Benefit of Self-Managed Anticoagulation in Patients with Left Ventricular Assist Device

Abstract

Background The exact monitoring of the therapeutic-range international normalized ratio (INR) after left ventricular assist device (LVAD) implantation is an important aim to reduce the risk of thrombosis or bleeding complications. Service providers offer a telemedical anticoagulation service (CS). Methods We compared LVAD patients using the CS (n = 15) to those who received regular medical care (RMC; n = 15) to investigate if telemedicine supervision increased the INR-specific time in the therapeutic range (TTR) during anticoagulation. All patients received self-management training for phenprocoumon medication according to their INR value. INR values were documented for 12 months. A survey (scale: 1 = not satisfied and 10 = very satisfied) was used to determine patient's satisfaction and psychological well-being. Results A total of 1,798 INR measurements were analyzed. The TTRRosendaal was higher in patients undergoing RMC (78.1 ± 14.3%) compared with that in patients using the CS (58.3 ± 28.0%, p = 0.03). The patient's satisfaction with the coagulation setting at the beginning of the study (RMC: 6.7 ± 3.1, CS: 7.2 ± 3.0, p = 0.74) and psychological wellbeing (RMC: 6.5 ± 1.9, CS: 6.5 ± 2.7, p = 0.97) were comparable between both groups. Conclusion We found that INR self-management is superior regarding the efficiency of post-LVAD anticoagulation therapy when compared with telemedical (CS)-based INR management in a small study cohort. Intensive training by experienced staff was able to replace CS.

Telemedicine-Based Management of Oral Anticoagulation Therapy: Systematic Review and Meta-analysis

“…Additionally, a higher heterogeneity is usually expected in meta-analyses of continuous outcomes [ 46 ]. Different baseline TTRs also could have influenced the impact of the intervention, as it is expected that populations with lower baseline TTRs derive a larger benefit from any intervention that promotes a better quality of therapy [ 7 , 34 - 36 ]. Even in recent clinical trials of DOAC versus warfarin, TTR in control groups varied widely across various geographical regions [ 47 ], reaching values as low as 36% in India.…”

“…The 25 studies included 3 cluster randomized controlled trials [17][18][19] and 22 individually randomized parallel-group trials [7][8][9][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38], totaling 25,746 patients. One study held 2 independent comparisons based on different INR target ranges, so these distinct pairs of comparisons are represented as "Vadher a" and "Vadher b" in some analyses [22].…”

“…In 11 studies [17,[20][21][22][25][26][27][28][29]31,35], the telemedicine intervention was mainly based on the use of clinical decision support system for VKA dose adjustment or scheduling of the next visit. Overall, 12 studies [7][8][9]23,24,30,[32][33][34][36][37][38] involved some kind of remote support (either by telephone, mobile app, or internet-based systems) for VKA dose adjustment-8 used self-testing with point-of-care devices for INR measurement, and 4 used conventional laboratory testing. Two studies [18,19] assessed the impact of a multitasking intervention (via a mobile app or a web-based clinical decision support system) for the management of AF in primary care, which included anticoagulation therapy indication and management, along with rate or rhythm control, symptom monitoring, and other cardiovascular risk factors management.…”

Telemedicine-Based Management of Oral Anticoagulation Therapy: Systematic Review and Meta-analysis (Preprint)

“…Additionally, a higher heterogeneity is usually expected in meta-analyses of continuous outcomes [46]. Different baseline TTRs also could have influenced the impact of the intervention, as it is expected that populations with lower baseline TTRs derive a larger benefit from any intervention that promotes a better quality of therapy [7,[34][35][36]. Even in recent clinical trials of DOAC versus warfarin, TTR in control groups varied widely across various geographical regions [47], reaching values as low as 36% in India.…”