Open Access

Quality of vitamin K antagonist control and outcomes in atrial fibrillation patients: a meta-analysis and meta-regression

  • Elizabeth S Mearns1, 2,
  • C Michael White1, 2,
  • Christine G Kohn1, 2,
  • Jessica Hawthorne1,
  • Ju-Sung Song1,
  • Joy Meng1,
  • Jeff R Schein3,
  • Monika K Raut3 and
  • Craig I Coleman1, 2Email author
Thrombosis Journal201412:14

https://doi.org/10.1186/1477-9560-12-14

Received: 28 February 2014

Accepted: 6 May 2014

Published: 24 June 2014

Abstract

Background

Atrial fibrillation (AF) patients frequently require anticoagulation with vitamin K antagonists (VKAs) to prevent thromboembolic events, but their use increases the risk of hemorrhage. We evaluated time spent in therapeutic range (TTR), proportion of international normalized ratio (INR) measurements in range (PINRR), adverse events in relation to INR, and predictors of INR control in AF patients using VKAs.

Methods

We searched MEDLINE, CENTRAL and EMBASE (1990-June 2013) for studies of AF patients receiving adjusted-dose VKAs that reported INR control measures (TTR and PINRR) and/or reported an INR measurement coinciding with thromboembolic or hemorrhagic events. Random-effects meta-analyses and meta-regression were performed.

Results

Ninety-five articles were included. Sixty-eight VKA-treated study groups reported measures of INR control, while 43 studies reported an INR around the time of the adverse event. Patients spent 61% (95% CI, 59–62%), 25% (95% CI, 23–27%) and 14% (95% CI, 13-15%) of their time within, below or above the therapeutic range. PINRR assessments were within, below, and above range 56% (95% CI, 53–59%), 26% (95% CI, 23–29%) and 13% (95% CI, 11-17%) of the time. Patients receiving VKA management in the community spent less TTR than those managed by anticoagulation clinics or in randomized trials. Patients newly receiving VKAs spent less TTR than those with prior VKA use. Patients in Europe/United Kingdom spent more TTR than patients in North America. Fifty-seven percent (95% CI, 50-64%) of thromboembolic events and 42% (95% CI, 35 – 51%) of hemorrhagic events occurred at an INR <2.0 and >3.0, respectively; while 56% (95% CI, 48-64%) of ischemic strokes and 45% of intracranial hemorrhages (95% CI, 29-63%) occurred at INRs <2.0 and >3.0, respectively.

Conclusions

Patients on VKAs for AF frequently have INRs outside the therapeutic range. While, thromboembolic and hemorrhagic events do occur patients with a therapeutic INR; patients with an INR <2.0 make up many of the cases of thromboembolism, while those >3.0 make up many of the cases of hemorrhage. Managing anticoagulation outside of a clinical trial or anticoagulation clinic is associated with poorer INR control, as is, the initiation of therapy in the VKA-naïve. Patients in Europe/UK have better INR control than those in North America.

Keywords

Vitamin K antagonists Atrial fibrillation International normalized ratio Anticoagulation

Background

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide and increases the risk of ischemic stroke by nearly 5-fold [1, 2]. Studies have demonstrated that adjusted-dose vitamin K antagonists (VKAs) significantly decrease the risk of stroke in AF patients versus placebo or aspirin therapy [3, 4]. However, VKA use can be challenging given the narrow therapeutic international normalized ratio (INR) range, requirement for periodic INR monitoring, high inter-patient variability in response, numerous drug and food interactions and risks related to non-adherence [5].

In previous meta-analyses [69] the quality of anticoagulation control with VKAs has proven to be poor; with an estimated time spent in the therapeutic INR range (TTR) between 55% and 64%. Numerous study-level factors (e.g., VKA dosing setting) have been shown to be an important determinant of the quality of INR control. Thromboembolic events may occur more frequently at an INR <2.0 and major hemorrhagic events at an INR >3.0 [10]. No previous meta-analyses have examined INR control in VKA-experienced as compared to naïve patients as a study-level factor, not all analyses have looked at AF alone, and few have assessed the percentage of INRs in therapeutic range (PINRR) as a quality measure of INR control. Moreover, there has been a substantive increase in the number of studies assessing INRs in patients with AF receiving VKAs in the past few years, lending more power and validity to a systematic assessment of INR control being conducted now.

The primary objective of this systematic review with meta-analyses and meta-regression analyses was to assess VKA INR control in AF patients and the effect of selected study-level factors (including prior VKA treatment experience) on TTR and the PINRR, and to evaluate the relationship between the proportion of VKA-associated hemorrhagic and thromboembolic events that occurred when the INR was above or below the therapeutic range.

Methods

Study selection

A systematic review of MEDLINE, CENTRAL and EMBASE (from 1990 through June 2013) was performed. Our search strategy for Medline is provided in the Additional file 1. Two investigators reviewed all potentially relevant articles independently, with disagreement resolved by a third investigator. Studies were selected for inclusion on the basis of the following criteria: English full-text randomized controlled trials (RCT), prospective cohort studies or retrospective analyses; contained ≥50 patients in each treatment group; conducted in adult patients (≥18 years of age) receiving dose-adjusted VKA with AF as their primary reason for anticoagulation; and INR control reported as TTR, PINRR or report an INR measurement at (within 48 hours of the event) or near (more than 48 hours from the event) the time of a hemorrhagic or thromboembolic event. Studies were excluded if the duration of study was <3 months, the target INR range was other than 2.0 to 3.0, or patient population overlapped with another study. Manual backward citation tracking of references from identified studies and review articles was also performed to identify additional relevant studies.

Data abstraction

Two investigators used a common data abstraction tool, but independently abstracted all data. If a disagreement arose it was resolved by a third investigator. The following study-level information was obtained: author identification, year of publication (1990–2000, 2001–2007 or 2008–2013), whether patients were VKA-naïve (<30% of the population receiving a VKA prior to entering the study) or experienced (>70% of the population receiving a VKA prior to entering the study), geographic location of the study (Europe/United Kingdom (UK), Asia, North America, multinational or other), duration of VKA treatment , specific VKA used, interpolation method, whether patients were utilizing VKA self-management to monitor INR control and the study setting (anticoagulation clinic, RCT, or community/standard practice). The setting was designated using the following definitions: an anticoagulation clinic, if the study took place in an anticoagulation clinic or if the stated role of the study clinicians in patient care was limited to managing anticoagulation; a randomized trial if random allocation was employed to assign subjects to receive warfarin or another non-warfarin therapy; and all others were classified as community practice.

