.: ORİJİNAL ARAŞTIRMA
Bleeding Due to Warfarin Treatment: Five Years of Experience
Varfarin Tedavisine Bağlı Kanama: Beş Yıllık Deneyim
Turkiye Klinikleri J Cardiovasc Sci. 2019;31(3):125-34
doi: 10.5336/cardiosci.2019-65895
Makale Dili: EN
Tam Metin
ABSTRACT
Objective: The aim of the study was to determine the factors contributing to the development of bleeding and mortality in patients admitted to emergency department with any nontraumatic bleeding (major or minor) complaint while under warfarin therapy. Material and Methods: Patients who admitted to the emergency department of a university hospital between 2009 and 2013 due to bleeding complications during warfarin treatment were included in the study which was conducted in a prospective and observational design. The demographic characteristics of the patients, the reasons for using warfarin, the types and localizations of the bleedings, the treatments applied, the duration of hospitalization and mortality data were recorded. The factors that are likely to be effective on bleeding and mortality (age, hemodynamic status on admission, initial INR levels, warfarin dose, etc.) were analyzed comparatively. SPSS version 16.0 program was used for statistical analysis and p<0.05 was considered statistically significant. Results: A total of 518 patients were enrolled in the study. The mean age of the patients was 64.19±13.28 years, 229 (44.2%) of the patients were male. More than half of the patients were over 65 years of age, the most common indication for warfarin was heart valve disease and atrial fibrillation, and the most mortal bleeding type was gastrointestinal bleeding. There was no correlation between the first INR levels on admission and the bleeding severity and mortality (p=0.577, p=0.788). The most significant indicator of mortality was hemodynamic instability during admission. Systolic and diastolic arterial blood pressure and haemoglobin levels were significantly lower (p=0.004, p=0.023, p=0.001, respectively) in nonsurvivors, whereas pulse and shock index were significantly higher (p<0.001, p<0.001). Conclusion: Patients under warfarin treatment admit to emergency services with major or minor bleeding independently from INR levels. Especially, patients aged 65 and over are at risk. The most significant indicator of mortality appears to be hemodynamic instability during admission.
Keywords: Warfarin; hemorrhage; drug-related side effects and adverse reactions
Objective: The aim of the study was to determine the factors contributing to the development of bleeding and mortality in patients admitted to emergency department with any nontraumatic bleeding (major or minor) complaint while under warfarin therapy. Material and Methods: Patients who admitted to the emergency department of a university hospital between 2009 and 2013 due to bleeding complications during warfarin treatment were included in the study which was conducted in a prospective and observational design. The demographic characteristics of the patients, the reasons for using warfarin, the types and localizations of the bleedings, the treatments applied, the duration of hospitalization and mortality data were recorded. The factors that are likely to be effective on bleeding and mortality (age, hemodynamic status on admission, initial INR levels, warfarin dose, etc.) were analyzed comparatively. SPSS version 16.0 program was used for statistical analysis and p<0.05 was considered statistically significant. Results: A total of 518 patients were enrolled in the study. The mean age of the patients was 64.19±13.28 years, 229 (44.2%) of the patients were male. More than half of the patients were over 65 years of age, the most common indication for warfarin was heart valve disease and atrial fibrillation, and the most mortal bleeding type was gastrointestinal bleeding. There was no correlation between the first INR levels on admission and the bleeding severity and mortality (p=0.577, p=0.788). The most significant indicator of mortality was hemodynamic instability during admission. Systolic and diastolic arterial blood pressure and haemoglobin levels were significantly lower (p=0.004, p=0.023, p=0.001, respectively) in nonsurvivors, whereas pulse and shock index were significantly higher (p<0.001, p<0.001). Conclusion: Patients under warfarin treatment admit to emergency services with major or minor bleeding independently from INR levels. Especially, patients aged 65 and over are at risk. The most significant indicator of mortality appears to be hemodynamic instability during admission.
