Qualidade da anticoagulação oral de pacientes com fibrilação atrial no HC-FMB-UNESP
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Data
2018-01-26
Autores
Secco, Karina Nogueira Dias
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
Fundamento: A fibrilação atrial (FA) é uma arritmia supraventricular caracterizada por uma completa desorganização na atividade elétrica atrial, fazendo com que os átrios percam sua capacidade de contração, não gerando sístole atrial. Sua prevalência aumenta com a idade e geralmente está associada a doenças estruturais cardíacas, trazendo prejuízos hemodinâmicos e complicações tromboembólicas. A anticoagulação oral (ACO) é capaz de prevenir os eventos tromboembólicos e sua monitorização é realizada através do INR (International Normalized Ratio). Objetivos: 1-avaliar a estabilidade do INR dos pacientes anticoagulados portadores de fibrilação atrial (FA) não valvar; 2- avaliar as complicações tromboembólicas ou hemorrágicas nestes pacientes; 3- identificar o subgrupo de maior risco para eventos tromboembólicos ou hemorrágicos. Casuística e Métodos: Foram revisados os prontuários médicos de 203 pacientes atendidos no ambulatório de anticoagulação da Disciplina de Cardiologia do Hospital das Clínicas da Faculdade de Medicina de Botucatu – UNESP (HC-FMB-UNESP) no período de janeiro de 2009 a janeiro de 2015, e calculado o tempo de permanência na faixa terapêutica (Time in Therapeutic Range – TTR), utilizando-se o método consagrado na literatura descrito por Rosendaal, uma interpolação linear para atribuir um valor de INR a cada dia do intervalo entre as aferições registradas. Resultados: O valor de TTR mediano foi de 53(10-88) e médio de 52,21%. Foram analisados os fatores que influenciaram o valor do TTR nesta população, sendo que os pacientes que apresentaram instabilidade do INR na fase de adaptação tiveram um TTR médio mais baixo (46,83%) que os pacientes sem instabilidade (53,88%). Em relação aos eventos (hemorrágicos ou tromboembólicos), 6,9% dos pacientes estudados sofreram eventos hemorrágicos e 8,4% sofreram acidente vascular cerebral (AVC). Foi também analisada a relação entre a ocorrência de eventos maiores (AVC e sangramento) e o valor do TTR, mostrando que o valor do TTR baixo (<60%) está associado à maior ocorrência de AVC, mas não houve significância estatística entre o valor do TTR e o risco de sangramentos. Aqueles pacientes que apresentaram instabilidade do INR na fase de adaptação foram identificados como um grupo de maior risco para a ocorrência de AVC e sangramentos. Conclusões: A qualidade da anticoagulação no ambulatório da Disciplina de Cardiologia do HC-FMB-UNESP é semelhante à qualidade dos centros de países em desenvolvimento. O grupo de pacientes que apresentou maior instabilidade do INR na fase de adaptação evoluiu com um TTR médio mais baixo durante o seguimento e apresentou 4,94 vezes mais chance de ter AVC e 3,35 vezes mais chance de ter sangramentos. Portanto, para este grupo de pacientes, seria adequada uma maior individualização na escolha da terapia anticoagulante, levando em conta o custo-benefício dessa iniciativa.
