Key result
Bleeding before LVAD events is linked to ~24-point higher time above range than thrombosis.
Why the study?
Left ventricular assist devices require anticoagulation with vitamin K antagonists to reduce thrombotic events, and the correlation between time in therapeutic range and bleeding or thrombotic clinical outcomes needed evaluation.
Does time in therapeutic range (TTR) and time above therapeutic range with warfarin correlate with bleeding and thrombotic events in patients with left ventricular assist devices?
Cohort (n=51)
No
Does time in therapeutic range (TTR) and time above therapeutic range with warfarin correlate with bleeding and thrombotic events in patients with left ventricular assist devices?
Spending a greater percentage of time with a supratherapeutic INR and concurrent low-dose aspirin use in the 30 days prior are significantly associated with bleeding events in LVAD patients on warfarin, highlighting the utility of TTR monitoring.
Left ventricular assist devices (LVADs) require anticoagulation therapy with vitamin K antagonists to reduce the risk of thrombotic events. The quality of anticoagulation may be assessed by the time in therapeutic range (TTR). We analyzed a retrospective cohort of LVAD patients at a single institution from January 2012 to September 2014. Primary outcomes included TTR during the study time period and TTR 30 days preceding a bleeding or thrombotic event. Fifty-one patients (mean age 57.0 ± 14.6 years; 78% male) had an overall TTR of 52%. Median international normalized ratio (INR) preceding a bleeding and thrombotic event was 2.7 and 2.2, respectively (p = 0.049). In the 30 days before an event, patients with a bleeding event were more likely to be on low-dose aspirin (37% vs. 12%; p = 0.018) and spend a higher proportion of time above therapeutic range (41% vs. 17%; p = 0.007) compared with those with thrombotic events. The association between a greater percentage of time above therapeutic range in the 30 days before a bleeding event demonstrates the importance of avoiding a supratherapeutic INR in the LVAD patient population and the usefulness of TTR as a measure of the overall quality of anticoagulation and monitoring in an LVAD cohort.
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Halder et al. (2016) conducted a cohort in Left ventricular assist device (LVAD) patients anticoagulated with warfarin (n=51). Warfarin anticoagulation quality (Time in Therapeutic Range [TTR] and time above therapeutic range) vs. Patients with bleeding events vs. patients with thrombotic events was evaluated on Time in therapeutic range (TTR) during the study time period and TTR 30 days preceding a bleeding or thrombotic event (p=0.007). Warfarin anticoagulation in LVAD patients yielded an overall TTR of 52%, with higher time above range in the 30 days before bleeding vs. thrombosis (41% vs. 17%; p=0.007).
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