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Time to therapeutic range (TtTR), anticoagulation control, and cardiovascular events in vitamin K antagonists–naive patients with atrial fibrillation

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Background: Vitamin K antagonists (VKAs) reduce cardiovascular events (CVEs) in atrial fibrillation (AF) when a time in therapeutic range (TiTR) >70% is achieved. Factors affecting the time to achieve the… Click to show full abstract

Background: Vitamin K antagonists (VKAs) reduce cardiovascular events (CVEs) in atrial fibrillation (AF) when a time in therapeutic range (TiTR) >70% is achieved. Factors affecting the time to achieve the TR (TtTR) are unknown. Methods: Prospective observational study including 1,406 nonvalvular AF patients starting VKAs followed for a mean of 31.3 months (3,690 patient/year); TiTR, TtTR, and SAMe‐TT2R2 score were calculated, and CVEs were recorded. Results: Median TtTR was 8.0 days (interquartile range 5.0‐18.0). Patients with high TtTR (ie, >75th percentile) were more likely to be in AF than in sinus rhythm at entry (odds ratio [OR]: 1.423, P = .011). Median TiTR was 60.0%; low TiTR (below median) was associated with SAMe‐TT2R2 score (OR: 1.175, P = .001), high TtTR (>75th percentile, OR: 1.357, P = .017), and number of international normalized ratio checks (OR: 0.998, P = .049). We recorded 113 CVEs (3.1%/y), with a higher rate seen in patients with TtTR >75th percentile compared to those below (log‐rank test, P = .006). A multivariable Cox regression analysis showed that SAMe‐TT2R2 score (hazard ratio [HR]: 1.331, P < .001), TtTR >75th percentile (HR: 1.505, P = .047), TiTR <70% (HR: 1.931, P = .004), number of international normalized ratio checks (HR: 0.988, P < .001), digoxin (HR: 1.855, P = .008), and proton‐pump inhibitors (HR: 0.452, P < .001) were independently associated with CVEs. Conclusions: High TtTR is associated with poorer long‐term quality of VKAs therapy. Patients with TtTR >18 days or with high SAMe‐TT2R2 score should be considered for treatment with non–vitamin K oral anticoagulants.

Keywords: titr; atrial fibrillation; range; time; cardiovascular events; vitamin antagonists

Journal Title: American Heart Journal
Year Published: 2018

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