Korean Journal of Clinical Pharmacy (한국임상약학회지)

Korean College Of Clinical Pharmacy (한국임상약학회)
권호 표지

Evaluation of Peri-procedural Anticoagulation Drug Therapy undergoing Radiofrequency Ablation in Patients with Atrial Fibrillation

심방세동 환자의 고주파 도자절제술 전.후의 항응고약물요법 사용실태 분석

  • Kim, Su-Hyun (Department of Pharmacy, Yeoido St. Mary's Hospital The Catholic University of Korea) ;
  • An, Sung-Shim (Department of Pharmacy, Seoul St. Mary's Hospital The Catholic University of Korea) ;
  • Kim, Soon-Joo (Department of Pharmacy, Seoul St. Mary's Hospital The Catholic University of Korea) ;
  • Bang, Joon-Seok (Department of Pharmacy, Seoul St. Mary's Hospital The Catholic University of Korea) ;
  • La, Hyen-Oh (Department of Pharmacy, Seoul St. Mary's Hospital The Catholic University of Korea)
  • 김수현 (가톨릭대학교 여의도성모병원 약제팀) ;
  • 안성심 (가톨릭대학교 서울성모병원 약제부) ;
  • 김순주 (가톨릭대학교 서울성모병원 약제부) ;
  • 방준석 (가톨릭대학교 서울성모병원 약제부) ;
  • 나현오 (가톨릭대학교 서울성모병원 약제부)
  • Received : 2010.08.27
  • Accepted : 2010.09.13
  • Published : 2010.09.30
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Abstract

Radiofrequency ablation (RA) is being used to manage atrial fibrillation (AF) with patients failed at the $1^{st}$-line anti-arrhythmic medications. Patients undergoing this procedure are at increased risk of thromboembolism after ablation, and anticoagulation management surrounding the ablation remains controversial. Although no conclusive recommendations can be made, published guidelines and data support therapeutic anticoagulation with warfarin. The purpose of this study was to analyze effectiveness of current therapy and to find factors fluctuate International Normalized Ratio (INR) values in patients undergone RA followed by anticoagulation service (ACS). Retrospective review was conducted utilizing database in a hospital. Among 110 patients under warfarin around ablation between January 2006 to September 2007, 54 patients were selected and allocated into 2 groups: Group A included 47 who discontinued warfarin after ablation, while 7 in B continued the medication. Information on demographics, amount and length of warfarin dosing, INR values and measuring frequencies, and the causing factors on INR fluctuation were abstracted. Differences were analyzed using chi-squared test, Fisher's Exact test, and unpaired Student t-test. Mean amount of warfarin before and after surgery was 4.0 mg, 4.1 mg in Group A and was 5.1 mg, 4.6 mg in Group B, respectively. Average duration of warfarin doing before ablation was 73.7 days in Group A, 129.9 days in B with no significant difference (p = 0.312). The duration time of warfarin on groups after ablation lasted several months. The number of checking INRs was 4.1 and 7.6, respectively. Inter-individual variability of INR fluctuations were $2.1{\pm}0.6$ in Group A and $2.2{\pm}0.7$ in B which were not significantly different (p = 0.062). 164 cases of decreased INR were: 'omission in taking medication, stressfulness and headache, 'increased intake of high vitamin K foods', 'lifestyle change of increased physical activities', and 'increase of food-intakes'. To the contrary, 36 cases of increased INR were: 'reduce of food-intake', 'use of non-prescription drugs', 'reduction in physical activities', and 'excessive restriction on food-intake', consecutively. In conclusion, the study validated therapeutic outcomes of RA patients who we treated with standard guideline and demonstrated 9 factors of INR fluctuations in the patient. A well-trained, pharmacist-monitored anticoagulation service could reduce the risk of adverse effects and prevent complications in patients with AF around RA operation.

