Relationship between time spent at extreme International Normalized Ratios and time in therapeutic range with bleeding and thrombosis in warfarin-treated patients.

Purpose: The relationship between the time spent at extreme International Normalized Ratios (INRs) and the time in the therapeutic range (TTR) with bleeding and thrombosis in warfarin-treated patients was examined.

Methods: Consecutive patients treated with warfarin for atrial fibrillation or for venous thrombosis who were managed by the anticoagulation management service or adult internal medicine clinic of a large, tertiary care, integrated health system between June 1, 2011, and October 9, 2012, were eligible for study inclusion. Data collected for the outcomes analysis included INRs and dates; current use of aspirin, clopidogrel, prasugrel, ticagrelor, ticlopidine, or nonsteroidal antiinflammatory drugs; and any clinically significant bleeding or thrombosis events identified.

Impact of a new method of warfarin management on patient satisfaction, time, and cost.

Study Objective: International normalized ratio self-testing with online remote monitoring and management (STORM₂) is an alternative to anticoagulation clinic management, but the patient's perspective of this method has not been evaluated in the United States; thus we sought to evaluate the impact of STORM₂ on patient satisfaction, time, and cost.

Design: Prospective pre- and postintervention study.

Setting: Freestanding clinical research center.

Evaluation of warfarin management with international normalized ratio self-testing and online remote monitoring and management plus low-dose vitamin k with genomic considerations: a pilot study.

Study Objectives: As better international normalized ratio (INR) control and self-testing reduce events in warfarin-treated patients, and vitamin K supplementation may improve INR control, our primary objective was to evaluate the effect of a system combining frequent INR self-testing with online remote monitoring and management (STORM₂) and low-dose vitamin K supplementation on INR control; our secondary objectives were to assess the impact of STORM₂ on clinician time and to evaluate the influence of pharmacogenomics on INR stability and warfarin dose after vitamin K supplementation.

Design: Prospective pre- and postintervention study.

Setting: Freestanding clinical research center.

Transforming oral anticoagulation by combining international normalized ratio (INR) self testing and online automated management.

Because of the number and complexity of issues addressed, this manuscript is divided into two major sections. The first section focuses on how new technology can transform vitamin K antagonist therapy. Specifically, evidence suggest that combining INR self testing with online automated management (STOAM) can greatly reduce the time, expense, and hassle of managing VKA therapy; improve the quality of INR control to a degree that, in large studies, has been associated with a 50% or more reduction in major events (such as stroke, myocardial infarction, major hemorrhage, and death); reduce health care costs by an estimated $4 million per 1,000 patients per year; and improve quality of life and patient satisfaction.

Retrievable and permanent inferior vena cava filters: selected considerations.

The use of inferior vena cava (IVC) filters is increasing rapidly, and the recent availability of retrievable IVC filters is certain to accelerate this process. Unfortunately, because the risks and benefits of these devices have not been adequately studied, several important issues remain. Limitations of the quality of the data in the available literature make it virtually impossible to accurately quantify the specific rates of complications with various devices.

Low-dose vitamin K to augment anticoagulation control.

Study Objectives: To determine the effect of daily low-dose oral vitamin K supplementation on reducing variations in the international normalized ratios (INRs) in patients taking warfarin.

Design: Retrospective analysis.

Setting: Anticoagulation clinic in a large, private-practice hematology group.

Duration of treatment of deep vein thrombosis: time for a new approach?

The American College of Chest Physicians Consensus Conference on Antithrombotic Therapy recommends that patients with initial idiopathic deep vein thrombosis (DVT) receive treatment for at least 6-12 months. However, controversy exists as to what treatment duration and intensity are optimal. Some investigators have suggested that it may be feasible to identify patients who are at low risk and those who are at high risk of recurrent venous thromboembolism.

Oral anticoagulation: challenges in the case-management setting.

By understanding barriers, providing education, and advocating appropriate treatment, case managers play an essential role in the prevention and treatment of thromboembolic disorders. Yet, thromboembolic events such as stroke and deep-vein thrombosis still result in substantial morbidity and mortality despite the availability of effective prophylactic anticoagulation therapy. Although oral warfarin, because of its established efficacy, remains the mainstay in the prevention and treatment of thromboembolic disorders associated with atrial fibrillation, a common antecedent, it is fraught with enduring impediments that hinder effectiveness, safety, and use.

Transitioning from traditional to novel anticoagulants: the impact of oral direct thrombin inhibitors on anticoagulation management.

Limitations of traditional anticoagulants have led to the need for structured services to provide anticoagulation monitoring. Anticoagulation management services have historically filled this role. Novel antithrombotic agents currently in development have the potential to improve on the limitations of vitamin K antagonists and injectable forms of heparin and to change the field of anticoagulation management.

The role of oral direct thrombin inhibitors in the treatment of venous thromboembolism.

Unfractionated heparin and warfarin have been the mainstay of treatment of venous thromboembolism (VTE) for approximately half a century. However, both agents are difficult to dose accurately, require frequent blood testing and dosage adjustment, and can cause serious adverse effects. Oral direct thrombin inhibitors may provide more predictable anticoagulation with oral dosing, without the need for frequent blood test monitoring and without the adverse effects seen with conventional agents.

Antithrombotic therapy in valvular heart disease--native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

This chapter about antithrombotic therapy in native and prosthetic valvular heart disease is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S).

An overview of anticoagulants, antiplatelet agents, and the combination in patients with mechanical heart valves.

Currently, and for the near future, well-managed warfarin appears to be the most effective method to prevent thromboembolism and bleeding in patients with mechanical heart valves. These patients, when in an anticoagulation management service, have 50-90% fewer complications than patients not managed in this way. Further, the complication rate in such settings approximates that in patients with bioprosthetic, tissue valves not receiving anticoagulation.