Measures of INR control and outcomes were abstracted from each study including TTR, time spent above range, time spent below range, PINRR, proportion of INR measurements above and below therapeutic range and clinical outcomes of major hemorrhage and thromboembolic events. Major hemorrhages included intracranial hemorrhage (ICH) and extracranial bleeding (bleeding requiring hospitalization, blood transfusion or surgical treatment or occurring at a critical anatomical location). All thromboembolic events were abstracted including ischemic stroke, systemic emboli, venous thromboembolism and myocardial infarction. INR measurements at or near each thromboembolic and hemorrhagic event were abstracted when reported.

Statistical analysis

TTR and PINRR for each study group, as well as the time/proportions below and above range for these measures were expressed as an incidence density using a person-time approach. The numerator was calculated as the proportion of time that the group spent within, below or above the INR range or proportion of INR measurements in, below, or above range multiplied by person-years of follow-up. The denominator was the total person-years of observation for each study group (or the mean/median observation time multiplied by the number of patients in each study group, if person-years of follow-up for the VKA arm(s) in a study was not reported). Ninety-five percent confidence intervals (CIs) were calculated for each incidence density using the Wilson score method without continuity correction. For the purposes of these analyses, all studies were pooled using a random-effects model.

In order to determine how study–level factors influenced TTR or PINRR, both subgroup and meta-regression analyses were conducted. Meta-regression analysis allows evaluating the effect of any given influencing factor independent of the effect of other aspects. A multiple linear mixed method model using both random- and fixed-effects was utilized for meta-regression, which was weighted by the inverse of the variance of TTR or PINRR. Fixed-effects were assumed for study-level factors, including the following covariates: prior experience with VKAs (naïve, experienced, mixed/not reported), study design (community, anticoagulation clinic, RCT), study year (from 1990–2000 and 2001–7, 2008–2013), use of self-management or not, interpolation method (linear or other), geographic region (North America [United States and Canada], Europe/UK, Asia, multinational, other) and duration of VKA treatment (<1 year, ≥1 year). No hierarchy was used in the model for these covariates.

The weighted proportion of thromboembolic and hemorrhagic events occurring outside of the INR range for each study group was also calculated. For this analysis, the numerator was the number of thromboembolic events occurring below an INR of 2.0 or the number of hemorrhagic events above an INR of 3.0. The denominators were the total number of thrombotic or hemorrhagic events for each study group. Ninety-five percent CIs were calculated for each proportion using the Wilson score method without continuity correction. Again, all studies were pooled using a random-effects model. Since not all studies measured INR values at the exact time of adverse outcomes, we conducted two separate analyses, one pooling studies regardless of the elapsed time between the INR measurement and the adverse event; and a second (sensitivity analysis) including only those studies specifically stating an INR was measured within 48 hours of the event.

For all meta-analyses, statistical heterogeneity was determined using the I2 statistic (with an I2 > 50% signifying an important degree of statistical heterogeneity) and publication bias was assessed using the Egger’s weighted regression statistic (with a p < 0.05 suggesting a higher likelihood of publication bias) and through review of funnel plots (scatterplots of effect size against standard error, where the each dot represents a study effect estimate and the vertical line represents the pooled effect). Statistical analyses were performed using StatsDirect version 2.7.6 (StatsDirect Ltd., Cheshire, England), SAS, version 9.2 (SAS Institute Inc., Cary, NC), and SPSS 15.0 for Windows (SPSS, Inc, Chicago, IL).

Results

We identified 5,326 citations, of which 5,231 were excluded (Figure 1). Ninety-five articles met our inclusion and exclusion criteria [11103]. Sixty-eight studies reported measures of INR control representing 87 VKA study arms, and 43 studies reported an INR at or near the time of the adverse event (16 studies reported both and were included in both analyses).
Figure 1

Flow diagram showing results of the literature search. CCTR = Cochrane Central Register of Controlled Trials; RCT = randomized controlled trial; OBS = observational; AF = atrial fibrillation; VKA = vitamin K antagonist; INR = international normalized ratio; TTR = time in therapeutic range; PINRR = proportion of INR measurements in range.

Of the 87 VKA study groups that reported a measure of INR control, 17 reported data on patients with no prior VKA exposure whereas 47 enrolled patients who were VKA-experienced and 23 did not report prior VKA exposure data or had mixed enrollment. Twenty-eight VKA groups were from RCTs, 27 were conducted in an anticoagulation clinic setting, and 32 were in a community practice setting (Table 1). Thirty-nine VKA study groups were recruited in Europe/UK, 5 from Asia, 13 were multinational, 1 from Israel and 29 from North America. The mean age ranged from 62 to 92 years (median, 72 years), the number of VKA-treated patients ranged from 55 to 11,770 (median, 249), and the person-years of VKA therapy ranged from 17 to 30,188 (median, 399). Of the 43 identified studies that reported an INR with an adverse event, 16 were RCTs, 14 were conducted in an anticoagulation clinic, and 13 were from community practice with the number of VKA-treated patients ranged from 55 to 9,217 (median, 288) (Table 1).
Table 1

Demographics of included studies

Study, Year

Study design/setting

VKA-treated N

Mean age

VKA experience, %

Geographic region

Interpolation method

Self -management

Duration of therapy, months (Patient-years)

VKA studied

Abdelhafiz 2004 [11]

PD/AC clinic

402

72

0%

Europe

Linear

N

19 (637)

W

Abdelhafiz (<75) 2008 [12]

PD/AC clinic

203

64

0%

Europe

Linear

N

19 (321)

W

Abdelhafiz (≥75) 2008 [12]

199

80

19 (315)

Akdeniz 2005 [13]

