Pharmaceutical Care Increases Time in Therapeutic Range of Patients With Poor Quality of Anticoagulation With Warfarin

Thromboembolic events are associated with high mortality and morbidity indexes. In this context, warfarin is the most widely prescribed oral anticoagulant agent for preventing and treating these events. This medication has a narrow therapeutic range and, consequently, patients usually have difficulty in achieving and maintaining stable target therapeutics. Some studies on the literature about oral anticoagulant management showed that pharmacists could improve the efficiency of anticoagulant therapy. However, the majority of these studies included general patients retrospectively. The aim of this study was to prospectively evaluate a pharmacist’s warfarin management in patients with poor quality of anticoagulation therapy (Time in the Therapeutic Range- TTR < 50%). We included 268 patients with atrial fibrillation (AF) and without stable dose of warfarin (TTR < 50%, based on the last three values of International Normalized Ratio-INR). We followed them up for 12 weeks, INR values were evaluated and, when necessary, the dose adjustments were performed. During the first four visits, patient’s INR was measured every 7 days. Then, if INR was within the target therapeutic range (INR: 2–3), the patient was asked to return in 30 days. However, if INR was out the therapeutic target, the patient was asked to return in 7 days. Adherence evaluation was measured through questionnaires and by counting the pills taken. Comparison between basal TTR (which was calculated based on the three last INR values before prospective phase) and TTR of 4 weeks (calculated by considering the INR tests from visits 0 to 4, in the prospective phase of the study) and basal TTR and TTR of 12 weeks (calculated based on the INR tests from visits 0 to 12, in the prospective phase of the study) revealed significant statistical differences (0.144 ± 0.010 vs. 0.382 ± 0.016; and 0.144 ± 0.010 vs. 0.543 ± 0.014, p < 0.001, respectively). We also observed that the mean TTR of 1 year before (retrospective phase) was lower than TTR value after 12 weeks of pharmacist-driven treatment (prospective phase) (0.320 ± 0.015; 0.540 ± 0.015, p < 0.001). In conclusion, pharmaceutical care was able to improve TTR values in patients with AF and poor quality of anticoagulation with warfarin

Association of clinical, electrocardiographic and genetic variables with severity outcomes in patients with arrhythmogenic right ventricular cardiomyopathy

Introdução: A cardiomiopatia arritmogênica do ventrículo direito (CAVD) é uma cardiopatia hereditária rara, que causa morte súbita, arritmias ventriculares e insuficiência cardíaca (IC). Nós investigamos características clínicas, achados genéticos, a história natural e a ocorrência de eventos em uma população com CAVD, para identificar preditores de risco. Métodos: Foram analisados o curso clínico de 111 pacientes com CAVD, preditores de eventos arrítmicos (EA), morte por insuficiência cardíaca e transplante cardíado (IC /Tx) e eventos combinados em toda a coorte e em um subgrupo de 40 pacientes sem arritmia ventricular sustentada antes do diagnóstico. Resultados: A probabilidade cumulativa de apresentar um primeiro evento combinado foi de 57,27%, de evento arrítmico (EA) foi de 30% e de morte por IC ou transplante cardíaco (Tx) foi de 10% em 5 anos. Os preditores de morte por IC/Tx foram: fração de ejeção reduzida (HR: 0.93, p=0.010), sintomas de IC (HR: 4.37, p=0.010), a presença de onda épsilon (HR:4,99; p=0,015) e o número de derivações com baixa voltagem (HR:1.28, p=0.001). Cada derivação adicional com baixa voltagem de QRS aumentou o risco de morte por IC/HTx em 28%. Os preditores de EA foram: síncope (HR: 1.81, p=0.040), número de derivações com inversão de onda T (HR: 1.17, p=0.039), baixa voltagem do QRS (HR: 1.12, p=0.021), idade jovem (HR: 0.97, p=0.006) e arritmia ventricular na apresentação clínica inicial (HR: 2.45, p=0.012). Cada derivação adicional com baixa voltagem aumentou o risco de EA em 17%. Em pacientes sem arritmia ventricular antes do diagnóstico de CAVD, o número de derivações com baixa voltagem do QRS (HR: 1,68, p=0,023) esteve associado de forma independente com morte por IC/Tx. Conclusão: Nosso estudo demonstrou as características de uma coorte específica de CAVD com alta prevalência de carga arrítmica, predominância do sexo masculino, idade jovem e desfechos graves de insuficiência cardíaca. Nosso principal resultado sugere que a presença e extensão de baixa voltagem do QRS pode ser um preditor de risco para morte por IC/Tx, independentemente do risco arrítmico. Este estudo pode contribuir para a estratificação global de risco nessa cardiopatia. Novos estudos são necessários para agregarem valor na determinação dos riscos de EA, morte por IC/Tx na CAVDBackground: Arrhythmogenic right ventricular cardiomyopathy (ARVC), a rare inherited disease, causes ventricular tachycardia (VT), sudden cardiac death (SCD) and heart failure (HF). We investigated ARVC clinical features, genetic findings, natural history and the occurrence of life-threatening arrhythmic events (LTAE), HF death or heart transplantation (HF-death/HTx), to identify risk factors. Methods: The clinical course of 111 consecutive patients with definite ARVC, predictors of LTAE, HF-death/HTx, and combined events were analyzed in the entire cohort and in a subgroup of 40 patients without sustained ventricular arrhythmia (VA) before diagnosis. Results: The 5-year cumulative probability of LTAE was 30% and HF-death/HTx was 10%. Predictors of HF-death/HTx were reduced RV ejection fraction (HR: 0.93, p=0.010), HF symptoms (HR: 4.37, p=0.010), epsilon wave (HR: 4.99, p=0.015) and number of leads with low QRS voltage (HR: 1.28, p=0.001). Each additional lead with low QRS voltage increased the risk of HF-death/HTx by 28%. Predictors of LTAE were prior syncope (HR: 1.81, p=0.040), number of leads with T wave inversion (HR: 1.17, p=0.039), low QRS voltage (HR: 1.12, p=0.021), younger age (HR: 0.97, p=0.006) and prior VA/VF (HR: 2.45, p=0.012). Each additional lead with low QRS voltage increased the risk of LTAE by 17%. In patients without VA before clinical diagnosis of ARVC, the number of leads with low QRS voltage (HR: 1.68, p=0.023) was independently associated with HF-death/HTx. Conclusion: Our study demonstrated the characteristics of a specific cohort with a high prevalence of arrhythmic burden at presentation, male predominance, younger age and HF severe outcomes. Our main results suggest that the presence and extension of low QRS voltage can be a risk predictor for HF-death/HTx in ARVC patients, regardless of the arrhythmic risk. This study can contribute to the global ARVC risk stratification, adding new insights to the international current scientific knowledg