Original Article
Primary care monitoring of patients under oral anticoagulation
Monitorização de doentes sob anticoagulação oral numa unidade de cuidados de saúde primários
Pedro Agnelo
, Denise Alexandra, Sara Matias
Corresponding author
Unidade de Saúde Familiar Santigo, Leiria, Portugal
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These drugs have a narrow therapeutic window, requiring monitoring and regular dose adjustment to ensure safe and effective levels of anticoagulation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The advent of new molecules that do not require laboratory control but are significantly more expensive has renewed interest in the classic agents and the quality of INR control. Some authors fear that the results of major clinical trials with these novel agents may have been distorted by comparison with controls in whom the quality of INR control was inadequate.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although studies<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> have shown that these new agents may be more cost-effective, their high direct cost cannot be disregarded since this is currently borne by the patient.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Monitoring of oral anticoagulation therapy</span><p id="par0020" class="elsevierStylePara elsevierViewall">There are three main ways to monitor OAC:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">in specialized hospital consultations or anticoagulation clinics;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">in primary care centers, usually by the patient's general practitioner, in some cases with computer-assisted dosing;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">by patients, using a point-of-care device, either by self-monitoring (patients contact their health center for dose adjustment) or by self-management (patients do the test at home and adjust the dose according to an individualized program).</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">The most common method in Portugal is hospital monitoring,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> with or without specialized clinics, although primary care monitoring is being implemented in less populated areas of the country with limited access to hospital care, as recommended by the Portuguese National Coordinating Body for Cardiovascular Disease. Patient self-monitoring is growing, albeit slowly, the main obstacle being the price of the device and test strips, which are not currently reimbursed under the National Health System. Another factor is the advanced age and/or low educational level of most patients.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Functions of an anticoagulation clinic</span><p id="par0045" class="elsevierStylePara elsevierViewall">According to a recent study by Cruz et al.,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> there are three main requirements for the efficient functioning of an anticoagulation clinic:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">logistical capacity to treat patients;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">technical capacity to perform laboratory tests;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">staff trained and experienced in monitoring oral anti-coagulation.</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">It is important to know whether primary care monitoring can achieve the same quality as specialized hospital units or anticoagulation clinics, since spreading INR monitoring among primary care centers would improve patient access and could result in significant savings. To this end, we present an analysis of our center's experience.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The patients followed in the Santiago family health unit (FHU) have their INR measured on site by a Siemens DCA Vantage<span class="elsevierStyleSup">®</span> analyzer and are then referred to their general practitioner. Two different dosing methods are used: computer-assisted dosing using the TAOnet<span class="elsevierStyleSup">®</span> program and dose adjustment according to the Santiago FHU protocol.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The quality of a center's anticoagulation control is assessed by the time in therapeutic range (TTR) of its patients. TTR can be determined in various ways, the most common of which are calculation of the percentage of all INR measurements within the therapeutic range, cross-sectional analysis of medical records to determine the percentage of patients with therapeutic values at a given point in time compared to the total of number of INR measurements at the same point, and application of the Rosendaal linear interpolation method, which assumes a linear relationship between two consecutive INR measurements and allocates a specific INR value to each day between tests.