PD/Community

208

66

NR

Turkey

-

-

-

W

Albers 2005 [14]

RCT

1962

72

85%

N. America

Linear

N

20 (3270)

W

Anderson 2004 [15]

RD/AC clinic

87

NR

100%

N. America

NR

N

12 (87)

W

Ansell (Italy) 2007 [16]

RD/AC clinic

177

72

100%

Multinational

Linear

N

12 (177)

W

Ansell (Spain) 2007 [16]

RD/AC clinic

218

72

12 (218)

A

Ansell (US) 2007 [16]

RD/Community

686

75

12 (686)

W

Ansell (Canada) 2007 [16]

RD/Community

152

74

12 (152)

W

Ansell (France) 2007 [16]

RD/Community

278

73

12 (278)

F

Aronow 1999 [17]

PD/Community

125

83

NR

N. America

NR

N

34 (354)

W

Boulanger 2006 [18]

RD/Community

6454

68

65%

N. America

Linear

N

12 (6454)

W

Burton (<75) 2006 [19]

RD/Community

260

NR

Mixed

Europe

Linear

N

25 (539)

W

Burton (>75) 2006 [19]

341

15 (414)

Cafolla (Manual) 2011 [20]

RD/Community

576

NR

100%

Europe

Linear

N

8 (384)

A,W

Cafolla 2012 [21]

PD/AC clinic

57

85

100%

Europe

Linear

N

18 (86)

W

Cheung 2005 [22]

RD/Community

555

70

100%

Asia

-

N

19 (893)

W

Chung 2011 [23]

RCT

75

65

55%

Asia

Linear

N

3 (19)

W

Connolly 1991 [24]

RCT

187

68

0%

N. America

Linear

N

15 (234)

W

Connolly 2006 [25]

RCT

3371

70

78%

N. America

Other

N

15 (4214)

NR

Copland 2001 [26]

RD/AC Clinic

328

70

100%

UK

-

N

21 (458)

W

Currie (stable) 2005 [27]

RD/Community

787

74

100%

Europe

Linear

N

35 (2282)

W

Currie (unstable) 2005 [27]

726

78

35 (2105)

Dentali 2012 [28]

PD/AC Clinic

221

75

100

Europe

-

N

3 (663)

W

DiMarco 2005 [29]

RCT

NR

70

NR

N. America

-

N

42 (−)

W

Dimberg (control SP) 2012 [30]

RD/Community

84

69

100%

Europe

Linear

N

12(84)

W

Dimberg (control ACC) 2012 [30]

RD/AC clinic

271

72

12(271)

EAFT 1995 [31]

RCT

214

71

0%

Europe

-

N

24 (377)

W,A,F

Ellis 2009 [32]

RCT

66

68

97%

N. America

Linear

N

3 (17)

T

Evans 2000 [33]

PD/AC clinic

288

76

0%

Europe

NR

N

24 (576)

W

Evans 2001 [34]

PD/AC clinic

214

78

NR

Europe

NR

N

24 (448)

W

Ezekowitz 2007 [35]

RCT

70

69

100%

Multinational

NR

N

3 (18)

W

Fang 2004 [36]

RD/AC Clinic

170

78

100

N. America

-

N

-

W

Gallagher 2011 [37]

RD/Community

18113

73

72%

Europe

Linear

N

20 (30188)

W

Garcia (naïve) 2013 [38]

RCT

3888

70

0%

Multinational

Linear

N

22 (7128)

W

Garcia (exp) 2013 [38]

5193

70

100%

22 (9521)

Gladstone 2009 [39]

RD/Community

423

78

100

N. America

-

N

-

W

Go 2003 [40]

RD/AC clinic

7445

71

Mixed

N. America

Linear

N

21 (12958)

W

Gullov 1998 [41]

RCT

170

73

0%

Europe

Linear

N

25 (355)

W

Gullov 1999 [42]

RCT

170

73

0

Europe

Linear

N

25 (355)

W

Gurwitz 1997 [43]

RD/Community

117

83

32%

N. America

Linear

N

12 (117)

W

Hannon 2011 [44]

PD/Community

43

77

100

Europe

-

N

-

W

Hart 2011 [45]

RCT

523

NR

0

N. America

-

N

13 (575)

W

Heidinger 2000 [46]

RD/Community

753

62

100%

Europe

NR

Y

12 (769)

NR

Hellemons 1999 [47]

RCT

131

70

0

Europe

-

N

32 (354)

P,A

Ho (hypertension) 2011 [48]

RD/Community

278

70

NR

Multinational

Linear

N

48 (1112)

W

Ho (no HTN) 2011 [48]

198

69

48 (792)

Holmes 2009 [49]

RCT

244

73

100%

Multinational

NR

N

18 (366)

W

Hori 2012 [50]

RCT

250

71

90%

Asia

Linear

N

30 (625)

W

Hylek 2003 [51]

RD/Community

188

76

100

N. America

-

N

-

W

Hylek 2007 [52]

PD/AC clinic

472

77

0%

N. America

Linear

N

12 (360)

W

Jacobs 2009 [53]

RD/Community

90

NR

85%

N. America

Linear

N

12 (90)

W

Jones 2005 [54]

RD/Community

2223

72

100%

Europe

Linear

N

31 (5743)

W

Kalra 2000 [55]

PD/AC clinic

167

77

0%

Europe

Linear

N

24 (296)

W

Kim 2009 [56]

RD/AC clinic

129

64

100%

Asia

Other

N

24 (258)

W

Kim 2010 [57]

PD/AC clinic

499

73

100%

N. America

Linear

N

5 (208)

W

Kulo (warfarin) 2009 [58]

PD/Community

60

66

100%

Europe

NR

N

12 (60)

W

Kulo (acenocoumarol) 2009 [58]

57

68

12 (57)

A

Lee 2012 [59]

RD/Community

200

67

NR

Asia

Linear

N

42 (700)

W

Malik 2000 [60]

RD/AC clinic

247

68

100%

N. America

Other

N

13 (268)

W

Mant 2007 [61]

RCT

488

82

40%

Europe

Linear

N

32 (1301)

W

Matchar (control) 2002 [62]

