Variation in Time in Therapeutic Range (TTR) of Warfarin Use in Atrial Fibrillation Patients at Hospital X, Banten
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia in adults. Stroke, resulting from thromboembolism, is the most frequent and severe complication associated with atrial fibrillation, and its prevention is a primary therapeutic goal. Anticoagulant therapy is the cornerstone for stroke prevention, with warfarin being the most commonly used anticoagulant. However, warfarin therapy poses a significant risk of bleeding, necessitating regular and strict monitoring. The Time in Therapeutic Range (TTR) is a parameter used to assess the quality of warfarin therapy management, reflecting the percentage of time a patient's INR remains within the target therapeutic range of 2.0–3.0. To evaluate the variation of Time in Therapeutic Range (TTR) and its association with complications in atrial fibrillation patients receiving warfarin therapy. TTR was calculated using the Rosendaal interpolation method. The risk of bleeding complications was assessed using the HAS-BLED score, and stroke risk was evaluated using the CHA₂DS₂-VASc score. This retrospective observational study included 78 atrial fibrillation patients receiving warfarin, whose medical records were collected from January to June 2022. Data were presented in tables and charts and analyzed descriptively. The study found that only 15.38% (12 patients) achieved the target TTR (>70%), while 84.62% (66 patients) had suboptimal TTR levels. Most patients with low TTR scores had moderate to high HAS-BLED and CHA₂DS₂-VASc scores, indicating an increased risk of bleeding and stroke.
References
Akbar, M. R., Febrianora, M., & Iqbal, M. (2023). Warfarin Usage in Patients With Atrial Fibrillation Undergoing Hemodialysis in Indonesian Population. In Current Problems in Cardiology (Vol. 48, Issue 5). Elsevier Inc. https://doi.org/10.1016/j.cpcardiol.2022.101104
Dincer, G. (1002). Journal of Clinical Chemistry and Laboratory Medicine Opinion Article Citation: Dincer G (2022) Importance of Therapeutic Drug Monitoring For Safe and Effective Drug Intake. J Clin Chem Lab Med, 5(9), 245. https://doi.org/10.35248/JCCLM.22.05.245
Elsheikh, S., Hill, A., Irving, G., Lip, G. Y. H., & Abdul-Rahim, A. H. (2024). Atrial fibrillation and stroke: State-of-the-art and future directions. In Current Problems in Cardiology (Vol. 49, Issue 1). Elsevier Inc. https://doi.org/10.1016/j.cpcardiol.2023.102181
Hindricks, G., Potpara, T., Kirchhof, P., Kühne, M., Ahlsson, A., Balsam, P., Bauersachs, J., Benussi, S., Brandes, A., Braunschweig, F., Camm, A. J., Capodanno, D., Casadei, B., Conen, D., Crijns, H. J. G. M., Delgado, V., Dobrev, D., Drexel, H., Fitzsimons, D., Zakirov, N. U. (2021). 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). In European Heart Journal (Vol. 42, Issue 5, pp. 373–498). Oxford University Press. https://doi.org/10.1093/eurheartj/ehaa612
Krittayaphong, R., Chantrarat, T., Rojjarekampai, R., Jittham, P., Sairat, P., & Lip, G. Y. H. (2020). Poor time in therapeutic range control is associated with adverse clinical outcomes in patients with non-valvular atrial fibrillation: A report from the nationwide cool-af registry. Journal of Clinical Medicine, 9(6). https://doi.org/10.3390/jcm9061698
Krittayaphong, R., Winijkul, A., Methavigul, K., & Lip, G. Y. H. (2023). Impact of Achieving Blood Pressure Targets and High Time in Therapeutic Range on Clinical Outcomes in Patients With Atrial Fibrillation Adherent to the Atrial Fibrillation Better Care Pathway: A Report From the COOL-AF Registry. Journal of the American Heart Association, 12(3). https://doi.org/10.1161/JAHA.122.028463
Lee, S. R., Choi, E. K., Kwon, S., Jung, J. H., Han, K. Do, Cha, M. J., Oh, S., & Lip, G. Y. H. (2020). Oral Anticoagulation in Asian Patients With Atrial Fibrillation and a History of Intracranial Hemorrhage. Stroke, 51(2), 416–423. https://doi.org/10.1161/STROKEAHA.119.028030
Page Clivon, & Pitchford Simon. (2021). Dale’s Pharmacology Condensed (THIRD EDITION). Elsevier LTD.
Pandey, A. K., Xu, K., Zhang, L., Gupta, S., Eikelboom, J., Cook, O., Mcintyre, W. F., Lopes, R. D., Crowther, M., Belley-Côté, E. P., & Whitlock, R. P. (2020). Lower versus Standard INR Targets in Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. In Thrombosis and Haemostasis (Vol. 120, Issue 3, pp. 484–494). Georg Thieme Verlag. https://doi.org/10.1055/s-0039-3401823
Perhimpunan Dokter Spesialis Kardivaskular Indonesia. (2019). Pedoman Tata Laksana Fibrilasi Atrium Nonvalvular (M. Munawar & Y. Yuniadi, Eds.). PT. Trans Medical International. www.transmedicalinstitute.com
Queensland Health. (2024). Guideline for Warfarin Management in the Community Guideline for Warfarin Management in the Community Guideline for Warfarin Management in the Community-February 2024. https://www.health.qld.gov.au/__data/assets/pdf_file/0025/443806/warfarin-
Rivera-Caravaca, J. M., Roldán, V., Esteve-Pastor, M. A., Valdés, M., Vicente, V., Lip, G. Y. H., & Marín, F. (2017). Importance of time in therapeutic range on bleeding risk prediction using clinical risk scores in patients with atrial fibrillation. Scientific Reports, 7(1). https://doi.org/10.1038/s41598-017-11683-2
Rosendaal, F. R., Cannegieter, S. C., Van der Meer, F. J. M., & Briet, E. (1993). A method to determine the optimal intensity of oral anticoagulant therapy. Thrombosis and Haemostasis, 69(3), 236–239. https://doi.org/10.1055/s-0038-1651587
Vestergaard, A. S., Skjøth, F., Larsen, T. B., & Ehlers, L. H. (2017). The importance of mean time in therapeutic range for complication rates in warfarin therapy of patients with atrial fibrillation: A systematic review and meta-regression analysis. PLoS ONE, 12(11). https://doi.org/10.1371/journal.pone.0188482
Zhu, W., He, W., Guo, L., Wang, X., & Hong, K. (2015). The HAS-BLED score for predicting major bleeding risk in anticoagulated patients with atrial fibrillation: A systematic review and meta-analysis. In Clinical Cardiology (Vol. 38, Issue 9, pp. 555–561). John Wiley and Sons Inc. https://doi.org/10.1002/clc.22435
1.png){kind=small}