Keywords: Warfarin; hemorrhage; drug-related side effects and adverse reactions
ÖZET
Amaç: Çalışmanın amacı, varfarin tedavisi altında iken (majör ya da minör) herhangi bir nontravmatik kanama şikayeti ile acil servise başvuran hastalarda, kanama gelişimi ve mortaliteye katkı sağlayan faktörleri belirlemektir. Gereç ve Yöntemler: Çalışmaya 2009-2013 yılları arasında bir üniversite hastanesi acil servisine nontravmatik kanama şikayeti ile başvuran ve varfarin kullanmakta olan hastalar dahil edildi. Çalışma prospektif, gözlemsel bir çalışma olarak yürütüldü. Hastaların demografik özellikleri, varfarin kullanma gerekçeleri, kanama tip ve lokalizasyonları, uygulanan tedaviler, yatış süreleri ve mortalite verileri kaydedildi. Kanama ve mortalite üzerine etkili olması muhtemel faktörler (yaş, başvurudaki hemodinamik durum, başlangıç INR düzeyleri, varfarin dozu vb.), karşılaştırmalı olarak analiz edildi. İstatistiksel incelemede SPSS ver. 16.0 programı kullanıldı. p <0,05 istatistiksel olarak anlamlı kabul edildi. Bulgular: Çalışmaya toplam 518 hasta alındı. Hastaların yaş ortalaması 64,19±13,28, 229'u (%44,2) erkekti. Hastaların yarısından fazlası 65 yaş üzerinde, en sık varfarin kullanım endikasyonu kalp kapak hastalığı ve atrial fibrilasyon, en fazla mortal seyreden kanama şekli gastrointestinal kanama idi. Başvuru sırasındaki ilk INR düzeyleri ile kanama ciddiyeti ve mortalite arasında bir ilişki tespit edilmemiştir (p=0,577, p=0,788). Mortal seyreden hastalarda sistolik ve diyastolik tansiyon arteryel ve hemoglobin düzeyleri anlamlı olarak (p=0,004, p=0,023, p=0,001, sırasıyla) daha düşük iken, nabız ve şok indeksi anlamlı olarak (p<0,001, p<0,001) daha yüksek bulunmuştur. Sonuç: Varfarin tedavisi altındaki hastalar, INR seviyelerinden bağımsız olarak majör ya da minör kanama şikayetleri ile acil servislere başvurmaktadırlar. Özellikle 65 yaş ve üzerindeki hastalar risk altındadırlar. Mortalitenin en anlamlı göstergesi başvuru esnasındaki hemodinamik kararsızlık olarak görünmektedir.
Anahtar Kelimeler: Varfarin; kanama; ilaç ilişkili yan etkiler ve istenmeyen reaksiyonlar
Amaç: Çalışmanın amacı, varfarin tedavisi altında iken (majör ya da minör) herhangi bir nontravmatik kanama şikayeti ile acil servise başvuran hastalarda, kanama gelişimi ve mortaliteye katkı sağlayan faktörleri belirlemektir. Gereç ve Yöntemler: Çalışmaya 2009-2013 yılları arasında bir üniversite hastanesi acil servisine nontravmatik kanama şikayeti ile başvuran ve varfarin kullanmakta olan hastalar dahil edildi. Çalışma prospektif, gözlemsel bir çalışma olarak yürütüldü. Hastaların demografik özellikleri, varfarin kullanma gerekçeleri, kanama tip ve lokalizasyonları, uygulanan tedaviler, yatış süreleri ve mortalite verileri kaydedildi. Kanama ve mortalite üzerine etkili olması muhtemel faktörler (yaş, başvurudaki hemodinamik durum, başlangıç INR düzeyleri, varfarin dozu vb.), karşılaştırmalı olarak analiz edildi. İstatistiksel incelemede SPSS ver. 16.0 programı kullanıldı. p <0,05 istatistiksel olarak anlamlı kabul edildi. Bulgular: Çalışmaya toplam 518 hasta alındı. Hastaların yaş ortalaması 64,19±13,28, 229'u (%44,2) erkekti. Hastaların yarısından fazlası 65 yaş üzerinde, en sık varfarin kullanım endikasyonu kalp kapak hastalığı ve atrial fibrilasyon, en fazla mortal seyreden kanama şekli gastrointestinal kanama idi. Başvuru sırasındaki ilk INR düzeyleri ile kanama ciddiyeti ve mortalite arasında bir ilişki tespit edilmemiştir (p=0,577, p=0,788). Mortal seyreden hastalarda sistolik ve diyastolik tansiyon arteryel ve hemoglobin düzeyleri anlamlı olarak (p=0,004, p=0,023, p=0,001, sırasıyla) daha düşük iken, nabız ve şok indeksi anlamlı olarak (p<0,001, p<0,001) daha yüksek bulunmuştur. Sonuç: Varfarin tedavisi altındaki hastalar, INR seviyelerinden bağımsız olarak majör ya da minör kanama şikayetleri ile acil servislere başvurmaktadırlar. Özellikle 65 yaş ve üzerindeki hastalar risk altındadırlar. Mortalitenin en anlamlı göstergesi başvuru esnasındaki hemodinamik kararsızlık olarak görünmektedir.
Anahtar Kelimeler: Varfarin; kanama; ilaç ilişkili yan etkiler ve istenmeyen reaksiyonlar
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