RCT

317

76

NR

N. America

Linear

N

9 (238)

W

Matchar (prior to ACC) 2002 [62]

PD/AC clinic

363

75

9 (272)

McBride 2007 [63]

PD/Community

361

71

90%

Europe

Linear

N

9 (271)

W

McCormick 2001 [64]

RD/Community

174

87

100%

N. America

Linear

N

12 (174)

W

Melamed 2011 [65]

RD/Community

906

72

100%

Israel

Linear

N

10 (769)

W

Menzin 2005 [66]

RD/AC clinic

600

72

63%

N. America

Linear

N

11 (525)

W

Morocutti 1997 [67]

RCT

454

72

NR

Europe

-

N

12

W

Neree 2006 [68]

RD/Community

395

74

100%

Europe

Linear

N

4 (132)

P,A,W

Nichol (ACC) 2008 [69]

RD/AC clinic

351

NR

100%

N. America

Linear

N

31 (920)

W

Nichol (UC) 2008 [69]

RD/Community

756

18 (1165)

Njaastad 2006 [70]

RD/AC clinic

421

NR

0%

Europe

Linear

N

14 (475)

W

Nozawa 2001 [71]

PD/Community

156

68

100

Asia

-

N

22 (286)

W

Ogawa 2011 [72]

RCT

75

72

0

Asia

Linear

N

3 (210)

W

Okumura (<70) 2011 [73]

PD/Community

208

NR

100%

Asia

Linear

N

23 (399)

W

Olsson 2003 [74]

RCT

1703

70

73%

Multinational

NR

N

16 (2271)

W

Ono 2005 [75]

PD/Community

63

76

0

Asia

Linear

N

28 (145)

W

Patel 2011 [76]

RCT

7133

73

63%

Multinational

Linear

N

20 (11888)

W

Pengo 1998 [77]

RCT

153

74

0%

Europe

Linear

N

14 (179)

W

Pengo 2001 [78]

PD/AC Clinic

433

68

0

Europe

Linear

N

17 (615)

W,A

Pengo 2010 [79]

RCT

132

79

0%

Multinational

Linear

N

64 (704)

W

Perez-Gomez 2004 [80]

RCT

237

70

0%

Europe

NR

N

33 (556)

A

Poli 2007 [81]

PD/AC clinic

290

82

100%

Europe

Linear

N

34 (814)

NR

Poli 2009 [82]

PD/AC Clinic

783

75

0%

Europe

Linear

N

39 (2567)

W

Poli 2009 [83]

PD/AC clinic

578

75

100%

Europe

Linear

N

38 (1854)

NR

Poli 2009 [84]

PD/AC clinic

780

75

100

Europe

Linear

N

36 (2406)

W

Poller (Manual) 2008 [85]

RCT

2967

67

0%

Multinational

Linear

N

17 (4203)

W, A, P

Sadanaga 2010 [86]

PD/Community

259

74

100

Asia

-

N

25 (544)

W

Samsa (ACC) 2000 [87]

RD/AC Clinic

43

69

NR

N. America

Linear

N

9 (32)

W

Samsa (Rochester) 2000 [87]

RD/Community

61

9 (46)

Samsa (R. Triangle) 2000 [87]

RD/Community

125

9 (94)

Schwammenthal 2010 [88]

PD/Community

111

76

100

Israel

-

N

-

W

Sconce (vitamin K) 2007 [89]

RCT

35

75

100%

Europe

Linear

N

6 (18)

W

Sconce (placebo) 2007 [89]

35

74

Shen 2007 [90]

RD/Community

NR

72

55%

N. America

NR

N

40 (24179)

W

Singer 2009 [91]

RD/Community

9217

77

100

N. America

-

N

72 (33497)

W

SPAF III 1996 [92]

RCT

523

71

56%

N. America

NR

N

13 (567)

W

Sullivan (women) 2012 [93]

RCT

1594

71

87%

Multinational

Linear

N

42 (5579)

W

Sullivan (men) 2012 [93]

2466

68

86%

42 (8631)

Tincani 2009 [94]

PD/AC Clinic

90

92

100%

Europe

Linear

N

12 (90)

W

Van Spall 2012 [95]

RCT

6022

72

47%

Multinational

Linear

N

24 (12044)

W

Voller (self-mgmt) 2005 [96]

RCT

101

65

0%

Europe

NR

Y

8 (68)

NR

Voller (UC) 2005 [96]

101

64

N

Walker (MHC) 2011 [97]

RD/AC Clinic

22

NR

100%

N. America

Linear

N

12 (22)

W

Walker (no MHC) 2011 [97]

62

12 (62)

Wieloch (AF) 2011 [98]

RD/Community

11770

73

100%

Europe

Linear

N

12 (11770)

W

Weitz 2010 [99]

RCT

250

66

35%

N. America

Linear

N

3 (63)

W

Wyse 2002 [100]

RCT

NR

70

NR

N. America

-

N

42

W

Yamaguchi 2000 [101]

RCT

55

66

NR

Asia

-

N

22 (101)

W

Yasaka 2001 [102]

PD/Community

88

 

100

Asia

-

N

22 (161)

W

Yousef 2004 [103]

RD/Community

739

73

100%

Europe

NR

N

24 (1484)

W

VKA = vitamin K antagonist; RCT = randomized controlled trial; RD = retrospective design; PD = prospective design; AC clinic = anticoagulation clinic; AF = atrial fibrillation; NR = not reported; N = North; VKA = Vitamin K Antagonist; W = warfarin; A = acenocoumarol; T = tecarfarin; P = phenprocoumon; F = fenprocoumon.

