Warfarin Initiation in Mechanical Mitral Valve Replacement Patients

Mitral Valve Disease Clinical Trial

Official title:

Evaluation of Warfarin Initiation at 3mg Versus 5mg for Anticoagulation of Mechanical Mitral Valve Replacement Patients

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT04235569
• Other study ID #: 11222
• Status: Completed
• Phase: Phase 4
• Start date: March 1, 2018
• Est. completion date: September 1, 2019

Study information

• Verified date: January 2020
• Source: Ain Shams University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

A prospective, comparative study evaluating warfarin initiation in a dose of 3mg versus 5mg in mechanical mitral valve prostheses patients who received anticoagulation with warfarin with the use of enoxaparen as a bridging agent .Fifty patients were included and compared in terms of the primary outcome time to reach therapeutic INR range.Other outcomes includes proportion of patients who achieved the target INR of 2.0-3.0 between day 3 and day 5, total dose of enoxaparin required for bridging, safety related to both doses of anticoagulants used

Description:

Inpatients of The Cardiovascular hospital who had undergone mitral heart valve replacement with a mechanical prosthesis and commencing warfarin were eligible for inclusion. Patients were included after they had newly undergone elective surgery for implantation of mechanical mitral heart valves, had commenced on warfarin, received enoxaparin as a bridging agent and had INR monitored for a minimum of 4 consecutive days after warfarin initiation.

A total of 50 consecutive MVR patients were recruited. Each was assigned to either the group I (25 patients) or the group II (25 patients) group. All patients received the conventional postoperative treatment including: Diuretics, beta-blockers, digoxin or heart rate-regulating calcium channel blockers and anticoagulation bridging therapy using LMWH according to the European Society of Cardiology (ESC) Guidelines for the management of MVR and antibiotic for 48hour after surgery according to the investigator's hospital's antibiotic protocol.

Baseline evaluation included demographics and history taking. After obtaining the informed consent, information including age, weight, height, smoking state, and other diseases e.g. hypertension, diabetes, hyperlipidemias, etc. were documented for each patient. Medication history in details, as well as the background cardiovascular treatment was considered.

Blood samples were withdrawn from patients for evaluation of INR. Complete blood count, kidney and liver function tests were performed as part of the routine admission care.

All patients were followed up daily post operative till reaching an in range INR value. All patients were observed daily for INR values and dose adjusted accordingly and also estimation of incidence and severity of bleeding complications was done.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 50
• Est. completion date: September 1, 2019
• Est. primary completion date: January 1, 2019
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 60 Years

Eligibility

Inclusion Criteria:

• New mechanical mitral valve prostheses patients who will receive anticoagulation with warfarin with the use of enoxaparen as a bridging agent.

Exclusion Criteria:

• Pregnant or lactating women

• Renal disorder (GFR = 45< mL/min) or patients on renal dialysis

• Hepatic disorder (Child Pugh class B or C)

• Clinically significant active bleeding.

• Recurrent DVT or PE.

• Baseline INR >1.2

• Asian ancestry

• Cancer

• Impaired nutritional status

• Alcohol abuse

Related Conditions & MeSH terms

• Mitral Valve Disease

Intervention

Drug:
• Warfarin Sodium 5 MG
warfarin sodium 5mg tablets
• Warfarin Sodium 3 MG
warfarin sodium 3mg tablets
• Enoxaparin Sodium 100 MG/ML Prefilled Syringe
Clexane® Syringes 2,000 IU (20 mg)/0.2 ml solution for injection in pre-filled syringes. Clexane® Syringes 4,000 IU (40 mg)/0.4 ml solution for injection in pre-filled syringes. Clexane® Syringes 6,000 IU (60 mg)/0.6 ml solution for injection in pre-filled syringes. Clexane® Syringes 8,000 IU (80 mg)/0.8 ml solution for injection in pre-filled syringes. Dose was determined individually for each patient as 1mg/kg every 12 hours.

