Predictors of 30-day mortality in patients with an international normalized ratio of 4.5 - 10 due to warfarin-related overanticoagulation: a retrospective cohort study
Öz
Purpose: Although it has been shown that vitamin K administration does not benefit patients with INR levels between 4.5 to 10, there are studies in the literature showing that some complications including the risk of bleeding in these patients increase significantly. For this reason, it is crucial to select high-risk patients who present with elevated INR to apply closer follow-up and monitoring. The primary objective of our study is to define the predictors for 30-day mortality of the patients with an INR between 4.5 to 10 due to warfarin-related overanticoagulation. The secondary objective of our study is to derive a regression model which can predict mortality in 30 days and to compare the performance of this model with the National Early Warning Score-2(NEWS-2).
Materials and Methods: We included patients older than 18 years old, admitted between the dates 01.01.2016 - 01.01.2022 who are using warfarin as medication and with an INR between 4.5 – 10 in our study. We excluded patients with trauma, major bleeding on admission or patients with missing data. For the regression model, backward-wald stepwise method was utilized. We used the Hosmer-Lemeshow test for the goodness of fit. For the overall performance of the model, we evaluated the Nagelkerke R Square, and the Reciever Operating Characteristics test. DeLong test was used to compare the area under the curves (AUC).
Results: A total of 263 patients were examined in the statistical analysis. Mean arterial pressure, SpO2, pulse rate, and age were the independent predictors of 30-day mortality. The model have classified 81.4% of the patients correctly. The AUC of the regression model was 0.848 (0.799 to 0.898). The sensitivity of the model as a tool for mortality prediction was 94.1%, specificity 66.5%, and accuracy 71.9%. The AUC of the NEWS-2 score for 30-day mortality was calculated as 0.782 (95%CI = 0.715 to 0.849). The difference between the AUCs of our model and the NEWS-2 score was statistically significant.
Conclusion: Mean arterial pressure, SpO2, heart rate, and age were the independent predictors for the 30-day mortality of patients with an INR between 4.5 to 10 due to overanticoagulation because of warfarin medication. The regression model we derived showed good overall discrimination and performed significantly better than NEWS-2 score.
Anahtar Kelimeler
Warfarin, Supratherapeutic INR, Overanticoagulation, Vitamin-K, Predictors of mortality
Destekleyen Kurum
Yoktur
Proje Numarası
Yoktur
Teşekkür
Yoktur
Kaynakça
- Crowther MA, Ageno W, Garcia D, Wang L, Witt MD, Clark NP et al. Oral vitamin K versus placebo to correct excessive anticoagulation in patients receiving warfarin: a randomized trial. Ann Intern Med. 2009;150:293-300.
- Chai-Adisaksopha C, Hillis C, Siegal DM, Movilla R, Heddle N, Iorio A et al. Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal. A systematic review and meta-analysis. Thromb Haemost. 2016;116:879-90.
- Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv. 2018;2:3257-91.
- Cressman AM, Macdonald EM, Yao Z, Austin PC, Gomes T, Paterson JM et al. Socioeconomic status and risk of hemorrhage during warfarin therapy for atrial fibrillation: A population-based study. Am Heart J. 2015;170:133-40.
- Dagar S, Emektar E, Uzunosmanoglu H, Cevik Y. Assessment of factors affecting mortality in geriatric patients with warfarin overdose. Turk J Emerg Med. 2020;20:180-5.
- Farrow GS, Delate T, McNeil K, Jones AE, Witt DM, Crowther MA et al. Vitamin K versus warfarin interruption alone in patients without bleeding and an international normalized ratio > 10. J Thromb Haemost. 2020;18:1133-40.
- İslam MM, Ademoğlu E, Uygun C, Delipoyraz M, Satıcı MO, Aksel G et al. Comparison of the effects of different treatment protocols on mortality in patients presenting with an INR≥10 due to warfarin-associated over-anticoagulation. Afr J Emerg Med. 2023;13:8-14.
- Smith GB, Redfern OC, Pimentel MA, Gerry S, Collins GS, Malycha J et al. The National Early Warning Score 2 (NEWS2). Clin Med (Lond). 2019;19:260.
- Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ; American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141;2 Suppl:7S-47S.
- Green SB. How many subjects does it take to do a regression analysis. Multivariate behavioral research. 1991;26:499–510.
