Management of oral anticoagulation in a population of children with cardiac disease using a computerised system to support decision-making

Abstract

anticoagulation is to ensure that treatment is effective and safe in preventing thromboembolism, and is without haemorrhagic complications. In patients with the Fontan circulation, the incidence of thromboembolism is reported as between 3 and 16 percent by retrospective studies. 1 In patients with a single mechanical valve not receiving any antithrombotic therapy, the risk of thromboembolism is between 5.7 and 20 percent per patient-year, depending on the site and type of valve. 2-4 With anticoagulation, the risk of thromboembolism is less than 5.3 percent per patient-year, 5 and the risk of serious haemorrhage is less than 3.2 percent per patient-year. 6 Furthermore achieving optimal anticoagulation in children with cardiac disease involves many complexities. Streif et al. 7 have demonstrated the profound effect of young age, and the effect of congenital cardiac disease, in particular the Fontan circulation, on dosages of warfarin. Antithrombotic therapy in children is also affected by recurrent infection, issues of compliance, Abstract Objective: To assess the impact of a computerised system to support decision-making concerning the management of warfarin used in maintenance of anti-coagulation. Design: Retrospective case series study comparing manual and computerised records of prescribing. Setting: A tertiary paediatric cardiology department in a teaching hospital. Participants: The 26 children receiving warfarin to maintain anticoagulation at the time of introduction of a computerised system to support decision-making. Interventions: A rules-based computerised system to support decisions, based on existing departmental guidelines, for management of anticoagulation using warfarin was introduced to aid prescribing physicians. Main outcomes: We assessed the stability of the International Normalised Ratio, along with the number of checks made of the ratio, and the adjustments of dosage. Dosages, and recheck interval prescriptions, were compared to the guidelines established by our department. Results: We compared 274 prescriptions made manually, and 608 made using the computerised system to support decision-making, covering periods of 4, and 11, months respectively. The mean proportion of time spent by the patients within their target range for the International ratio was maintained during the period studied, at 76 percent versus 79 percent (p ϭ 0.79). The median number of checks of the ratio made for each patient over a period of 28 days was unchanged, at 1.9 versus 2.1 (p ϭ 0.58). There was a significant change in prescribing practices, which more closely followed the departmental guidelines. Conclusion: The introduction of a computerised system to support decision-making maintained the stability of the International ratio using warfarin, without increasing the number of checks or adjustments of dosages, in a point-of-care service for anticoagulation in children.

Improved Long-Term Survival for Rheumatic Mitral Valve Repair Compared to Replacement in the Young

“…This is despite the use of a computerized anticoagulation service that has shown to improve stability of international normalized ratio, by our New Zealand resident patients. 15 In comparison, those who underwent MV repair were all free from these events. These data, not surprisingly, are concordant with previous studies showing up to 100% freedom from thrombotic, embolic, and events with MV repair in the young.…”

Recommendations for the development of a dedicated pediatric anticoagulation service: communication from the SSC of the ISTH

“…Options for data management include computerized dosing systems (such as DAWN; 4S, Milnthorpe, UK), a dosing nomogram, or a database. Two pediatric cohort studies reported increased efficacy of vitamin K antagonist (VKA) management with a computerized dosing program as compared with manual dosing, with improvements in target INR range achievement . Neither study was conducted in centers with a dedicated anticoagulation service, and the method used to determine target range achievement varied between the studies .…”

“…Two pediatric cohort studies reported increased efficacy of vitamin K antagonist (VKA) management with a computerized dosing program as compared with manual dosing, with improvements in target INR range achievement . Neither study was conducted in centers with a dedicated anticoagulation service, and the method used to determine target range achievement varied between the studies . Pediatric dosing nomograms for VKA therapy and low molecular weight heparin (LMWH) have been published, and safety and efficacy have been successfully demonstrated .…”

Position statement of the World Heart Federation on the prevention and control of rheumatic heart disease

“…Point-of-care portable monitoring of anticoagulant status is feasible and has been shown to improve clinical care. 72 However, the majority of low-income countries, many with geographically dispersed populations, rely on centralized laboratories and are stymied by transport, procurement, and communication issues. The result is often suboptimal therapeutic monitoring of anticoagulation with c atastrophic outcomes, particularl y embolic and h aemorrhagic stroke.…”