Quality of vitamin K antagonist control and outcomes in atrial fibrillation patients: a meta-analysis and meta-regression
Quality of vitamin K antagonist control and outcomes in atrial fibrillation patients: a meta-analysis and meta-regression
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DOI：
10.1186/1477-9560-12-14
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发表时间：
2014-01-01
影响因子：
3.1
通讯作者：
Coleman, Craig I.
中科院分区：
文献类型：
--
作者：
Mearns, Elizabeth S.;White, C. Michael;Coleman, Craig I.
背景资料：房颤（AF）患者经常需要使用维生素K拮抗剂（VKA）进行抗凝治疗以预防血栓栓塞事件，但使用VKA会增加出血风险。我们评估了使用VKA的AF患者在治疗范围内花费的时间（TTR）、国际标准化比值（INR）测量值在范围内的比例（PINRR）、与INR相关的不良事件以及INR控制的预测因素。我们搜索了MEDLINE，中央和EMBASE（1990年-2013年6月）报告INR控制措施的AF患者接受调整剂量VKA的研究（TTR和PINRR）和/或报告INR测量值与血栓栓塞或出血事件一致。结果：共纳入95篇文献。68个VKA治疗研究组报告了INR控制指标，而43项研究报告了不良事件发生前后的INR。患者在治疗范围内、低于或高于治疗范围的时间分别为61%（95% CI，59-62%）、25%（95% CI，23-27%）和14%（95% CI，13-15%）。PINRR评估在56%（95% CI，53-59%）、26%（95% CI，23-29%）和13%（95% CI，11-17%）的时间范围内、低于和高于范围。在社区接受VKA管理的患者花费的TTR少于抗凝诊所或随机试验中接受VKA管理的患者。新接受VKA的患者花费的TTR少于既往使用VKA的患者。欧洲/英国患者的TTR花费高于北美患者。百分之五十七（95% CI，50-64%）和42%（95% CI，35 - 51%）出血性事件分别发生在INR 3.0时;而56%（95% CI，48-64%）和45%的颅内出血（95%CI，29-63%）发生在INR 3.0，分别。结论：VKA治疗AF的患者经常有治疗范围外的INR。然而，治疗性INR的患者确实会发生血栓栓塞和出血事件; INR 3.0的患者构成了许多出血病例。在临床试验或抗凝诊所之外管理抗凝与INR控制较差相关，在VKA初治患者中开始治疗也是如此。欧洲/英国患者的INR控制优于北美患者。
Background: Atrial fibrillation (AF) patients frequently require anticoagulation with vitamin K antagonists (VKAs) to prevent thromboembolic events, but their use increases the risk of hemorrhage. We evaluated time spent in therapeutic range (TTR), proportion of international normalized ratio (INR) measurements in range (PINRR), adverse events in relation to INR, and predictors of INR control in AF patients using VKAs.Methods: We searched MEDLINE, CENTRAL and EMBASE (1990-June 2013) for studies of AF patients receiving adjusted-dose VKAs that reported INR control measures (TTR and PINRR) and/or reported an INR measurement coinciding with thromboembolic or hemorrhagic events. Random-effects meta-analyses and meta-regression were performed.Results: Ninety five articles were included. Sixty eight VKA treated study groups reported measures of INR control, while 43 studies reported an INR around the time of the adverse event. Patients spent 61% (95% CI, 59-62%), 25% (95% CI, 23-27%) and 14% (95% CI, 13-15%) of their time within, below or above the therapeutic range. PINRR assessments were within, below, and above range 56% (95% CI, 53-59%), 26% (95% CI, 23-29%) and 13% (95% CI, 11-17%) of the time. Patients receiving VKA management in the community spent less TTR than those managed by anticoagulation clinics or in randomized trials. Patients newly receiving VKAs spent less TTR than those with prior VKA use. Patients in Europe/United Kingdom spent more TTR than patients in North America. Fifty-seven percent (95% CI, 50-64%) of thromboembolic events and 42% (95% CI, 35 - 51%) of hemorrhagic events occurred at an INR 3.0, respectively; while 56% (95% CI, 48-64%) of ischemic strokes and 45% of intracranial hemorrhages (95% CI, 29-63%) occurred at INRs 3.0, respectively.Conclusions: Patients on VKAs for AF frequently have INRs outside the therapeutic range. While, thromboembolic and hemorrhagic events do occur patients with a therapeutic INR; patients with an INR 3.0 make up many of the cases of hemorrhage. Managing anticoagulation outside of a clinical trial or anticoagulation clinic is associated with poorer INR control, as is, the initiation of therapy in the VKA-naive. Patients in Europe/UK have better INR control than those in North America.