. 47.1%, = 0.002 by log-rank test) than the GC group. The results from the PSM cohort confirmed this finding. No significant differences in the incidences of thromboembolic events (5.3 vs. 5.3%, = 1.000) and bleeding events (4.3 vs. 3.5%, = 1.000) were observed between the two groups. Four variables were explored as predictors related to high anticoagulation quality: treatment within a PPCC, history of bleeding, history of bleeding, and the presence of more than four comorbidities. The nomogram revealed a moderate predictive ability (c-index: 0.718, 95% confidence interval (95%CI): 0.669-0.767) and a moderately fitted calibration curve. The PPCC model contributed to improved anticoagulation quality in AF patients receiving warfarin. The nomogram might be an effective tool to predict anticoagulation quality and could aid physicians and pharmacists in the selection of patients who will likely benefit from sustained and active intervention.
在接受华法林治疗的心房颤动（AF）患者中，治疗范围内时间（TTR）控制不佳与中风和出血风险增加相关。本研究旨在确定医师 - 药师协作门诊（PPCC）模式是否能提高抗凝质量，并创建一个用于预测AF患者抗凝质量的列线图。这项回顾性观察性研究纳入了2016年1月1日至2021年1月1日期间在我们机构最初接受华法林治疗或停药后重新使用华法林的AF患者。主要结局是TTR的动态变化（TTR≥60%被认为抗凝质量高）。次要结局是随访期间的血栓栓塞和出血事件。我们比较了普通门诊（GC）组和PPCC组在原始队列和倾向评分匹配（PSM）队列中TTR的动态变化。此外，我们探索了高抗凝质量的潜在预测因素，并随后制定了一个列线图来预测抗凝质量。总共纳入了265例AF患者，其中PPCC组57例，GC组208例。在中位随访期为203天期间，PPCC组达到TTR≥60%的时间更短（76天对199天，<0.001），且达到TTR≥60%的患者更多（73.7%对47.1%；对数秩检验P = 0.002）。PSM队列的结果证实了这一发现。两组之间血栓栓塞事件（5.3%对5.3%，P = 1.000）和出血事件（4.3%对3.5%，P = 1.000）的发生率没有显著差异。探索了四个与高抗凝质量相关的预测变量：在PPCC内治疗、出血史、出血史以及存在四种以上合并症。列线图显示出中等预测能力（c指数：0.718，95%置信区间（95%CI）：0.669 - 0.767）和拟合度适中的校准曲线。PPCC模式有助于提高接受华法林治疗的AF患者的抗凝质量。列线图可能是预测抗凝质量的有效工具，可帮助医生和药师选择可能从持续积极干预中获益的患者。
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