Varfarin ilişkili aşırı antikoagülasyona bağlı olarak international normalized ratio değeri 4.5 - 10 arasında olan hastalarda 30 günlük mortalitenin prediktörlerinin belirlenmesi: retrospektif kohort çalışması.

Amaç: K vitamini uygulamasının international normalized ratio(INR) değeri 4.5 ila 10 arasında olan hastalara fayda sağlamadığı gösterilmiş olmasına rağmen, literatür bu hasta grubunda kanama dahil olmak üzere bazı komplikasyonların önemli ölçüde arttığını göstermektedir. Bu nedenle, INR düzeyi artmış hastalarda yüksek risk taşıyan hastaların belirlenmesi ve daha yakın takip ve izlem altına alınması önemlidir. Çalışmamızın birincil amacı, varfarin ilişkili aşırı antikoagülasyon nedeniyle INR değeri 4.5 - 10 arasında olan hastaların 30 günlük mortalite prediktörlerini belirlemektir. Çalışmamızın ikincil amacı, 30 gün içindeki mortaliteyi öngören bir regresyon modeli oluşturmak ve bu modelin performansını National Early Warning Score-2 (NEWS-2) ile karşılaştırmaktır. Gereç ve Yöntem: Çalışmamıza, 01.01.2016 - 01.01.2022 tarihleri arasında hastaneye başvuran, 18 yaşından büyük, warfarin kullanan ve INR değeri 4.5 ila 10 arasında olan hastalar dahil edildi. Travma ile başvuran, başvuru esnasında majör kanaması olan veya veri eksiği olan hastalar çalışmamızdan dışlandı. Regresyon modeli için, backward-Wald stepwise yöntemi kullanıldı. Modelin fitliği Hosmer-Lemeshow ile test edildi. Modelin genel performansı Nagelkerke R Square ile değerlendirildi ve Reciever Operating Characteristics testi uygulandı. Eğri altında kalan alanların (AUC) karşılaştırması için DeLong testi kullanıldı. Bulgular: İstatistiksel analizde toplam 263 hasta dahil edildi. Ortalama arteriyel basınç, SpO2, nabız ve yaş, 30 günlük mortalitenin bağımsız prediktörleri olarak bulundu. Model, hastaların %81.4'ünü doğru şekilde sınıflandırdı. Regresyon modelinin AUC değeri 0.848 0.799 - 0.898) olarak hesaplandı. Mortalite tahminindeki tanısal performansı incelendiğinde duyarlılığı %94.1, özgüllüğü %66.5 ve doğruluğu %71.9 olarak hesaplandı. 30 günlük mortalite için NEWS-2 skorunun AUC değeri 0.782(95% CI = 0.715 - 0.849) olarak hesaplandı. Modelimizin ve NEWS-2 skoru arasındaki AUC farkı istatistiksel olarak anlamlı bulundu. Sonuç: Ortalama arteriyel basınç, SpO2, nabız ve yaş, varfarin kullanımına bağlı olarak INR değeri 4.5-10 arasında olan hastalarda 30 günlük mortalite için bağımsız prediktörler olduğu saptandı. Elde ettiğimiz regresyon modeli genel olarak iyi bir sınıflama sağladı ve NEWS-2 skorundan anlamlı şekilde daha iyi performans gösterdi.

Anahtar Kelimeler:

Varfarin, yüksek INR, aşırı antikoagülasyon, K vitamini, mortalite prediktörleri

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

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.

Keywords:

Warfarin, Supratherapeutic INR, Overanticoagulation, Vitamin-K, Predictors of mortality,

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