심방세동 환자의 심율동전환 시행 전·후 warfarin 치료의 적절성 평가
Evaluation of Peri-procedural Warfarin Therapy Undergoing Cardioversion in Patients with Atrial fibrillation
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Objective: Direct current cardioversion for atrial fibrillation could be associated with the risk of thromboembolic events. Anticoagulation therapy with warfarin (INR 2.0-3.0) is recommended 3 weeks before and 4 weeks after cardioversion to reduce the risk of thromboembolism. This study evaluated warfarin therapy in pharmacist-managed anticoagulant services (ACS). Methods: This retrospective study was performed in 106 patients with atrial fibrillation from 2012 to 2013. The primary efficacy endpoint was the composite of stroke, transient ischemic attack, myocardial infarction, and cardiovascular death. The primary safety measure was major bleeding. To evaluate the peri-procedural effects of warfarin treatment, we studied whether target INR was maintained, as well as the maintenance period of the therapeutic range. Quality of treatment was measured by time in therapeutic range (TTR) by using the Rosendaal method. Results: There were no thromboembolic events, but TEE examination at time of cardioversion showed a left atrial thrombus in three patients (2.8%). Bleeding complications after cardioversion occurred in 2 patients (1.9%). The average INR value at the time of cardioversion was 2.59±0.8, and was within the therapeutic range in 83 patients (78%). Analysis of the patients in whom the value was within the therapeutic range twice consecutively showed that the ratio of TTR was 80% and the therapeutic range was maintained in 67 patients (63%) for an average of 4.90 weeks prior to cardioversion. Similarly, 76 patients (72%) had a stable INR within the therapeutic range for an average of 5.70 weeks and a mean TTR of 83%. Conclusion: Pharmacists significantly contributed to appropriate warfarin treatment with close monitoring during cardioversion. Likewise, active pharmacist monitoring and systemic management should be considered to reduce thromboembolism and bleeding complications in the peri-cardioversion period.
Abstract
Objective: Direct current cardioversion for atrial fibrillation could be associated with the risk of thromboembolic events. Anticoagulation therapy with warfarin (INR 2.0-3.0) is recommended 3 weeks before and 4 weeks after cardioversion to reduce the risk of thromboembolism. This study evaluated warfarin therapy in pharmacist-managed anticoagulant services (ACS). Methods: This retrospective study was performed in 106 patients with atrial fibrillation from 2012 to 2013. The primary efficacy endpoint was the composite of stroke, transient ischemic attack, myocardial infarction, and cardiovascular death. The primary safety measure was major bleeding. To evaluate the peri-procedural effects of warfarin treatment, we studied whether target INR was maintained, as well as the maintenance period of the therapeutic range. Quality of treatment was measured by time in therapeutic range (TTR) by using the Rosendaal method. Results: There were no thromboembolic events, but TEE examination at time of cardioversion showed a left atrial thrombus in three patients (2.8%). Bleeding complications after cardioversion occurred in 2 patients (1.9%). The average INR value at the time of cardioversion was 2.59±0.8, and was within the therapeutic range in 83 patients (78%). Analysis of the patients in whom the value was within the therapeutic range twice consecutively showed that the ratio of TTR was 80% and the therapeutic range was maintained in 67 patients (63%) for an average of 4.90 weeks prior to cardioversion. Similarly, 76 patients (72%) had a stable INR within the therapeutic range for an average of 5.70 weeks and a mean TTR of 83%. Conclusion: Pharmacists significantly contributed to appropriate warfarin treatment with close monitoring during cardioversion. Likewise, active pharmacist monitoring and systemic management should be considered to reduce thromboembolism and bleeding complications in the peri-cardioversion period.
참고문헌 (17)
- Heeringa, J., "Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study", Eur Heart J, 27(8), pp.949~953 (2006)
- Jeong Joon Hoon, "Prevalence of and Risk Factors for Atrial Fibrillation in Korean Adults Older than 40 Years", Journal of Korean Medical Science, 20(1), pp.26~ (2005), 대한의학회
- Wolf, P.A., "Atrial fibrillation as an independent risk factor for stroke: the Framingham Study", Stroke, 22(8), pp.983~988 (1991)
- January, C.T., "2014 AHA", ACC, Circulation, pp.2014, 130(23)[DOI]
- 정병천, "The Korean Heart Rhythm Society’s 2014 Statement on Antithrombotic Therapy for Patients with Nonvalvular Atrial Fibrillation: Korean Heart Rhythm Society", Korean Circulation Journal, 45(01), pp.9~19 (2015), 대한심장학회
- Rosendaal, F.R., "A method to determine the optimal intensity of oral anticoagulant therapy", Thromb Haemost, 69(3), pp.236~239 (1993)
- Garcia, D., "Warfarin maintenance dosing patterns in clinical practice: Implications for safer anticoagulation in the elderly population", Chest, 127(6), pp.2049~2056 (2005)
- Apostolakis, S., "Low stroke risk after elective cardioversion of atrial fibrillation: An analysis of the Flec-SL trial", Int J Cardiol, 168(4), pp.3977~3981 (2013)
- Hansen, M.L., "risk in 16 274 atrial fibrillation patients undergoing direct current cardioversion with and without oral anticoagulant therapy", Europace, 17(1), pp.18~23 (2015)
- Gallagher, M.M., "Embolic complications of direct current cardioversion of atrial arrhythmias: association with low intensity of anticoagulation at the time of cardioversion", J Am Coll Cardiol, 40(5), pp.926~933 (2002)
- Ageno, W., "Oral anticoagulant therapy:Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines", Chest, 141(2 Suppl), pp.e44S~e88S (2012)
- Connolly, S.J., "Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range", Circulation, 118(20), pp.2029~2037 (2008)
- Coleman, C.M., "Novel Oral Anticoagulants for DC Cardioversion Procedures: Utilization and Clinical Outcomes Compared with Warfarin", Pacing Clin Electrophysiol, 38(6), pp.731~737 (2015)
- Cappato, R., "Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation", Eur Heart J, 35(47), pp.3346~3355 (2014)
- Kyoung nam Ye, "Effect of anticoagulation service on patients treated with warfarin", J Kor Soc Health-Syst Pharm, 22(1), pp.46~53 (2005)
- Willey, M.L., "A pharmacist-managed anticoagulation clinic: six-year assessment of patient outcomes", Am J Health Syst Pharm, 60(10), pp.1033~1037 (2003)
- Witt, D.M., "Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy", Chest, 127(5), pp.1515~1522 (2005)