Keywords

References

  1. Benjamin EJ, Wolf PA, D'Agostino RB, et al., Impact of atrial fibrillation on the risk of death. Circulation 1998; 98: 946-52. https://doi.org/10.1161/01.CIR.98.10.946
  2. Feinburg WM, Blackshear JL, Laupacis A, et al., Prevalence, age distribution, a gender of patients with atrial fibrillation: analysis and implications. Arch Intern Med 1995; 155: 469-73. https://doi.org/10.1001/archinte.155.5.469
  3. Ryder KM, Benjamin EJ. Epidemiology and significance of atrial fibrillation. Am J Cardiol 1999; 84: 131R-8R. https://doi.org/10.1016/S0002-9149(99)00713-4
  4. AHA 2006 Guidelines for the Management of Patients with Atrial Fibrillation. 2006 American Heart Association, Inc. 2006; 114: e257-e354. https://doi.org/10.1161/CIRCULATIONAHA.106.177292
  5. Pratola C, Baldo E, Notarstefano P, et al., Radiofrequency ablation of atrial fibrillation: is the persistence of all intraprocedural targets necessary for long-term maintenance of sinus rhythm? Circulation 2008; 117: 136-43. https://doi.org/10.1161/CIRCULATIONAHA.106.678789
  6. Mateos JC, Mateos EI, Lobo TJ, et al., Radiofrequency catheter ablation of atrial fibrillation guided by spectral mapping of atrial fibrillation nests in sinus rhythm. Arq Bras Cardiol 2007; 89: 124-34, 140-50.
  7. Martin-Suarez S, Claysset B, Botta L, et al., Surgery for atrial fibrillation with radiofrequency ablation. Interact Cardiovasc Thorac Surg 2007; 6: 71-6.
  8. Nehra D, Liberman M, Vagefi PA, et al., Complete pulmonary venous occlusion after radiofrequency ablation for atrial fibrillation. Ann Thorac Surg 2009; 87: 292-5. https://doi.org/10.1016/j.athoracsur.2008.06.060
  9. De Piccoli B, Rossillo A, Zanella C, et al., Role of transoesophageal echocardiography in evaluating the effect of catheter ablation of atrial fibrillation on anatomy and function of the pulmonary veins. Europace 2008; 10: 1079-84. https://doi.org/10.1093/europace/eun188
  10. Scanavacca MI, Kajita LJ, Vieira M, et al., Pulmonary vein stenosis complicating catheter ablation of focal atrial fibrillation. J Cardiovasc Electrophysiol 2000; 11: 677-81. https://doi.org/10.1111/j.1540-8167.2000.tb00030.x
  11. American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation): Developed in Collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
  12. Bubien RS, Knotts-Dolson SM, Plumb VJ, et al., Effect of radiofrequency catheter ablation on health-related quality of life and activities of daily living in patients with recurrent arrhythmias. Circulation 1996; 94: 1585-91. https://doi.org/10.1161/01.CIR.94.7.1585
  13. Hindricks G, Piorkowski C, Tanner H, et al., Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence. Circulation 2005; 112: 307-13. https://doi.org/10.1161/CIRCULATIONAHA.104.518837
  14. Isma'eel H, Zebian R, El-Accaoui R, et al., Anticoagulation clinics are needed in developing countries. Int J Cardiol 2007; 115: 410-1. https://doi.org/10.1016/j.ijcard.2006.04.024
  15. Burkiewicz JS. Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation. Pharmacotherapy 2005; 25: 1062-7. https://doi.org/10.1592/phco.2005.25.8.1062
  16. Matchar DB, Samsa GP, Cohen SJ, et al., Improving the quality of anticoagulation of patients with atrial fibrillation in managed care organizations: results of the managing anticoagulation services trial. Am J Med 2002; 113: 42-51. https://doi.org/10.1016/S0002-9343(02)01131-2
  17. Mortada ME, Chandrasekaran K, Nangia V, et al., Periprocedural anticoagulation for atrial fibrillation ablation. J Cardiovasc Electrophysiol 2008; 19: 362-6. https://doi.org/10.1111/j.1540-8167.2007.01071.x