Locations

Country	Name	City	State
Egypt	The Cardiovascular Hospital	Heliopolis	Cairo

Sponsors (1)

Lead Sponsor	Collaborator
Sarah Sabry Hashem

Country where clinical trial is conducted

Egypt, 

References & Publications (7)

Bayliss A, Faber P, Dunning J, Ronald A. What is the optimal level of anticoagulation in adult patients receiving warfarin following implantation of a mechanical prosthetic mitral valve? Interact Cardiovasc Thorac Surg. 2007 Jun;6(3):390-6. Epub 2007 Feb 9. Review. — View Citation

Dong L, Shi YK, Xu JP, Zhang EY, Liu JC, Li YX, Ni YM, Yang Q, Han T, Fu B, Chen J, Ren L, Wei SL, Chen H, Liu KX, Yu FX, Liu JS, Xiao MD, Wu SM, Zhang KL, Huang HL, Jiang SL, Qiao CH, Wang CS, Xu ZY, Zhou XM, Wang DJ, Ni LX, Xiao YB, Jiang SL, Zhang GM, Liang GY, Yang SY, Bo P, Zhong QJ, Zhang JB, Zhang X, Zhu YB, Teng X, Zhu P, Huang F, Xiao YM, Cao GQ, Tian H, Xia LM, Lu FL, Liu YQ, Liu DX, Xu H, Yuan Y, Li M, Chang C, Wu XC, Xu Z, Guo P, Bai YJ, Xue WB, Jiang XY, Na ZH, Zeng QY, Cai H, Wang YL, Xiong R, Jin S, Zheng XM, Wu D. [The multicenter study on the registration and follow-up of low anticoagulation therapy for the heart valve operation in China]. Zhonghua Yi Xue Za Zhi. 2016 May 24;96(19):1489-94. doi: 10.3760/cma.j.issn.0376-2491.2016.19.006. Chinese. — View Citation

Mahtani KR, Heneghan CJ, Nunan D, Bankhead C, Keeling D, Ward AM, Harrison SE, Roberts NW, Hobbs FD, Perera R. Optimal loading dose of warfarin for the initiation of oral anticoagulation. Cochrane Database Syst Rev. 2012 Dec 12;12:CD008685. doi: 10.1002/14651858.CD008685.pub2. Review. — View Citation

Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-289. doi: 10.1016/j.jacc.2017.03.011. Epub 2017 Mar 15. — View Citation

Roberts G, Razooqi R, Quinn S. Comparing Usual Care With a Warfarin Initiation Protocol After Mechanical Heart Valve Replacement. Ann Pharmacother. 2017 Mar;51(3):219-225. doi: 10.1177/1060028016676830. Epub 2016 Oct 26. — View Citation

Suwanawiboon B, Kongtim P, Chinthammitr Y, Ruchutrakool T, Wanachiwanawin W. The efficacy of 3-mg warfarin initiating dose in adult Thai patients, who required long-term anticoagulant therapy. J Med Assoc Thai. 2011 Feb;94 Suppl 1:S225-31. — View Citation

Yoon IK, Lee KE, Lee JK, Chang BC, Gwak HS. Adequate intensity of warfarin therapy for Korean patients with mechanical cardiac valves. J Heart Valve Dis. 2013 Jan;22(1):102-9. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Efficacy of warfarin initiating dose and the corresponding dosing schedule: Time to reach therapeutic INR range (TTR)	Time to reach therapeutic INR range (TTR):The time in days required for the patient from the start of warfarin initiation till reaching the therapeutic	4-16 days
Secondary	Evaluation of overanticoagulation	Proportion of patients who achieved the target INR of 2.0-3.0 between day 3 and day 5	from 3 to 5 days
Secondary	Anticoagulation Safety evaluation	Incidence of major and minor bleeding events	from 4 to 16 days
Secondary	Low Molecular Weight Heparin consumption	The total dose of enoxaparin in mg that the patient received till discontinuation of bridging	from 4 to 16 days
Secondary	The Overall cost evaluation	total cost spent in LE during the follow up period calculated by the summation of the cost of treatment , cost of bleeding event management and cost of hospital stay.	from 4 to 16 days