Oral anticoagulation and risk of death: a medical record linkage study

Odén, Anders; Fahlén, Martin

doi:10.1136/bmj.325.7372.1073

Cited by 218 publications

(87 citation statements)

References 19 publications

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“…3 A recent report has documented an excess mortality, from bleeding, associated with high INR values and advocates less intensive treatment with INRs of 2.2-2.3 irrespective of the indication for treatment. 4 The latest (1998) guidelines from the British Committee for Standards in Haematology (BCSH) set a target INR for each indication allowing a variation of 0.5 units above or below this figure. 5 Previous studies of patients anticoagulated for atrial fibrillation have stated target INRs ranging from 1.5 to 4.5.…”

Section: Discussionmentioning

confidence: 99%

Spinal subdural haematoma: how relevant is the INR?

2004

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Study design: Case report. Objective: To report a rare cause of spinal cord compression. Setting: University Hospital, Wales, UK. Case report: A 67-year-old gentleman on oral anticoagulation for atrial fibrillation presented with a 4-h history of progressive loss of sensation and weakness in both legs; there was no history of trauma. On examination, he had a flaccid paraplegia with altered sensation in the L1,2,3 dermatomes and complete anaesthesia in the L4,5 distribution. Knee and ankle jerk reflexes were absent, plantars were equivocal and anal sphincter tone was reduced. The patient's international normalized ratio (INR) was 4.1. An MR scan showed an extensive intradural haematoma compressing the cauda equina. The anticoagulation was reversed and an urgent T12-L2 laminectomy was performed; findings were a circumferential haematoma at L1 extending in the anterior canal between T10 and L3. The patient had an uneventful postoperative course generally, but at 1 week there was no neurological recovery. Conclusion: This case highlights that anticoagulation even when well controlled is not without risk. This is particularly of concern as the number of patients receiving long-term anticoagulation therapy has doubled between 1993 and 1998.

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Section: Discussionmentioning

confidence: 99%

Spinal subdural haematoma: how relevant is the INR?

2004

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“…Of these, 14 reported both hemorrhagic and thromboembolic events, 6,21,23,25,[27][28][29][32][33][34][35][36][37]39 3 reported only hemorrhagic events, 22,38,40 and 2 reported only thromboembolic events. 24,26 Half were retrospective cohort studies and two-thirds (68%) were community-based studies.…”

Section: Study Identification and Selectionmentioning

confidence: 99%

“…We included 19 studies published between 1992 and 2007 in our analysis 6,[21][22][23][24][25][26][27][28][29][32][33][34][35][36][37][38][39][40] (Table 1). Of these, 14 reported both hemorrhagic and thromboembolic events, 6,21,23,25,[27][28][29][32][33][34][35][36][37]39 3 reported only hemorrhagic events, 22,38,40 and 2 reported only thromboembolic events.…”

Section: Study Identification and Selectionmentioning

confidence: 99%

“…20,21 For this reason, we conducted a subanalysis of studies that limited their analyses to severe hemorrhagic events, including intracranial hemorrhages and fatal hemorrhages. [21][22][23] Second, it is possible that the indication for oral anticoagulant therapy could influence results. Therefore, we conducted a subanalysis of studies involving only patients who required anticoagulation for atrial fibrillation, venous thromboembolic disease or atherosclerotic disease, including cerebrovascular disease, coronary artery disease and peripheral vascular disease.…”

Section: Sensitivity Analysismentioning

confidence: 99%

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Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis

Oake¹,

Jennings²,

Forster³

et al. 2008

Canadian Medical Association Journal

149

124

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O ral anticoagulant therapy is essential for the treatment and prevention of many thromboembolic disorders. Since anticoagulants can cause serious adverse events, 1-3 physicians monitor the international normalized ratios of patients taking these drugs to ensure that their ratios fall within a target range.An international normalized ratio of 2-3 is the most common target range. Results of previous studies revealed an increased risk of bleeding among patients whose ratios exceeded 4, an increased risk of stroke among patients whose ratios were 1.5-2 and a decreased risk of stroke at a ratio of 2.4. 4,5 However, the evidence supporting the range of 2-3 has some deficiencies. We sought to determine whether the risk of hemorrhagic and thromboembolic events is minimized at an international normalized ratio of 2-3 among patients taking anticoagulants. In addition, it has been observed that patients spend more time with a ratio below 2 than above 3.6,7 The impact of such systematic underanticoagulation on patient outcomes is unknown. We sought to determine the effect of under-or overanticoagulation on the risk of thromboemboli and hemorrhage. Methods Data sourcesWe searched MEDLINE (1966MEDLINE ( -2006 for potentially pertinent studies. We then modified our strategy to include EMBASE (1980EMBASE ( -2006, the Cochrane Central Register of Controlled Trials (1980Trials ( -2006 and CINAHL (1982CINAHL ( -2006 databases. We manually searched references in the Science Citation Index. Our search strategy is outlined in Appendix 1 (available at www.cmaj.ca/cgi/content/full/179/3/235/DC2). Study selection

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“…It remains that a target INR between 1.5 -2.0 is considered by some an effective and safe alternative for patients who need prolonged anticoagulant therapy but are at higher bleeding risk [20]. A review of hemorrhagic risk with anticoagulant therapy shows that exponential risk of bleeding and associated mortality are mostly present at INR values above 3.5 to 4.5 [21][22][23]. These results gave birth to the now famous INR u-shaped risk curve, showing the risk of thrombosis increases steeply at values lower than 1.5, and the risk of bleeding increases sharply at values higher than 5.0 [24].…”

Section: Discussionmentioning

confidence: 99%

Experience Always Wins the Day: Measure of Warfarin Anticoagulation Efficiency in the Internal Medicine Clinic

Nguyen¹

2013

J Hematol

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Background: In the real-life setting of a specialized anticoagulation clinic we think that the patient's INRs fall within the therapeutical range most of the time. Our study aimed to assess the time spent by patients treated by Warfarin with INR between 2.0 and 3.0, as well the time spent between 1.5 and 3.5. We chose this new range (1.5 -3.5) because we think that it is safe and completely acceptable in real-life situation, and requires only minor adjustments to return to treatment goal of 2.0 to 3.0.

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Oral anticoagulation and risk of death: a medical record linkage study

Cited by 218 publications

References 19 publications

Spinal subdural haematoma: how relevant is the INR?

Spinal subdural haematoma: how relevant is the INR?

Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis

Experience Always Wins the Day: Measure of Warfarin Anticoagulation Efficiency in the Internal Medicine Clinic

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