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Admission international normalized ratio levels, early treatment strategies, and major bleeding risk among non-ST-segment-elevation myocardial infarction patients on home warfarin therapy: insights from the National Cardiovascular Data Registry.

Publication ,  Journal Article
Subherwal, S; Peterson, ED; Chen, AY; Roe, MT; Washam, JB; Gage, BF; Bach, RG; Bhatt, DL; Wiviott, SD; Lopes, RD; Alexander, KP; Wang, TY
Published in: Circulation
March 20, 2012

BACKGROUND: Non-ST-segment-elevation myocardial infarction patients on home warfarin pose treatment concerns because of their potential increased risk of bleeding. Expert opinion from the American College of Cardiology/American Heart Association guidelines suggest holding anticoagulants and initiating antiplatelet therapy among therapeutically anticoagulated non-ST-segment-elevation myocardial infarction patients. Yet, little is known about contemporary treatment patterns and bleeding risks in this population. METHODS AND RESULTS: We stratified 5787 non-ST-segment-elevation myocardial infarction patients on home warfarin therapy using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines by admission international normalized ratio (INR) levels: subtherapeutic (INR <2), therapeutic (INR, 2-3), and supratherapeutic (INR >3). Multivariable logistic generalized estimating equations models were constructed to examine the associations between admission INR level, early antithrombotic treatment and invasive therapy, and risk of in-hospital major bleeding. Among these patients, 46%, 35%, and 19% had subtherapeutic, therapeutic, and supratherapeutic admission INR levels, respectively. Risk of major bleeding was higher among patients with therapeutic (15%; adjusted odds ratio, 1.25; 95% confidence interval [CI], 1.03-1.50) and supratherapeutic (22%; odds ratio, 1.60; 95% CI, 1.30-1.97) anticoagulation compared with the subtherapeutic group (12%). Among patients with admission INR ≥2, 45% were treated with early (within 24 hours) heparin, 35% with early clopidogrel, 14% with early glycoprotein IIb/IIIa inhibitor, and 36% with early invasive strategy. Early antithrombotic treatment was associated with increased bleeding risk (odds ratio, 1.40 [95% CI, 1.14-1.72] for heparin; 1.50 [95% CI, 1.22-1.84] for clopidogrel; and 1.82 [95% CI, 1.43-2.32] for glycoprotein IIb/IIIa inhibitor); however, an early invasive strategy was not (odds ratio, 1.09; 95% CI, 0.86-1.37). No significant interactions were observed between INR level and use of each early treatment in its association with bleeding. CONCLUSIONS: National patterns of early antithrombotic treatment for non-ST-segment-elevation myocardial infarction patients on home warfarin diverge from expert opinion provided by current practice guidelines. Early antithrombotic treatment was associated with increased bleeding risk regardless of admission INR level.

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Published In

Circulation

DOI

EISSN

1524-4539

Publication Date

March 20, 2012

Volume

125

Issue

11

Start / End Page

1414 / 1423

Location

United States

Related Subject Headings

  • Warfarin
  • Treatment Outcome
  • Time Factors
  • Risk Factors
  • Registries
  • Myocardial Infarction
  • Middle Aged
  • Male
  • International Normalized Ratio
  • Humans
 

Citation

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Subherwal, S., Peterson, E. D., Chen, A. Y., Roe, M. T., Washam, J. B., Gage, B. F., … Wang, T. Y. (2012). Admission international normalized ratio levels, early treatment strategies, and major bleeding risk among non-ST-segment-elevation myocardial infarction patients on home warfarin therapy: insights from the National Cardiovascular Data Registry. Circulation, 125(11), 1414–1423. https://doi.org/10.1161/CIRCULATIONAHA.111.059188
Subherwal, Sumeet, Eric D. Peterson, Anita Y. Chen, Matthew T. Roe, Jeffrey B. Washam, Brian F. Gage, Richard G. Bach, et al. “Admission international normalized ratio levels, early treatment strategies, and major bleeding risk among non-ST-segment-elevation myocardial infarction patients on home warfarin therapy: insights from the National Cardiovascular Data Registry.Circulation 125, no. 11 (March 20, 2012): 1414–23. https://doi.org/10.1161/CIRCULATIONAHA.111.059188.
Subherwal S, Peterson ED, Chen AY, Roe MT, Washam JB, Gage BF, Bach RG, Bhatt DL, Wiviott SD, Lopes RD, Alexander KP, Wang TY. Admission international normalized ratio levels, early treatment strategies, and major bleeding risk among non-ST-segment-elevation myocardial infarction patients on home warfarin therapy: insights from the National Cardiovascular Data Registry. Circulation. 2012 Mar 20;125(11):1414–1423.

Published In

Circulation

DOI

EISSN

1524-4539

Publication Date

March 20, 2012

Volume

125

Issue

11

Start / End Page

1414 / 1423

Location

United States

Related Subject Headings

  • Warfarin
  • Treatment Outcome
  • Time Factors
  • Risk Factors
  • Registries
  • Myocardial Infarction
  • Middle Aged
  • Male
  • International Normalized Ratio
  • Humans