A prospective validation of the SAME-TT2R2 score: How to identify atrial fibrillation patients who will have good anticoagulation control on warfarin

Internal and Emergency Medicine (Impact Factor: 2.62). 03/2014; 9(4). DOI: 10.1007/s11739-014-1065-8
Source: PubMed


Stroke prevention, achieved with oral anticoagulation therapy (OAT), is central to the management of patients with atrial fibrillation (AF). Well-managed OAT, as reflected by a long time in therapeutic range (TTR), is associated with good clinical outcomes. The SAME-TT2R2 score has been proposed to identify patients who will maintain a high average TTR on vitamin K antagonists (VKA) treatment. The objective of the study was to validate this score in a cohort of AF patients followed by an anticoagulation clinic. We applied the SAME-TT2R2 score to 1,089 patients with AF on VKAs followed by two anticoagulation clinics. The median TTR overall for the whole cohort was 73.0 %. There was a significant decline in mean (or median) TTR in relation to the SAME-TT2R2 score (p = 0.042). When the SAME-TT2R2 scores were categorized we find a TTR 74.0 % for score ≤2 and 68.0 % for score >2 (p = 0.006). The rate of major bleeding events and stroke/TIA was 1.78 × 100 patient-years (pt-yrs) and 1.26 × 100 pt-yrs, respectively. No relationship exists between the SAME-TT2R2 score and adverse events. We describe the first validation of the SAME-TT2R2 score in AF patients where, despite an overall good quality of anticoagulation, the SAME-TT2R2 score is able to identify the patients who are less likely to do well on VKA therapy if this is the chosen OAT.

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Available from: Daniela Poli, Feb 19, 2015
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    Preview · Article · Jun 2014 · Internal and Emergency Medicine
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    ABSTRACT: Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a high prevalence rate amongst the elderly. It is associated with increased mortality and morbidity, as a result of ischaemic stroke, systemic thromboembolism and heart failure. Stroke prevention is central to the initial management of AF, irrespective of the clinical subtype of AF. The keystone of AF management remains stroke prevention. The risk of ischaemic stroke in AF is related to increasing age and co-existent comorbidities, such as hypertension, diabetes mellitus, valvular heart disease, heart failure and previous strokes. All patients with AF should be risk stratified for stroke and bleeding, with the CHA2DS2-VASc and HAS-BLED scores, respectively, before initiation of oral anticoagulant treatment. Until recently, the vitamin K antagonists were the mainstay of antithrombotic therapy, but non-warfarin oral anticoagulants (NOACs) are now increasingly being preferred. The subsequent approach to management of AF is largely patient centred and symptom driven, and can be broadly described as ‘rhythm control’ for paroxysmal and persistent AF, using anti-arrhythmic agents, and ‘rate control’ for permanent AF. Rate control is usually with β-blockers or non-dihydropyridine calcium channel blockers, with or without digitalis. Rhythm control may require anti-arrhythmic drugs and/or electrophysiological procedures, such as catheter ablation.
    No preview · Article · Aug 2014 · Medicine
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    ABSTRACT: Non-valvular atrial fibrillation (AF) is the most common cardiac arrhythmia in the clinical setting. AF increases both the risk and severity of strokes, and is associated with substantial morbidity and mortality. Despite the clear net clinical benefit of oral anticoagulants (OACs) in patients with AF at risk for stroke, major bleeding events, especially intracranial bleeds, may be devastating. In the last decade, four new OACs have been approved for stroke prevention in patients with AF and are at least as effective as warfarin with better bleeding profiles. These new agents have changed and simplified our approach to stroke prevention because the threshold for initiation of OACs is lowered. An important clinical practice shift is the initial identification of "low-risk" patients who do not need antithrombotic therapy, with low-risk comprising CHA2DS2-VASc {Congestive heart failure, Hypertension, Age ≥75 years (double), Diabetes mellitus, previous Stroke/transient ischemic attack/thromboembolism (double), Vascular disease, Age 65-74 years, and female gender (score of 0 for males and 1 for female)}. Subsequent to this step, effective stroke prevention consisting of OACs can be offered to patients with one or more stroke risk factors. Apart from stroke risk, another consideration is bleeding risk assessment, with a focus on the use of the validated HAS-BLED {Hypertension, Abnormal renal/liver function, Stroke, Bleeding history, Labile international normalized ratio (INR), Elderly (age >65 years), drugs or alcohol concomitantly} score. A high HAS-BLED score can flag patients potentially at risk for bleeding, and alert clinicians to the need for careful review and follow up, and the need to consider potentially correctable bleeding risk factors that include uncontrolled hypertension, labile INRs, concomitant aspirin use, and alcohol excess.
    Full-text · Article · Sep 2014 · Korean Circulation Journal
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