Patients' time in therapeutic range on warfarin among atrial fibrillation patients in Warfarin Medication Therapy Adherence Clinic

Abstract

Background: The quality of warfarin therapy can be determined by the time in the therapeutic range (TTR) of international normalized ratio (INR). The estimated minimum TTR needed to achieve a benefit from warfarin therapy is ≥ 60%.

Aim: To determine TTR and the predictors of poor TTR among atrial fibrillation patients who receive warfarin therapy.

Methods: A retrospective observational study was conducted at a cardiology referral center in Selangor, Malaysia. A total of 420 patients with atrial fibrillation and under follow-up at the pharmacist led Warfarin Medication Therapeutic Adherence Clinic between January 2014 and December 2018 were included. Patients' clinical data, information related to warfarin therapy, and INR readings were traced through electronic Hospital Information system. A data collection form was used for data collection. The percentage of days when INR was within range was calculated using the Rosendaal method. The poor INR control category was defined as a TTR < 60%. Predictors for poor TTR were further determined by using logistic regression.

Results: A total of 420 patients [54.0% male; mean age 65.7 (10.9) years] were included. The calculated mean and median TTR were 60.6% ± 20.6% and 64% (interquartile range 48%-75%), respectively. Of the included patients, 57.6% (n = 242) were in the good control category and 42.4% (n = 178) were in the poor control category. The annual calculated mean TTR between the year 2014 and 2018 ranged from 59.7% and 67.3%. A high HAS-BLED score of ≥ 3 was associated with poor TTR (adjusted odds ratio, 2.525; 95% confidence interval: 1.6-3.9, P < 0.001).

Conclusion: In our population, a high HAS-BLED score was associated with poor TTR. This could provide an important insight when initiating an oral anticoagulant for these patients. Patients with a high HAS-BLED score may obtain less benefit from warfarin therapy and should be considered for other available oral anticoagulants for maximum benefit.

Keywords: Atrial fibrillation; HAS-BLED score; International normalized ratio; Oral anticoagulants; Time in therapeutic range; Warfarin Medication Therapeutic Adherence Clinic.

Figure 1

Flow diagram describing the selection of data for the analysis reported. AF: Atrial fibrillation; INR: International normalized ratio; MTAC: Medication Therapeutic Adherence Clinic.

Figure 2

Mean percentage of the time in therapeutic range among atrial fibrillation patients. TTR: Time in therapeutic range.

Figure 3

HAS-BLED score vs median time in therapeutic range (%). TTR: Time in therapeutic range.