Zusammenfassung
Hintergrund
Das hohe Komplikationsrisiko bei Patienten mit oraler Antikoagulationstherapie kann durch das INR-Selbstmanagement reduziert werden. Welche Faktoren zur Risikoreduktion beitragen, ist bislang unzureichend geklärt.
Methodik
330 konsekutive Patienten mit oraler Langzeit-Antikoagulation nahmen an einer strukturierten Schulung teil. In Abhängigkeit von manueller und kognitiver Fähigkeit sowie der Bereitschaft zum INR-Selbstmanagement, wurden die Patienten der Therapiekontrolle durch den Gerinnungsmonitor CoaguChek® oder der Betreuung durch den Hausarzt zugeordnet. Nach im Mittel 13,3±4,4 Monaten erfolgte anhand eines strukturierten Fragebogens die Nachbeobachtung bezüglich hämorrhagischer und thromboembolischer Komplikationen sowie eingetretener Todesfälle.
Ergebnisse
Im Vergleich zur Hausarztgruppe waren Patienten mit INR-Selbstmanagement jünger (58 vs 64 Jahre) und wiesen weniger Komorbiditäten (Diabetes mellitus oder arterielle Hypertonie) sowie eine höhere Ejektionsfraktion auf (53,6 vs 51,1%). Die Indikation zur Antikoagulation, das Alter sowie der Rhythmus erklärten 58% der Unterschiede bezüglich der Zuordnung zu den beiden Methoden der Therapiekontrolle. Die Komplikationsrate war in der Hausarztgruppe im Vergleich zum Selbstmanagement nicht signifikant different: schwere Blutung 0,5 vs 0,9%, zerebrale Ischämie (TIA oder Schlaganfall) 1,9 vs 0,9%, erneute Krankenhausaufenthalte 2,3 vs 1,8%. Demgegenüber waren Adipositas (OR=1,5; 95% CI 1,06–1,25; p=0,001) sowie eine hohe Antikoagulationsintensität (OR=2,42; 95% CI 1,16–5.1; p=0,019) mit einer höheren Komplikationsrate assoziiert.
Schlussfolgerung
Übergewichtige bzw. Patienten mit hoher Antikoagulationsintensität erleiden sowohl unter INR-Selbstmanagement wie unter Hausarztbetreuung häufiger Komplikationen als andere Patienten.
Summary
Background
INR self-management can reduce the risk of complications for patients with indication of long-term oral anticoagulation therapy. However, little is known about early indicators of complication risk.
Methods
In a prospective study on 330 consecutive patients all participants were informed about oral anticoagulation by a structured teaching program. The two groups were divided as to whether they received usual medical care provided by a family physician (n=220) or self-management (n=110) on a portable coagulation monitor (CoaguChek System). After a mean follow up of 13.3±4.4 months, the participants of the study were interviewed by a structured questionnaire to obtain information about hemorrhagic and thromboembolic complications as well as survival.
Results
In comparison to patients under usual care, patients with INR selfmanagement were significantly younger (58 vs 64 years) and had fewer comorbidities (diabetes and hypertension) as well as a higher ejection fraction (53.6 vs 51.1%). Indication for anticoagulation, age and heart rhythm explained 58% of the differences between the management groups. There was no significant difference in the overall complication rates between the two groups (usual care vs selfmanagement): major bleeding 0.5 vs 0.9%, cerebral embolism (TIA or stroke) 1.9 vs 0.9%, hospital admission 2.3 vs 1.8%. A high BMI (OR=1.5; 95% CI 1.06–1.25; p=0.001) or a high therapeutic INR range (OR=2.42; 95% CI 1.16–5.1; p=0.019) is associated with a higher complication rate.
Conclusions
Complication rates for patients with long-term oral anticoagulant therapy did not differ significantly between usual care and self-management. Rather, the patient’s body weight and the requirement of high anticoagulation intensity drive the complication risk under both management systems.
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Voeller, H., Dovifat, C. & Wegscheider, K. Experience with INR self-management: Patient selection and complication rates. ZS Kardiologie 94, 801–807 (2005). https://doi.org/10.1007/s00392-005-0304-4
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DOI: https://doi.org/10.1007/s00392-005-0304-4