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Objectives</span><p id="par0080" class="elsevierStylePara elsevierViewall">We set out to analyze the TTR of patients under OAC monitored in the Santiago FHU and to ascertain whether there was any association between the dosing method and the TTR achieved.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Methods</span><p id="par0085" class="elsevierStylePara elsevierViewall">This was a cross-sectional observational study analyzing all INR values determined in the Santiago FHU between January 1 and June 30, 2012 in patients under OAC.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Dose adjustment was performed in one of two ways: computer-assisted dosing using the TAOnet<span class="elsevierStyleSup">®</span> program, in which the current INR value is entered and the program calculates the dose and time to next control, or according to the unit protocol, shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The following characteristics of the study population were analyzed: gender, age, dosing method (protocol vs. computer-assisted), disease necessitating OAC (atrial fibrillation, valve disease, deep vein thrombosis, pulmonary embolism or antiphospholipid syndrome), INR values, and TTR.</p><p id="par0100" class="elsevierStylePara elsevierViewall">TTR was calculated as the percentage of INR measurements within the therapeutic range for each patient (number of INR measurements within the therapeutic range divided by the total number of tests), based on the following values in accordance with national and international guidelines<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">subtherapeutic: INR <2.0;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">therapeutic: INR ≥2.0–≤3.0;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">supratherapeutic: INR >3.0.</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">Patients with a different target therapeutic range from that defined above were excluded.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Data were recorded and analyzed using Excel 2007. For bivariate analysis, the data were imported into SPSS version 17.0 and the Student's t test was applied, after confirmation of normal distribution of data by the Shapiro-Wilks test and of homogeneity of variance by Levene's test. A level of statistical significance of 0.05 was used.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0130" class="elsevierStylePara elsevierViewall">We analyzed all INR values determined during the first six months of 2012, a total of 320 tests in 35 individuals, mean age 69.9±11.25 years (median 73, interquartile range of 17), 63% (n=22) male. The dosing method was chosen by the attending physician and there was no crossover between methods during the study period.</p><p id="par0135" class="elsevierStylePara elsevierViewall">One patient with a mechanical valve prosthesis and a target therapeutic range of 2.5–3.5 was excluded.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Most individuals (n=26, 74%) were under OAC for atrial fibrillation, four (11%) for deep vein thrombosis, two (6%) for pulmonary embolism, two (6%) for valve disease and one (3%) for antiphospholipid syndrome.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Dose adjustments were made according to the unit protocol in most cases (77%), corresponding to 240 tests, while computed-assisted dosing was performed in eight patients (23%), corresponding to 80 tests (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">INR values ranged between 1.1 and 5.0 in the 320 tests, of which 209 (65.3%) were within the target therapeutic range, 77 (24.1%) were subtherapeutic (48.1%<1.5), and 10.6% were supratherapeutic.</p><p id="par0155" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> compares TTR for the three ranges under analysis, overall and according to dosing method. TTR was better in the patient group with computer-assisted dosing, but without statistical significance.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> shows mean, maximum and minimum values per patient. There was a greater tendency for better TTR and less variation in the group with computer-assisted dosing (white circles), as well as lower mean INR and greater variation in the group with dose adjustment according to the protocol.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">TTR in patients under OAC followed in the Santiago FHU was 65.3%. Although TTR was greater and there was less INR variation in patients with computer-assisted dosing, there was no statistically significant association between dosing method and level of INR control.</p><p id="par0170" class="elsevierStylePara elsevierViewall">These results are in agreement with the latest Portuguese studies in this area, and are similar to those achieved in anticoagulation clinics and other primary care centers and higher than those found in a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> of 67 studies, which reported a TTR of only 57% for primary care monitoring.