For the first meta-analysis, 78 out of 87 (90%) study groups reported a TTR and 55 (63%) reported the time spent below and above range; 22 of 87 (25%) study groups reported a PINRR and 21 (24%) reported the percent of INR measures below and above range (Table 2). Thirteen study groups (15%) reported both TTR and PINRR. Overall, patients spent 61% of their TTR (95% CI, 59–62%), 25% (95% CI, 23–27%) below, and 14% (95% CI, 13-15%) above range. Similarly for PINRR, 56% of INR measurements were in the therapeutic range (95% CI, 53–59%), 26% (95% CI, 23–29%) below and 13% (95% CI, 11-17%) above range. Statistical heterogeneity was observed to be high between the groups included in these analyses (I2 ≥ 97%). The likelihood of publication bias appeared low for TTR, time above range, PINRR, and proportion of INR measurements below and above range. However, publication bias was deemed more likely for the time below range analysis (Egger’s p = 0.03) (Additional file 1).
Table 2

Time in range and percentage of INR values in range and major adverse event rates

Study, year

N

TTR, %

PINRR, %

Event rate, % per patient-year

  

In range

Below range

Above range

In range

Below range

Above range

Bleeding

ICH

Ischemic stroke

Abdelhafiz 2004 [11]

402

66

19.7

14.3

-

-

-

1.7

-

-

Abdelhafiz (<75) 2008 [12]

203

58

16

26

-

-

-

1.6

0

-

Abdelhafiz (≥75) 2008 [12]

199

58

16

26

-

-

-

1.9

0

-

Albers 2005 [14]

1962

68

20

12

-

-

-

2.8

0.2

1.1

Anderson 2004 [15]

87

-

-

-

60.4

25.2

14.3

-

  

Ansell (Italy) 2007 [16]

177

68.9

21

10.1

60

26.3

13.6

-

-

-

Ansell (Spain) 2007 [16]

218

64.4

18.6

17

59

23.3

17.7

-

-

-

Ansell (US) 2007 [16]

686

57

29.1

13.9

50.8

32

17.3

-

-

-

Ansell (Canada) 2007 [16]

152

61

25.9

13.1

58.4

27.6

14

-

-

-

Ansell (France) 2007 [16]

278

58.1

15.4

26.5

51.3

19.7

29

-

-

-

Aronow 1999 [17]

125

-

-

-

68

26

6

-

-

11.3

Boulanger 2006 [18]

6454

48

38

14

-

-

-

2.8

-

-

Burton (<75) 2006 [19]

260

68

17

15

-

-

-

2.8

  

Burton (>75) 2006 [19]

341

68

19

13

-

-

-

2.4

Cafolla (Manual) 2011 [20]

576

60.4

-

-

-

-

-

-

-

-

Cafolla 2012 [21]

57

64.4

-

-

-

-

-

0

-

-

Chung 2011 [23]

75

45.1

43.9

10.9

-

-

-

10.5

0

0

Connolly 1991 [24]

187

43.7

39.6

16.6

-

-

-

2.1

0.4

2.1

Connolly 2006 [25]

3371

63.8

20.8

15.4

-

-

-

2.2

-

1.0

Currie (stable) 2005 [27]

787

74.9

-

-

-

-

-

0.4

-

-

Currie (unstable) 2005 [27]

726

55.7

-

-

-

-

-

1.2

-

-

Dimberg (UC) 2012 [30]

84

64.3

-

-

-

-

-

-

-

-

Dimberg (ACC) 2012 [30]

271

73.6

-

-

-

-

-

-

-

-

Ellis 2009 [32]

66

71.4

-

-

70.7

16.0

13.3

5.8

  

Evans 2000 [33]

288

55

26

19

-

-

-

3.1

0.5

5.5

Evans 2001 [34]

214

66

-

-

-

-

-

3.1

0.7

4.2

Ezekowitz 2007 [35]

70

57.2

-

-

-

-

-

0

-

-

Gallagher 2011 [37]

18113

63.1

20.7

16.2

-

-

-

-

-

-

Garcia (naïve) 2013 [38]

3888

61.4

-

-

-

-

-

3.0

0.8

-

Garcia (exp) 2013 [38]

5193

69.1

-

-

-

-

-

3.2

0.8

-

Go 2003 [40]

7445

62.5

26.8

10.7

-

-

-

1.5

0.4

1.1

Gullov 1998 [41]

170

73

18

9

-

-

-

1.1

0.6

0.8

Gurwitz 1997 [43]

117

39.6

44.8

15.6

-

-

-

-

-

-

Heidinger 2000 [46]

753

-

-

-

69.5

23.5

7.0

1.7

-

-

Ho (HTN) 2011 [48]

278

49.7

45.4

4.9

-

-

-

1.7

0.5

2.2

Ho (no HTN) 2011 [48]

198

49.8

44.2

6.0

-

-

-

Holmes 2009 [49]

244

66

-

-

-

-

-

2.7

-

1.6

Hori 2012 [50]

250

-

-

-

51.8

43.8

4.2

0.8

 

0.3

Hylek 2007 [52]

472

58

29

11

-

-

-

7.2

2.5

-

Jacobs 2009 [53]

90

49

35

15

-

-

-

5.6

  

Jones 2005 [54]

2223

68.9

16.7

15.4

53.4

-

-

-

-

-

Kalra 2000 [55]

167

61

26

13

-

-

-

1.4

0.3

2.0

Kim 2009 [56]

129

-

-

-

60.9

31.2

9.1

0

  

Kim 2010 [57]

499

73.4

-

-

-

-

-

-

-

-

Kulo (warfarin) 2009 [58]

60

-

-

-

51.8

42.8

5.4

-

-

-

Kulo (acenocoum) 2009 [58]

57

-

-

-

53.6

35.9

10.5

-

-

-

Lee 2012 [59]

200

48.5

-

-

-

-

-

6.6

-

-

Malik (AF) 2000 [60]

247

58.9

27.4

14.1

-

-

-

-

-

-

Mant 2007 [61]

488

67

19

14

-

-

-

1.9

-

0.8

Matchar (control) 2002 [62]

317

52.3

31.8

15.9

-

-

-

2.1

-

-

Matchar (ACC) 2002 [62]

363

55.6

31.2

13.1

-

-

-

2.2

-

-

McBride 2007 [63]

361

56

16

28

-

-

-

-

-

-

McCormick 2001 [64]

174

51

36

13

-

-

-

-

-

-

Melamed 2011 [65]

906

48.6

32.0

19.3

-

-

-

-

-

-

Menzin 2005 [66]

600

62

25

13

-

-

-

3.6

-

1.0

Neree 2006 [68]

