Telemedicine-guided, very low-dose international normalized ratio self-control in patients with mechanical heart valve implants

• Published in: European heart journal Vol. 36; no. 21; pp. 1297 - 1305
• Main Authors: Koertke, Heinrich, Zittermann, Armin, Wagner, Otto, Secer, Songuel, Sciangula, Alfonso, Saggau, Werner, Sack, Falk-Udo, Ennker, Jürgen, Cremer, Jochen, Musumeci, Francesco, Gummert, Jan F
• Format: Journal Article
• Language: English
• Published: England 01.06.2015
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Analysis of Variance; Anticoagulants - administration & dosage; Aortic Valve; Drug Administration Schedule; Female; Heart Valve Diseases - surgery; Heart Valve Prosthesis - adverse effects; Hemorrhage - chemically induced; Humans; International Normalized Ratio; Male; Middle Aged; Mitral Valve; Self Care - methods; Telemedicine; Thromboembolism - prevention & control; Treatment Outcome; Vitamin K - antagonists & inhibitors; Young Adult; Bleeding event; Oral anticoagulation; Thrombotic event; Vitamin K antagonists; Mechanical heart valve replacement; International normalized ratio
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehu330

To study in patients performing international normalized ratio (INR) self-control the efficacy and safety of an INR target range of 1.6-2.1 for aortic valve replacement (AVR) and 2.0-2.5 for mitral valve replacement (MVR) or double valve replacement (DVR). In total, 1304 patients undergoing AVR, 189 undergoing MVR and 78 undergoing DVR were randomly assigned to low-dose INR self-control (LOW group) (INR target range, AVR: 1.8-2.8; MVR/DVR: 2.5-3.5) or very low-dose INR self-control once a week (VLO group) and twice a week (VLT group) (INR target range, AVR: 1.6-2.1; MVR/DVR: 2.0-2.5), with electronically guided transfer of INR values. We compared grade III complications (major bleeding and thrombotic events; primary end-points) and overall mortality (secondary end-point) across the three treatment groups. Two-year freedom from bleedings in the LOW, VLO, and VLT groups was 96.3, 98.6, and 99.1%, respectively (P = 0.008). The corresponding values for thrombotic events were 99.0, 99.8, and 98.9%, respectively (P = 0.258). The risk-adjusted composite of grade III complications was in the per-protocol population (reference: LOW-dose group) as follows: hazard ratio = 0.307 (95% CI: 0.102-0.926; P = 0.036) for the VLO group and = 0.241 (95% CI: 0.070-0.836; P = 0.025) for the VLT group. The corresponding values of 2-year mortality were = 1.685 (95% CI: 0.473-5.996; P = 0.421) for the VLO group and = 4.70 (95% CI: 1.62-13.60; P = 0.004) for the VLT group. Telemedicine-guided very low-dose INR self-control is comparable with low-dose INR in thrombotic risk, and is superior in bleeding risk. Weekly testing is sufficient. Given the small number of MVR and DVR patients, results are only valid for AVR patients.