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Computer-assisted dosing resulted in greater TTR and less INR variation, as well as a lower frequency of extreme, particularly subtherapeutic, INR values, as also reported in the literature.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The therapeutic range was defined as INR 2.0–3.0, in accordance with international guidelines, and the cut-offs for dose adjustment were therefore ≤1.9 and ≥3.1. However, according to Rose et al.,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> cut-offs of 1.7 and 3.3 are more appropriate since this avoids excessive dose adjustments which tend to destabilize INR and results in greater TTR.</p><p id="par0185" class="elsevierStylePara elsevierViewall">One obvious limitation of the present study is the small sample size, which would have contributed to the lack of statistical significance in its results.</p><p id="par0190" class="elsevierStylePara elsevierViewall">The authors intend to implement certain improvements in the future, particularly making computer-assisted dosing the preferred method of dose adjustment. They also plan to extend the study to other centers in order to increase the population base, followed by a re-evaluation.</p><p id="par0195" class="elsevierStylePara elsevierViewall">In our experience, computer-assisted dosing appears to facilitate the task of dose adjustment, as well as reducing risk to the patient.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> It also enables dose adjustment to be performed by non-physicians, such as home monitoring by nursing teams.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Some authors fear that the results obtained in major trials with new anticoagulants may have been distorted by comparison with controls in whom the quality of INR control was inadequate. Our results indicate that it would be difficult to obtain similar TTR rates to those reported in these trials, since highly specialized centers would be required, which would inevitably lead to increased indirect costs and concentration of services.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Although most studies report greater efficacy and safety with the new oral anticoagulants, their high cost could be a major barrier to their widespread use, especially since the number of patients under OAC is predicted to rise. Rigorous cost-effectiveness studies are required to dispel doubts concerning the real savings to be gained with these new drugs. Until then, the classic drugs will continue to be used in everyday practice, and hence the quality of anticoagulation control remains just as relevant.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0210" class="elsevierStylePara elsevierViewall">Primary care monitoring of OAC appears to be comparable to that in anticoagulation clinics, is more convenient for patients, and may result in savings through improved patient access and cost reductions in staff and equipment.</p><p id="par0215" class="elsevierStylePara elsevierViewall">The authors are not advocating either classic or novel drugs; while the new agents do not require laboratory control, they entail higher direct costs, which are not currently reimbursed under the National Health Service, with the exception of dabigatran 110 mg, which has not been shown to be superior to warfarin.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:2 [ "identificador" => "xres381478" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction and Objectives" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec360289" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres381479" "titulo" => array:5 [ 0 => "Resumo" 1 => "Introdução e objetivos" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusões" ] ] 3 => array:2 [ "identificador" => "xpalclavsec360290" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Monitoring of oral anticoagulation therapy" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Functions of an anticoagulation clinic" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Objectives" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Methods" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 12 => array:3 [ "identificador" => "sec0045" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Right to privacy and informed consent" ] ] ] 13 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-06-27" "fechaAceptado" => "2013-12-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec360289" "palabras" => array:3 [ 0 => "Anticoagulants" 1 => "International normalized ratio" 2 => "Primary health care" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec360290" "palabras" => array:3 [ 0 => "Anticoagulantes" 1 => "Índice internacional normalizado" 2 => "Cuidados de saúde primários" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">With the advent of new oral anticoagulants that do not require regular laboratory control but are significantly more expensive, there has been renewed interest in the quality of the classic agents and the monitoring of patients taking them. We set out to analyze time in therapeutic range of patients under oral anticoagulation monitored in our health unit, to determine whether primary care monitoring is comparable to that in anticoagulation clinics. At the same time, we aimed to ascertain whether there was any association between the dosing method (unit protocol vs. computer-assisted) and the time in therapeutic range achieved.