395

53

-

-

52.8

8.7

38.5

4.4

-

-

Nichol (ACC) 2008 [69]

351

68

21

11

-

-

-

2.3

-

-

Nichol (UC) 2008 [69]

756

42

49

9

-

-

-

6.3

-

-

Njaastad 2006 [70]

421

71.5

-

-

-

-

-

0.8

-

-

Okumura (<70) 2011 [73]

208

46

51

2

-

-

-

-

-

-

Olsson 2003 [74]

1703

66

-

-

-

-

-

2.2

-

1.9

Patel 2011 [76]

7133

55

-

-

-

-

-

3.4

0.7

-

Pengo 1998 [77]

153

70

18

12

-

-

-

2.8

0.6

0

Pengo 2010 [79]

132

65

25

9

-

-

-

3.0

-

-

Perez-Gomez 2004 [80]

237

65

19

16

-

-

-

1.8

  

Poli 2007 [81]

290

69

15

16

-

-

-

2.1

1.4

-

Poli 2009 [82]

783

71

14

15

-

-

-

1.4

0.7

0.9

Poli 2009 [83]

578

68

16

16

-

-

-

-

-

-

Poller (Manual) 2008 [85]

2967

66.2

-

-

-

-

-

-

-

-

Samsa (ACC) 2000 [87]

43

60.3

25.9

13.8

54.9

26.7

18.3

-

-

-

Samsa (Rochester) 2000 [87]

61

46.9

33.9

19.3

43.6

33.5

22.9

-

-

-

Samsa (R. Triangle) 2000 [87]

125

35.6

52.1

12.2

34.2

51.0

14.8

-

-

-

Sconce (vitamin K) 2007 [89]

35

87

-

-

-

-

-

-

-

-

Sconce (placebo) 2007 [89]

35

78

-

-

-

-

-

-

-

-

Shen 2007 [90]

NR

54.5

36.3

9.2

-

-

-

-

0.5

-

SPAF III 1996 [92]

523

-

-

-

61

25

14

   

Sullivan (women) 2012 [93]

1594

60

29

11

-

-

-

-

-

0.8

Sullivan (men) 2012 [93]

2466

63

26

14

-

-

-

-

-

0.5

Tincani 2009 [94]

90

66

19

14

-

-

-

5.5

3.3

2.2

Van Spall 2012 [95]

6022

64

22

13

-

-

-

-

-

-

Voller (self-mgmt) 2005 [96]

101

72.4

13.6

14

67.8

15.2

17.0

2.9

-

-

Voller (UC) 2005 [96]

101

63.6

19.5

16.9

58.5

22.1

19.4

0

-

-

Walker (MHC) 2011 [97]

22

56.8

34.2

9.0

-

-

-

-

-

-

Walker (no MHC) 2011 [97]

62

65.9

30.7

3.4

-

-

-

-

-

-

Wieloch (AF) 2011 [98]

11770

76.5

-

-

-

-

-

2.6

-

-

Weitz 2010 [99]

250

49.7

-

-

-

-

-

1.6

-

-

Yousef 2004 [103]

739

-

-

-

62.8

22.9

14.3

1.9

-

-

AC = Anticoagulation; AF = atrial fibrillation; ICH = Intracranial Hemorrhage; HTN = Hypertension, INR = international normalized ratio; MGMT = Management; N = Number; SP = Standard Practice; TTR = time in the therapeutic range; PINRR = proportion of INR Measurements in range.

Upon meta-regression to determine how study-level factors influenced TTR, community VKA management was associated with less time in range than therapy managed in an anticoagulation clinic or RCT setting, European/UK study patients spent more time in range than North American study patients, and the VKA-naïve (and mixed/not reported) spent less time in range than VKA-experienced patients (Table 3). For PINRR, no study-level factor was found to be significantly different than the referent upon meta-regression (p > 0.05) (Table 4).
Table 3

Results of traditional meta-analysis and meta-regression analyses of time in the therapeutic range

  

Time spent in therapeutic range

Study-level factors

No. (%)

Unadjusted pooled mean upon subgroup analysis, % (95% CI)

Adjusted difference, % (95% CI)

p-v alue

All study groups

78 (100)

61 (59 to 62)

NA

NA

Study setting

    

  AC Clinic

25 (32.1)

64 (62 to 66)

7.2 (3.2 to 11.2)

<0.001

  RCT

26 (33.3)

63 (61 to 65)

9.1 (4.3 to 13.9)

<0.001

  Community

27 (34.6)

55 (52 to 59)

Referent

 

Study year

    

  1990-2000

10 (12.8)

53 (46 to 61)

−4.3 (−10.2 to 1.6)

0.16

  2001-2007

34 (43.6)

64 (62 to 65)

2.2 (−1.7 to 6.1)

0.28

  2008-2013

34 (43.6)

60 (57 to 63)

Referent

Interpolation method

    

  NR/Other

11 (14.1)

63 (60 to 65)

−2.1 (−6.8 to 2.6)

0.38

  Linear

67 (85.9)

60 (59 to 62)

Referent

 

Self-management

    

  No

77 (98.7)

60 (58 to 62)

−6.8 (−23.7 to 10.1)

0.43

  Yes

1 (1.3)

72 (68 to 77)

Referent

 

Geographic region

    

  Europe/UK

35 (44.9)

67 (64 to 69)

9.7 (6.0 to 13.4)

<0.001

  Asia

3 (3.8)

47 (44 to 49)

−5.5 (−14.7 to 3.7)

0.24

  Other

1 (1.3)

49 (46 to 52)

−3.0 (−16.1 to 10.1)

0.65

  Multinational

13 (16.7)

61 (57 to 65)

1.8 (−4.1 to 7.7)

0.55

  North America

26 (33.3)

55 (50 to 60)

Referent

 

VKA experience

    

  NR/Mixed

21 (26.9)

54 (49 to 60)

−4.6 (−8.3 to −0.9)

0.02

  No

17 (21.8)

63 (60 to 66)

−5.3 (−9.6 to −1.0)

0.02

  Yes

40 (51.3)

63 (60 to 66)

Referent

 

Duration of VKA treatment

    

  ≥1 year

59 (75.6)

62 (60 to 63)

2.7 (−1.7 to 7.1)

0.23

  <1 year

19 (24.4)

58 (52 to 65)

Referent

 

AC = anticoagulation; CI = confidence interval; NA = not applicable; No. = number of study arms; NR = Not Reported; RCT = randomized controlled trial; UK = United Kingdom, VKA = Vitamin K Antagonists.

