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Temporal trends of time in therapeutic range and incidence of cardiovascular events in patients with non-valvular atrial fibrillation

Published:April 11, 2018DOI:https://doi.org/10.1016/j.ejim.2018.04.007

      Highlights

      • Optimal time in therapeutic range (TTR) is essential for an effective stroke prevention.
      • To prospectively analyse temporal trends of TTR in atrial fibrillation (AF) patients
      • A decrease of TTR <70% over time is observed in almost 20% of AF patients.
      • Temporally worsening TTR (from > to <70%) is associated with higher cardiovascular risk.

      Abstract

      Background

      Optimal time in therapeutic range (TTR) of vitamin K antagonists (VKAs) is crucial for cardiovascular events (CVEs) prevention in non-valvular atrial fibrillation (NVAF). The relationship between temporal changes of TTR and the incidence of CVEs has been poorly investigated. We investigated 1) temporal trends of TTR in a long-term follow-up of NVAF patients; 2) the incidence of CVEs according to changes of TTR.

      Methods

      Prospective observational study including 1341 NVAF outpatients (mean age 73.5 years, 42.5% male) starting VKAs. Patients were divided into 4 groups: Group 0: Optimal TTR, consistently ≥70% (n = 241); Group 1: Temporally worsening TTR, from above to below 70% (n = 263); Group 2: Temporally improving TTR, from below to above 70% (n = 270); Group 3: Suboptimal TTR, consistently <70% (n = 567).

      Results

      In a mean follow-up of 37.7 months (4214.2 patient-years), 108 CVEs occurred (2.6%/year). Survival analysis showed a graded increased risk of CVEs in relation to temporal changes in TTR, with the worst outcomes in Groups 1 and 3 (log-rank test p = 0.013). Multivariable Cox proportional hazards regression analysis showed that Group 1 vs. 0 (HR: 2.096; 95%CI 1.061–4.139, p = 0.033), Group 3 vs. 0 (HR: 2.292; 95%CI 1.205–4.361, p = 0.011), CHA2DS2VASc score (HR:1.316; 95%CI 1.153–1.501, p < 0.001) and PPIs (HR:0.453; 95%CI 0.285–0.721, p = 0.001) were independently associated with CVEs.

      Conclusion

      A decrease of TTR <70% over time is observed in almost 20% of NVAF patients. Patients with worsening TTR temporally (ie. from initially above 70% to below 70%) have similar risk of CVEs of patients with consistently suboptimal anticoagulation.

      Keywords

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