In 2010, when Thomas McGeough developed atrial fibrillation, a condition that can increase the risk for stroke, he began taking Coumadin, a brand of warfarin.
This blood-thinning medication is used to treat and prevent blood clots, which can cause stroke, heart attack or other serious conditions, such as deep vein thrombosis or pulmonary embolism.
“I haven’t had any problem with atrial fibrillation since I’ve been taking Coumadin,” said the 73-year-old retired corporate lawyer from Staten Island. “It works.”
Theresa Pepio is in a similar situation. She has been taking Coumadin for atrial fibrillation since 2007. “It keeps my afib under control,” said the 66-year-old retired Staten Island kindergarten teacher.
Mr. McGeough and Ms. Pepio are just two of the more than two million people who take a daily blood thinner.
PUT TO THE TEST
To maximize Coumadin’s effectiveness, patients like Mr. McGeough and Ms. Pepio need an international normalized ratio (INR), a blood-clotting test, once a week or so. This test is vital to the overall care of atrial fibrillation.
“Coumadin relies on a very narrow therapeutic range to engender its positive effects,” said Alex Spyropoulos, MD, director of Anticoagulation and Clinical Thrombosis Services (ACTS) for the North Shore-LIJ Health System. To maximize Coumadin’s effectiveness, it’s important that patients maintain an INR of 2.0 to 3.0, which indicates that their blood is two to three times thinner than normal.
Both Mr. McGeough and Ms. Pepio are fortunate. They monitor their INRs regularly, adjust their Coumadin dosages and change their diets as needed (Coumadin is sensitive to food and other medication), and their INR readings have basically stayed within the target range.
According to nationwide statistics, however, most Coumadin patients don’t do as well. The average time patients spend in the therapeutic range is 55 percent or less, said Dr. Spyropoulos.
Time spent in the therapeutic range (TTR) signals how likely a patient is to experience adverse effects, such as bleeding or stroke. “Coumadin is a dangerous drug and can have more harm than benefits. It’s the number one cause of drug adverse events in the United States, which includes death,” Dr. Spyropoulos said. “Only patients with a TTR of 65 percent or more, indicating that they’re in the therapeutic range of 2.0 to 3.0 for Coumadin 65 percent of the time or more, maximize the benefits of the drug.”
KEEPING PATIENTS IN THE SAFETY ZONE
To help more patients achieve an optimal TTR, Dr. Spyropoulos is leading the ACTS outpatient program.
Studies show that a centralized, evidence-based anticoagulant management service like ACTS can dramatically improve patient outcomes while reducing emergency department visits and hospitalizations.
With a sensitive drug like Coumadin, and because of patient limitations, a TTR of 75 percent is as good as it gets. “Our goal is to get the average patient TTR at 72 to 73 percent,” Dr. Spyropoulos said. Every 10 percent TTR improvement is associated with a six percent reduction in adverse outcomes.
To improve the efficacy and safety of anticoagulation medications, ACTS focuses on:
- Managing venous thromboembolicdisease on an outpatient basis for patients taking Coumadin or any of the new blood-thinning agents that have recently been approved by the US Food and Drug Adminis-tration. Unlike Coumadin, these small-molecule, target-specific novel oral anticoagulants don’t need routine monitoring. ACTS specializes in patients requiring these agents, as well.
- Teaching eligible patients how to perform an INR self-test, which they can do at home;
- Providing inpatient antocoagulationtherapy for patients with heparin-induced thrombocytopenia (a blood disorder) and cancer;
- Consulting on high-risk andcomplicated patients with thrombotic disorders, such as antiphospholipids syndrome (a disorder of the immune system) and pregnancy-associated thrombolic disorders; and
- Perioperative “bridging” for chronicanticoagulation patients — this service can help patients manage their doses of blood-thinning medication before and after an elective medical procedure.
To ensure the highest quality of care, the ACTS team of physicians and nurse practitioners collaborates with a patient’s primary care provider, cardiologist and other referring physician. “We strive to provide the best in anticoagulation therapy to prevent complications through in-creased understanding, communication, patient education and anticipation of potential issues through close monitoring,” Dr. Spyropoulos said
STROKE CENTER EXCELLENCE
North Shore University Hospital and LIJ Medical Center recently won the Gold Plus Quality Achievement Award from the American Heart Association for implementing a higher standard of care for stroke patients according to nationally accepted guidelines. LIJ also earned a spot on the Target: Stroke Honor Roll for improving outcomes for ischemic stroke patients. As New York State-designated stroke centers, North Shore and LIJ have multidisciplinary stroke teams available 24 hours a day to assess and treat stroke patients.