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We analyzed all INR values determined in our health unit during the first six months of 2012, using Excel 2007 and SPSS version 17.0, and applying the Student's t test for a level of significance of 0.05.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All INR assessments during the first six months of 2012 were recorded, a total of 320 tests; mean patient age was 69.9±11.25 years, 63% male. Dose adjustments were made according to the unit protocol in 77% of cases. Atrial fibrillation was the most prevalent indication. Most values (65.3%) were within the target therapeutic range; 24.1% were subtherapeutic and 10.6% supratherapeutic. Computer-assisted dosing achieved better control than the protocol (72.5% vs. 62.9%), without statistical significance.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Primary care monitoring of oral anticoagulation appears to be comparable to that in anticoagulation clinics, while affording better access and cost reductions.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introdução e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O aparecimento de novos anticoagulantes orais sem necessidade de controlo laboratorial, mas com custos elevados, relançou o debate sobre a importância da qualidade da anticoagulação oral e do controlo dos doentes. Pretendemos determinar o tempo em intervalo terapêutico dos doentes a fazer anticoagulação oral, seguidos na nossa unidade de cuidados primários, analisando se o controlo em cuidados de saúde primários pode ter qualidade comparável à dos centros hospitalares especializados, e verificar a existência de associação entre o método de ajuste de dose (protocolo do serviço <span class="elsevierStyleItalic">versus</span> programa informático) e o nível de controlo.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo analítico, com registo de todos os valores de INR determinados na nossa unidade no primeiro semestre de 2012. Programas: Excel 2007, SPSS v. 17.0. Testes: t de Student (n.s. 0,05).</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Obtivemos resultados de 320 testes referentes a 35 doentes, com uma média de idades de 69,9±11,25 anos, sendo 63% do sexo masculino. O ajuste da dose foi feito em 77%, de acordo com o protocolo do serviço. A fibrilhação auricular foi a indicação mais prevalente. A maioria dos testes (65,3%) encontrava-se dentro do intervalo terapêutico; 24,1% apresentaram valores infraterapêuticos e 10,6% supraterapêuticos. O ajuste informático obteve melhor controlo que o protocolo (72,5 <span class="elsevierStyleItalic">versus</span> 62,9%), sem significado estatístico.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusões</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A monitorização a nível de cuidados de saúde primários pode ter qualidade igual à das clínicas de anticoagulação, permitindo o controlo mais conveniente dos doentes, dispondo de facilidade de acesso e a diluição dos custos.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Agnelo P, Alexandra D, Matias S. Monitorização de doentes sob anticoagulação oral numa unidade de cuidados de saúde primários. Rev Port Cardiol. 2014;33:397–401.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 861 "Ancho" => 1590 "Tamanyo" => 98547 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Time in therapeutic range according to dosing method.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1854 "Ancho" => 2527 "Tamanyo" => 211468 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Mean INR values and variation by patient.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patients with active bleeding or INR >7 are referred to the emergency department.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">INR value \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Action \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase dose by 2.5 mg/week \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥1.5 and <1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase dose by 1.25 mg/week \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9–3.