Table 4

Results of traditional meta-analysis and meta-regression analyses of proportion of INR measurements in range

  

Proportion of INR measurements in range

Study-level factors

No. (%)

Unadjusted pooled mean upon subgroup analysis, % (95% CI)

Adjusted difference, % (95% CI)

p-v alue

All study groups

24 (100)

56 (53 to 59)

NA

NA

Study setting

    

  AC Clinic

5 (20.8)

60 (58 to 62)

6.9 (−0.02 to 15.2)

0.13

  RCT

5 (20.8)

61 (54 to 68)

5.6 (−0.06 to 17.0)

0.36

  Community

14 (58.3)

54 (50 to 57)

Referent

 

Study year

    

  1990-2000

6 (25.0)

54 (46 to 64)

3.3 (−25.3 to 31.9)

0.82

  2001-2007

13 (54.2)

56 (54 to 59)

−2.8 (−14.8 to 9.2)

0.65

  2008-2013

5 (20.8)

56 (51 to 62)

Referent

 

Self-management

    

  No

22 (91.7)

55 (43 to 57)

−9.3 (−32.4 to 13.8)

0.45

  Yes

2 (8.3)

69 (67 to 72)

Referent

 

Geographic region

    

  Europe/UK

13 (54.2)

57 (54 to 60)

−1.7 (−10.7 to 7.3)

0.71

  Asia

2 (8.3)

56 (48 to 66)

−8.8 (−26.4 to 8.8)

0.32

  Other

0 (0)

NA

NA

NA

  Multinational

0 (0)

NA

NA

NA

  North America

9 (37.5)

54 (48 to 62)

Referent

 

VKA experience

    

  NR/Mixed

5 (20.8)

51 (41 to 63)

−5.7 (−34.7 to 23.3)

0.83

  No

3 (12.5)

63 (55 to 73)

7.9 (−15.2 to 31.0)

0.65

  Yes

17 (70.8)

56 (54 to 59)

Referent

 

Duration of VKA treatment

    

  ≥1 year

17 (70.8)

57 (54 to 60)

9.1 (−0.5 to 18.7)

0.09

  <1 year

7 (29.2)

53 (44 to 65)

Referent

 

AC = anticoagulation; CI = confidence interval; NA = not applicable; No. = number of study arms; NR = not reported; RCT = randomized controlled trial; UK = United Kingdom; VKA = Vitamin K Antagonists.

In the second meta-analysis, 30 of 43 studies (70%) reported an INR measure with thromboembolic events, 21 (49%) reported an INR with ischemic stroke, 32 (74%) reported INRs with major hemorrhage, and 16 (37%) reported an INR with ICH. INR data was incomplete in 58% of the studies that reported adverse events; not all events were reported with an INR measure. Thirty percent of the studies used previously reported INRs, allowing INR measures from 3 days up to 12 days prior to be considered as temporally related to the adverse event.

Overall, 57% of the thromboembolic events occurred at an INR <2.0 (95% CI, 50-64%) and 42% of hemorrhagic events occurred at an INR >3.0 (95% CI, 35 – 51%) (Figures 2 and 3). A high degree of heterogeneity was present for studies that reported thromboembolic and hemorrhagic events (I2 = 80% and 77% respectively); however, the presence of publication bias was deemed low (Egger’s p = 0.31 and p = 0.69, respectively) (Additional file 1). When ischemic stroke and ICH were evaluated separately from other events, we found that 56% of ischemic strokes (95% CI, 48 – 64%) and 45% of ICHs (95% CI, 29-63%) occurred at INRs <2.0 and >3.0, respectively, but a high degree of heterogeneity was still present (I2 = 76% and 85%, respectively) (Figures 4 and 5). Furthermore, when studies that allowed previously reported INRs (more than 48 hours prior to an event) were excluded, we found a higher proportion of events that occurred outside the therapeutic range for 59% of thromboembolic events (95% CI, 51 – 66%) and 47% of hemorrhagic events (95% CI, 37 – 58%).
Figure 2

Results of random-effects meta-analysis of the proportion of thromboembolic events that occurred when INRs were below 2.0. The squares represent individual studies, and the size of the square represents the weight given to each study in the meta-analysis. Error bars represent 95% confidence intervals. The diamond represents the combined results. List of studies shows name of first author and year of publication. CI = Confidence Interval.

Figure 3

Results of random-effects meta-analysis of the proportion of major hemorrhagic events that occurred when INRs were above 3.0. The squares represent individual studies, and the size of the square represents the weight given to each study in the meta-analysis. Error bars represent 95% confidence intervals. The diamond represents the combined results. List of studies shows name of first author and year of publication. CI = Confidence Interval.

Figure 4

Results of random-effects meta-analysis of the proportion of ischemic strokes that occurred when INRs were below 2.0. The squares represent individual studies, and the size of the square represents the weight given to each study in the meta-analysis. Error bars represent 95% confidence intervals. The diamond represents the combined results. List of studies shows name of first author and year of publication. CI = Confidence Interval.

Figure 5

Results of Random-Effects Meta-Analysis of the Proportion of Intracranial Hemorrhages That Occurred When INRs Were Above 3.0. The squares represent individual studies, and the size of the square represents the weight given to each study in the meta-analysis. Error bars represent 95% confidence intervals. The diamond represents the combined results. List of studies shows name of first author and year of publication. CI = Confidence Interval; ICH = Intracranial hemorrhage.

