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Thromb Haemost 2018; 118(11): 1930-1939
DOI: 10.1055/s-0038-1673380
Stroke, Systemic or Venous Thromboembolism
Georg Thieme Verlag KG Stuttgart · New York

Management of Oral Anti-Coagulation in Patients with Heart Failure—Insights from the ThrombEVAL Study

Sebastian Göbel   *
1   German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
2   Center for Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Jürgen H. Prochaska   *
1   German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
3   Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
4   Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Lisa Eggebrecht
4   Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Ronja Schmitz
4   Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Claus Jünger
4   Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Heidrun Lamparter
3   Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
4   Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Markus Nagler
3   Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
4   Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Karsten Keller
3   Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Meike Coldewey
2   Center for Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Sven-Oliver Tröbs
1   German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
2   Center for Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Simon Diestelmeier
1   German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
2   Center for Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Sören Schwuchow-Thonke
1   German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
2   Center for Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Christoph Bickel
5   Department of Medicine I, Federal Armed Forces Central Hospital, Koblenz, Germany
,
Michael Lauterbach
6   Department of Medicine 3, Barmherzige Brüder Hospital Trier, Trier, Germany
,
Karl J. Lackner
1   German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
7   Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Hugo ten Cate
3   Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
8   Thrombosis Center Maastricht, Cardiovascular Research Institute Maastricht and Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
,
Thomas Münzel
1   German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
2   Center for Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
3   Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Roland Hardt
9   Center for General Medicine and Geriatrics, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
,
Philipp S. Wild
1   German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
3   Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
4   Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg, University Mainz, Mainz, Germany
› Author Affiliations Funding This work was supported by grants of the state initiative ‘health economy’ of the Ministries of Health and Economics, Rhineland-Palatinate, Germany (grant identifier: AZ.623–1), the Federal Ministry of Education and Research, Germany (grant identifier: BMBF 10E01003), the Center for Translational Vascular Biology (CTVB) of the University Medical Center Mainz, Boehringer Ingelheim Pharma GmbH & Co. KG, Bayer Vital GmbH, Daiichi Sankyo Europe GmbH, Sanofi-Aventis Germany GmbH, IMO Institute GmbH, Portavita BV and the German Heart Foundation. The sponsoring bodies played no role in the planning, conduct or analysis of this investigator-initiated study.
Further Information

Publication History

23 March 2018

23 August 2018

Publication Date:
24 October 2018 (online)

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Abstract

Patients with heart failure (HF) are frequently anti-coagulated with vitamin K-antagonists (VKAs). The use of long-acting VKA may be preferable for HF patients due to higher stability of plasma concentrations. However, evidence on phenprocoumon-based oral anti-coagulation (OAC) therapy in HF is scarce. The aim of this study was to assess the impact of the presence of HF on quality of phenprocoumon-based OAC and the subsequent clinical outcome. Quality of OAC therapy and the incidence of adverse events were analysed in a cohort of regular care (n = 2,011) from the multi-centre thrombEVAL study program (NCT01809015) stratified by the presence of HF. To assess the modifiability of outcome, results were compared with data from individuals receiving specialized care for anti-coagulation (n = 760). Overall, the sample comprised of 813 individuals with HF and 1,160 subjects without HF in the regular care cohort. Quality of OAC assessed by time in therapeutic range (TTR) was 66.1% (47.8%/82.8%) for patients with HF and 70.6% (52.1%/85.9%) for those without HF (p = 0.0046). Stratification for New York Heart Classification (NYHA)-class demonstrated a lower TTR with higher NYHA classes: TTRNYHA-I 69.6% (49.4%/85.6%), TTRNYHA-II 66.5% (50.1%/82.9%) and TTRNYHA-≥III 61.8% (43.1%/79.9%). This translated into a worse net clinical benefit outcome for HF (hazard ratio [HR] 1.63 [1.31/2.02]; p < 0.0001) and an increased risk of bleeding (HR 1.40 [1.04/1.89]; p = 0.028). Management in a specialized coagulation service resulted in an improvement of all, TTR (∆+12.5% points), anti-coagulation-specific and non-specific outcome of HF individuals. In conclusion, HF is an independent risk factor for low quality of OAC therapy translating into an increased risk for adverse events, which can be mitigated by specialized care.

Keywords

heart failure - oral anti-coagulation - clinical outcome - quality of care - health care model

* Sebastian Göbel and Jürgen H. Prochaska contributed equally to the study.


Supplementary Material

 

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