Background: Atrial fibrillation (AF) is a supraventricular arrhythmia characterized by complete disorganization of atrial electrical activity, causing the atriums to lose their contractile capacity, thereby not generating atrial systole. Its prevalence increases with age and may be associated with cardiac structural diseases, provoking hemodynamic damage and thromboembolic complications. Oral anticoagulation (OAC) is capable of preventing thromboembolic events and is monitored through the INR (International Normalized Ratio). Objectives: 1- to evaluate INR stability in anticoagulated patients with non-valvular Atrial Fibrillation (AF); 2- to evaluate thromboembolic and hemorrhagic complications in these patients; 3- to identify the subgroup of higher risk for thromboembolic or hemorrhagic events. Methods: The medical charts of 203 patients attended at the anticoagulation ambulatory unit in the Cardiology Department at HC-FMB-UNESP in the period from January 2009 to January 2015 were reviewed; the Time in Therapeutic Range (TTR) was calculated by the method esteemed in the literature described by Rosendaal, a linear interpolation to attribute an INR value to each day of the interval between the recorded measurements. Results: The median TTR value was 53 (10-88) and the mean 52.21%. The factors that influenced the TTR value were analyzed in this population, showing that the patients presenting INR instability in the adaptation phase had a lower mean TTR (46.83%) than those without instability (53.88%). As to the events (hemorrhagic or thromboembolic), 6.9% of the patients studied suffered hemorrhagic events and 8.4% a stroke. The relation between the occurrence of major events (stroke and bleeding) and the TTR value was analyzed, showing that a lower TTR value (<60%) is associated with greater stroke occurrence, but there was no statistically significance between the TTR value and bleeding risk. Those patients that presented INR instability in the adaptation phase were identified as the group at greater risk for stroke and bleeding. Conclusions: The anticoagulation quality in the ambulatory unit at the Cardiology Department at HC-FMB-UNESP is similar to the quality observed in centers in developing countries. The group of patients that showed greater INR instability in the adaptation phase evolved with a lower mean TTR during follow-up and presented a 4.94-fold greater chance of stroke and 3.35 times higher chance of bleeding. Therefore, for this patient group, greater individualization would be suitable in the choice of anticoagulant therapy, taking into account the cost versus benefit of this initiative.
Background: Atrial fibrillation (AF) is a supraventricular arrhythmia characterized by complete disorganization of atrial electrical activity, causing the atriums to lose their contractile capacity, thereby not generating atrial systole. Its prevalence increases with age and may be associated with cardiac structural diseases, provoking hemodynamic damage and thromboembolic complications. Oral anticoagulation (OAC) is capable of preventing thromboembolic events and is monitored through the INR (International Normalized Ratio). Objectives: 1- to evaluate INR stability in anticoagulated patients with non-valvular Atrial Fibrillation (AF); 2- to evaluate thromboembolic and hemorrhagic complications in these patients; 3- to identify the subgroup of higher risk for thromboembolic or hemorrhagic events. Methods: The medical charts of 203 patients attended at the anticoagulation ambulatory unit in the Cardiology Department at HC-FMB-UNESP in the period from January 2009 to January 2015 were reviewed; the Time in Therapeutic Range (TTR) was calculated by the method esteemed in the literature described by Rosendaal, a linear interpolation to attribute an INR value to each day of the interval between the recorded measurements. Results: The median TTR value was 53 (10-88) and the mean 52.21%. The factors that influenced the TTR value were analyzed in this population, showing that the patients presenting INR instability in the adaptation phase had a lower mean TTR (46.83%) than those without instability (53.88%). As to the events (hemorrhagic or thromboembolic), 6.9% of the patients studied suffered hemorrhagic events and 8.4% a stroke. The relation between the occurrence of major events (stroke and bleeding) and the TTR value was analyzed, showing that a lower TTR value (<60%) is associated with greater stroke occurrence, but there was no statistically significance between the TTR value and bleeding risk. Those patients that presented INR instability in the adaptation phase were identified as the group at greater risk for stroke and bleeding. Conclusions: The anticoagulation quality in the ambulatory unit at the Cardiology Department at HC-FMB-UNESP is similar to the quality observed in centers in developing countries. The group of patients that showed greater INR instability in the adaptation phase evolved with a lower mean TTR during follow-up and presented a 4.94-fold greater chance of stroke and 3.35 times higher chance of bleeding. Therefore, for this patient group, greater individualization would be suitable in the choice of anticoagulant therapy, taking into account the cost versus benefit of this initiative.
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Palavras-chave
anticoagulação, fibrilação atrial, hemorragia, complicações, acidente vascular cerebral, anticoagulation, atrial fibrillation, bleeding, complications, stroke