Discussion

In a pooled analysis of AF studies performed worldwide between 1990 and June 2013, we found patients spent only 61% of their TTR and only 56% of their measured INRs were in range. Moreover, when patients were out of range, they were more likely to be below range and at an increased risk of thrombosis, as compared to being above range with an increased risk of bleeding. While, thromboembolic and hemorrhagic events did occur in patients with a therapeutic INR; we demonstrated more than half of all thromboembolic events occurred when the INR was less than 2.0 and more than 40% of all hemorrhagic events happened at an INR > 3.0. As such, the efficacy and safety of VKAs appear strongly tethered to the quality of INR control achieved.

Our meta-regression analyses showed three important findings. First, patients having their VKAs managed in the community setting spent significantly less TTR when compared to patients managed in an anticoagulation clinic or in a RCT setting. This data supports the growing body of literature demonstrating that patients whose care is managed in an anticoagulation clinic have better outcomes (improved TTR, lower rates of major bleeding and thrombosis, and decreased health care costs) than those managed in community practice [104106]. The improved INR control in RCTs and anticoagulation clinics may be the result of increasing the frequency of monitoring, providing more organized care and focusing more on improving poor VKA-drug persistence (as low as 68% at 6-months) [107, 108] than typically done in community settings. Unfortunately, not all patients receiving a VKA have access to anticoagulation clinics [109]. In fact, it is estimated that only about one-third of patients receiving a VKA in the US have access to an anticoagulation clinic due to time, distance, economic or other access-to-care issues. Second, patients who were VKA-naive spent significantly less time in the therapeutic range than VKA-experienced patients. This is likely a result of poorer INR control early on in treatment, as clinicians attempt to control the INR within the narrow therapeutic window without any prior knowledge of the patient’s-specific dosing requirements. It may also suggest that patients learn to manage their VKA better over time. This observation may warrant researchers to stratify analyses according to whether patients are newly initiated to warfarin or experienced warfarin patients. Finally, people in North America spent significantly less time in the therapeutic range than those in Europe or the UK. This may be a result of North America’s near exclusive use of warfarin, which has been shown in previous analyses to result in as much as a 9% lower TTR compared to other VKAs [6], as well as, North America’s less wide-spread use of proven strategies to increase TTR such as and anticoagulation clinics as noted above [6, 8, 9, 109] and patient self-monitoring [6].

Our systematic review and meta-analysis supports and extends the knowledge of VKA use in contemporary practice. Our TTR or PINRR results are in general agreement with the systematic reviews by van Walraven et al. [6] and Cios et al. [9], but these analyses included all therapeutic indications for VKAs, which lowers their applicability for an AF-specific population. The meta-analyses by Baker et al. [8] and Wan et al. [7] focused on AF only populations, but each had some limitations. The Baker meta-analysis was limited to a United States population, and therefore, contained only 8 studies. Despite this, they did find that care within an anticoagulation clinic yielded a higher TTR than usual care in the community, a finding we extend into the worldwide AF population as well. The Wan meta-analysis was published in 2008, evaluated a worldwide AF population and found similar TTR and PINRR results to our own. However, they only included 47 VKA groups from 38 published studies. They found that TTR was significantly correlated with PINRR in retrospective studies and TTR was significantly negatively correlated to both major hemorrhage and thromboembolic events. Given the intense focus on thromboembolism in contemporary practice, our literature search was able to almost double the number of articles included in the Wan et al. by updating the search to 2013. Over the 5 years since the publication of Wan et al.’s meta-analysis, we found the TTR and PINRR to be only slightly increased (overall TTR increased from 57% to 61% and PINRR from 51 to 56%) [7]. This suggests that we still have a long way to go to enhance the quality of INR control. Our findings that the majority of thromboembolic events happen in AF patients when the INR is less than 2.0 and more than 40% of hemorrhages occur when an INR is greater than 3.0 confirms the findings from the systematic review of Oake et al. [10]. Their systematic review did not limit the studies to an AF population and was published in 2009, so our findings through June 2013 in the target AF population extend knowledge in this area as well.

There are several limitations of our meta-analysis worth discussion. First, the potential for publication bias and possibility of missed eligible articles could exist. However, we consider this risk to be minimized due to our systematic search strategy and manual backwards citation tracking. In addition, having such a large cadre of studies, as we do in our meta-analysis, minimizes the impact that a missed individual study might have on our pooled result. Another limitation of our analysis includes the fact that very few identified studies evaluated PINRR. As a result, our meta-regression analysis was likely underpowered; although similar trends could be seen to TTR. Future evaluation of PINRR should be conducted when there is a sufficient literature base to make firmer conclusions. Another limitation of our analysis is the possibility of a language bias; as we only included English language studies which may not represent all of the published evidence. Finally, there was a high degree of statistical heterogeneity observed in our analyses, suggesting that the included studies varied clinically and/or methodologically. However, this was one of our rationales for conducting meta-regression. In our meta-regression analyses, we found some potential explanations for the identified heterogeneity; although there may still be additional factors that we could not think to evaluate or for which there is insufficient data to allow evaluation.

Conclusions

Patients on VKAs for thromboembolism prevention in AF are frequently outside the normal INR range and tend to be under-anticoagulated rather than over-anticoagulated. While, thromboembolic and hemorrhagic events do occur patients with a therapeutic INR; patients with an INR < 2.0 make up many of the cases of thromboembolism, while those with an INR > 3.0 make up many of the cases of major hemorrhage. Managing anticoagulation outside of a clinical trial or anticoagulation clinic is associated with poorer INR control as is initiation of therapy in patients who are VKA-naïve. Patients in Europe/UK have better INR control than those in North America.

Abbreviations

AF: 

Atrial fibrillation

VKA: 

Vitamin K antagonist

TTR: 

Time in therapeutic range

PINRR: 

Proportion of INR measurements in range

INR: 

International normalized ratio

CI: 

Confidence interval

UK: 

United Kingdom

RCT: 

Randomized controlled trial

ICH: 

Intracranial hemorrhage.

Declarations

Acknowledgements

This study was funded by Janssen Scientific Affairs, LLC. The authors maintained full control over the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation and review of the manuscript. Janssen reviewed the final manuscript prior to submission.

Authors’ Affiliations

(1)
Department of Pharmacy Practice, University of Connecticut School of Pharmacy
(2)
Hartford Hospital Division of Cardiology
(3)
Janssen Scientific Affairs

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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