INR-Selbstmanagement nach mechanischem Herzklappenersatz: ESCAT (Early Self-Controlled Anticoagulation Trial)

Abstract

Severe thromboembolic and hemorrhagic complications following mechanical heart valve replacement essentially occur due to intense oral anticoagulation and fluctuating individual INR values around the target range. INR self-management can help to minimize these fluctuations. Beginning this therapeutic control immediately after mechanical heart valve replacement further reduces anticoagulant-induced complications. Included in the study were 1200 patients. The quality of oral anticoagulation also improved through INR self-management. Over an observation period of two years, nearly 80 % of INR values recorded by the patients themselves were within the target therapeutic range of 2.5-4.5. This corresponds to a high significance of p < = 0.001 in favor of INR self-management. Only 64.9 % of INR values monitored by family practitioners were within the desired range. The results differed slightly in quality between patient groups with different levels of training (comprehensive, secondary modern, grammar with or without university). Of patients trained in INR self-management following mechanical heart valve replacement, 91.7 % maintained their competence in this technique throughout the entire follow-up period. Only 8.3 % of those trained immediately after surgery were unable to continue with INR self-management.

Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data

“…For other disorders, over 10% of participants from nine trials 17,[19][20][21][22][23][24]36,37 were included. In eight trials, [17][18][19][20][21]23,37,38 just under half (46%) of those in the intervention group used self-management and in three trials, 22,24,36 just over half (54%) used self-testing only with dose adjustments undertaken by their regular clinician (table 1).…”

“…Of 21 original trials, including 7598 participants, we present results for 6417 (84%) participants. Table 1 shows 11 included trials: three in the USA, 22,24,36 two in Germany, 18,38 and one each from Austria and Germany, 23 Canada, 37 Denmark, 21 Nether lands, (table 1). For all trials, we verifi ed clear methods for randomisation, allocation concealment, and intention-to-treat analyses.…”

“…Over a third of participants had a mechanical heart valve insertion; one trial 18 included only participants with this indication. Over half of participants had atrial fi brillation; one trial 38 included only participants with this indication.…”

“…Suffi cient data from eight trials [17][18][19][20][21][22][23][24] were available for us to calculate the mean time in therapeutic range at timepoints of 7 days, 30 days, 90 days, 6 months, and 1 year by the method of linear interpolation set out by Rosendaal and colleagues. 25 We assessed publication bias by constructing a funnel plot of precision (SE of the log hazard ratio) against hazard ratio for the endpoints of major haemorrhage and thromboembolic events, 6 Data are range (mean) or number (%).…”

In defence of current treatment options: where are we now?

“…PSM provides an average increase of 20-25% in the proportion of patients achieving their target INR, and a substantial reduction in the rate of complications. [33][34][35][36][37] The reason for these improvements lies in the fact that with PSM, patients are able to control their therapy on a weekly basis when compared with substantially longer intervals (3-4 weeks) during usual care. In defence of current treatment options E7…”