  18. Oral H, Chugh A, Ozaydin M, et al., Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation. Circulation 2006; 114: 759-65. https://doi.org/10.1161/CIRCULATIONAHA.106.641225
  19. European Heart Rhythm Association, Heart Rhythm Society, Fuster V, Ryden LE, Cannom DS, et al., ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2006; 48: 854-906. https://doi.org/10.1016/j.jacc.2006.07.009
  20. Laupacis A, Boysen G, Connolly S, et al., Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994; 154: 1449-57. https://doi.org/10.1001/archinte.154.13.1449
  21. Vazquez SR, Johnson SA, Rondina MT. Peri-procedural anticoagulation in patients undergoing ablation for atrial fibrillation. Thrombosis Research 2010; 126: 69-77. https://doi.org/10.1016/j.thromres.2009.11.031
  22. Jones C, Lacombe G. Enhancing patient care via a pharmacistmanaged rural anticoagulation clinic. Healthc Q 2009; 13: 69-74.
  23. Bond CA, Raehl CL. Pharmacist-provided anticoagulation management in United States hospitals: death rates, length of stay, Medicare charges, bleeding complications, and transfusions. Pharmacotherapy 2004; 24: 953-63. https://doi.org/10.1592/phco.24.11.953.36133
  24. Garcia DA, Witt DM, Hylek E, et al., Delivery of optimized anticoagulant therapy: consensus statement from the Anticoagulation Forum. Ann Pharmacother. 2008; 42: 979-88. https://doi.org/10.1345/aph.1L098
  25. Poon IO, Lal L, Brown EN, et al., The impact of pharmacist-managed oral anticoagulation therapy in older veterans. J Clin Pharm Ther 2007; 32: 21-9. https://doi.org/10.1111/j.1365-2710.2007.00792.x
  26. Sullivan PW, Arant TW, Ellis SL, et al., The Cost Effectiveness of Anticoagulation Management Services for Patients with Atrial Fibrillation and at High Risk of Stroke in the US. Pharmacoeconomics 2006; 24: 1021-33. https://doi.org/10.2165/00019053-200624100-00009
  27. Dager WE, Branch JM, King JH, et al., Optimization of inpatient warfarin therapy: impact of daily consultation by a pharmacist-managed anticoagulation service. Ann Pharmacother 2000; 34: 567-72. https://doi.org/10.1345/aph.18192
  28. Waterman AD, Milligan PE, Banet GA, et al., Establishing and running an effective telephone-based anticoagulation service. J Vasc Nurs 2001; 19: 126-34. https://doi.org/10.1067/mvn.2001.119940
  29. Waterman AD, Banet G, Milligan PE, et al., Patient and Physician Satisfaction with a Telephone-based Anticoagulation Service. J Gen Intern Med 2001; 16: 460-3. https://doi.org/10.1046/j.1525-1497.2001.016007460.x
  30. Chenella FC, Klotz TA, Gill MA, et al., Comparison of physician and pharmacist management of anticoagulant therapy of inpatients. Am J Hosp Pharm 1983; 40:1642-5.
  31. Tschol N, Lai DK, Tilley JA, et al., Comparison of physician- and pharmacist-managed warfarin sodium treatment in open heart surgery patients. Can J Cardiol 2003; 19: 1413-7.
  32. Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs. Arch Intern Med 1998; 158: 1641-7. https://doi.org/10.1001/archinte.158.15.1641
  33. Gray DR, Garabedian-Ruffalo SM, Chretien SD. Costjustification of a clinical pharmacist-managed anticoagulation clinic. Drug Intell Clin Pharm 1985; 19: 575-80.
  34. Anderson RJ. Cost analysis of a managed care decentralized outpatient pharmacy anticoagulation service. J Manag Care Pharm 2004; 10: 159-65.
  35. Lip GY, Huber K, Andreotti F, et al., Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting. Thromb Haemost 2010; 103: 13-28.
  36. Ross KA, Bigham AW, Edwards M, et al., Worldwide allele frequency distribution of four polymorphisms associated with warfarin dose requirements. J Human Genet (advance online publication 17 June 2010); doi: 10.1038/jhg.2010.73.