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maintain dose \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>3.1–4.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Omit one dose and reduce dose by 2.5 mg/week \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspend medication for three days and reduce dose by 5 mg/week. Weekly control until level stabilizes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab581522.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Santiago Family Health Unit protocol according to INR value.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Dosing method \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">TTR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unit protocol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p=0.356<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Computer-assisted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab581521.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Student's t test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Time in therapeutic range according to dosing method.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L. Wallentin" 1 => "S. Yusuf" 2 => "M.D. Ezekowitz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(10)61194-4" "Revista" => array:7 [ "tituloSerie" => "Lancet" "fecha" => "2010" "volumen" => "376" "paginaInicial" => "975" "paginaFinal" => "983" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20801496" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S030573721300090X" "estado" => "S300" "issn" => "03057372" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The future landscape of anticoagulation management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.I. Bussey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1592/phco.31.12.1151" "Revista" => array:6 [ "tituloSerie" => "Pharmacotherapy" "fecha" => "2011" "volumen" => "31" "paginaInicial" => "1151" "paginaFinal" => "1155" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22122177" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Análisis de coste-efectividad de dabigatrán para la prevención de ictus y embolia sistémica en fibrilación auricular no valvular en Espanã" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.R. González-Juanatey" 1 => "J. Álvarez-Sabin" 2 => "J.M. Lobos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.recesp.2012.06.006" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "2012" "volumen" => "65" "paginaInicial" => "901" "paginaFinal" => "910" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22958943" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clínicas de anticoagulação, situação atual e perspectivas futuras" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Cruz" 1 => "M. Campos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0870-2551(12)70040-9" "Revista" => array:7 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2012" "volumen" => "31" "numero" => "Suppl. I" "paginaInicial" => "51" "paginaFinal" => "57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22541036" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevenção do tromboembolismo na fibrilhação auricular" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C. Aguiar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2012" "volumen" => "31" "numero" => "Suppl. I" "paginaInicial" => "13" "paginaFinal" => "22" "itemHostRev" => array:3 [ "pii" => "S0959804909700474" "estado" => "S300" "issn" => "09598049" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Terapêutica Antitrombótica da Fibrilhação Auricular" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Coordenação Nacional para as Doenças Cardiovasculares" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2009" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "European guidelines on cardiovascular disease prevention in clinical practice (version 2012)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Joint ESC Guidelines" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehs092" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2012" "volumen" => "33" "paginaInicial" => "1635" "paginaFinal" => "1701" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22555213" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of study setting on anticoagulation control: a systematic review and metaregression" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Van Walraven" 1 => "A. Jennings" 2 => "N. Oake" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.129.5.1155" "Revista" => array:5 [ "tituloSerie" => "Chest" "fecha" => "2006" "volumen" => "129" "paginaInicial" => "1155" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16685005" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Warfarin dose management affects INR control" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.J. Rose" 1 => "A. Ozonoff" 2 => "D.R. Berlowitz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1538-7836.2008.03199.x" "Revista" => array:6 [ "tituloSerie" => "J Thromb Haemost" "fecha" => "2009" "volumen" => "7" "paginaInicial" => "94" "paginaFinal" => "101" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18983486" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Computerised assistance for warfarin dosage – effects on treatment quality" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Dimberg" 1 => "B. Grzymala-Lubanski" 2 => "A. Hägerfelth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejim.2012.07.011" "Revista" => array:6 [ "tituloSerie" => "Eur J Intern Med" "fecha" => "2012" "volumen" => "23" "paginaInicial" => "742" "paginaFinal" => "744" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22917757" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An international multicentre randomized study of computer-assisted oral anticoagulant dosage versus medical staff dosage" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L. Poller" 1 => "M. Keown" 2 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 3 | 10 |
| 2024 October | 48 | 28 | 76 |
| 2024 September | 52 | 27 | 79 |
| 2024 August | 57 | 28 | 85 |
| 2024 July | 49 | 36 | 85 |
| 2024 June | 43 | 26 | 69 |
| 2024 May | 47 | 23 | 70 |
| 2024 April | 41 | 26 | 67 |
| 2024 March | 56 | 30 | 86 |
| 2024 February | 31 | 31 | 62 |
| 2024 January | 17 | 26 | 43 |
| 2023 December | 19 | 28 | 47 |
| 2023 November | 46 | 25 | 71 |
| 2023 October | 20 | 18 | 38 |
| 2023 September | 29 | 22 | 51 |
| 2023 August | 27 | 18 | 45 |
| 2023 July | 28 | 8 | 36 |
| 2023 June | 26 | 13 | 39 |
| 2023 May | 45 | 30 | 75 |
| 2023 April | 23 | 7 | 30 |
| 2023 March | 38 | 28 | 66 |
| 2023 February | 37 | 26 | 63 |
| 2023 January | 24 | 17 | 41 |
| 2022 December | 35 | 25 | 60 |
| 2022 November | 48 | 29 | 77 |
| 2022 October | 27 | 18 | 45 |
| 2022 September | 32 | 36 | 68 |
| 2022 August | 25 | 32 | 57 |
| 2022 July | 36 | 40 | 76 |
| 2022 June | 16 | 19 | 35 |
| 2022 May | 29 | 36 | 65 |
| 2022 April | 32 | 33 | 65 |
| 2022 March | 29 | 40 | 69 |
| 2022 February | 28 | 40 | 68 |
| 2022 January | 39 | 28 | 67 |
| 2021 December | 33 | 24 | 57 |
| 2021 November | 42 | 40 | 82 |
| 2021 October | 52 | 28 | 80 |
| 2021 September | 25 | 32 | 57 |
| 2021 August | 35 | 32 | 67 |
| 2021 July | 24 | 20 | 44 |
| 2021 June | 26 | 15 | 41 |
| 2021 May | 26 | 29 | 55 |
| 2021 April | 59 | 42 | 101 |
| 2021 March | 47 | 12 | 59 |
| 2021 February | 60 | 18 | 78 |
| 2021 January | 25 | 10 | 35 |
| 2020 December | 33 | 7 | 40 |
| 2020 November | 34 | 9 | 43 |
| 2020 October | 8 | 5 | 13 |
| 2020 September | 50 | 16 | 66 |
| 2020 August | 14 | 6 | 20 |
| 2020 July | 39 | 4 | 43 |
| 2020 June | 20 | 2 | 22 |
| 2020 May | 44 | 6 | 50 |
| 2020 April | 34 | 9 | 43 |
| 2020 March | 35 | 13 | 48 |
| 2020 February | 49 | 17 | 66 |
| 2020 January | 23 | 6 | 29 |
| 2019 December | 26 | 9 | 35 |
| 2019 November | 19 | 5 | 24 |
| 2019 October | 41 | 12 | 53 |
| 2019 September | 18 | 4 | 22 |
| 2019 August | 33 | 3 | 36 |
| 2019 July | 40 | 8 | 48 |
| 2019 June | 23 | 5 | 28 |
| 2019 May | 42 | 8 | 50 |
| 2019 April | 25 | 14 | 39 |
| 2019 March | 80 | 10 | 90 |
| 2019 February | 71 | 12 | 83 |
| 2019 January | 57 | 5 | 62 |
| 2018 December | 51 | 11 | 62 |
| 2018 November | 97 | 3 | 100 |
| 2018 October | 217 | 14 | 231 |
| 2018 September | 53 | 10 | 63 |
| 2018 August | 46 | 12 | 58 |
| 2018 July | 39 | 3 | 42 |
| 2018 June | 59 | 10 | 69 |
| 2018 May | 81 | 10 | 91 |
| 2018 April | 69 | 5 | 74 |
| 2018 March | 102 | 8 | 110 |
| 2018 February | 82 | 4 | 86 |
| 2018 January | 75 | 3 | 78 |
| 2017 December | 98 | 8 | 106 |
| 2017 November | 51 | 12 | 63 |
| 2017 October | 39 | 13 | 52 |
| 2017 September | 45 | 11 | 56 |
| 2017 August | 40 | 18 | 58 |
| 2017 July | 30 | 11 | 41 |
| 2017 June | 53 | 9 | 62 |
| 2017 May | 41 | 9 | 50 |
| 2017 April | 30 | 2 | 32 |
| 2017 March | 48 | 23 | 71 |
| 2017 February | 42 | 1 | 43 |
| 2017 January | 36 | 5 | 41 |
| 2016 December | 31 | 17 | 48 |
| 2016 November | 26 | 7 | 33 |
| 2016 October | 34 | 9 | 43 |
| 2016 September | 47 | 14 | 61 |
| 2016 August | 12 | 1 | 13 |
| 2016 July | 25 | 4 | 29 |
| 2016 June | 12 | 7 | 19 |
| 2016 May | 8 | 4 | 12 |
| 2016 April | 24 | 1 | 25 |
| 2016 March | 49 | 20 | 69 |
| 2016 February | 57 | 32 | 89 |
| 2016 January | 47 | 17 | 64 |
| 2015 December | 47 | 19 | 66 |
| 2015 November | 55 | 16 | 71 |
| 2015 October | 51 | 22 | 73 |
| 2015 September | 54 | 22 | 76 |
| 2015 August | 46 | 19 | 65 |
| 2015 July | 30 | 5 | 35 |
| 2015 June | 33 | 9 | 42 |
| 2015 May | 53 | 11 | 64 |
| 2015 April | 34 | 16 | 50 |
| 2015 March | 33 | 8 | 41 |
| 2015 February | 30 | 7 | 37 |
| 2015 January | 48 | 9 | 57 |
| 2014 December | 54 | 18 | 72 |
| 2014 November | 46 | 16 | 62 |
| 2014 October | 67 | 23 | 90 |
| 2014 September | 88 | 40 | 128 |
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