Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data
Heneghan C, Ward A, Perera R, Bankhead C, Fuller A, Stevens R, et al.
Lancet. 2012;379(9813):322-334
Background:
Uptake of self-testing and self-management of oral anticoagulation [corrected] has remained inconsistent, despite good evidence of their effectiveness. To clarify the value of self-monitoring of oral anticoagulation, we did a meta-analysis of individual patient data addressing several important gaps in the evidence, including an estimate of the effect on time to death, first major haemorrhage, and thromboembolism.
Methods:
We searched Ovid versions of Embase (1980-2009) and Medline (1966-2009), limiting searches to randomised trials with a maximally sensitive strategy. We approached all authors of included trials and requested individual patient data: primary outcomes were time to death, first major haemorrhage, and first thromboembolic event. We did prespecified subgroup analyses according to age, type of control-group care (anticoagulation-clinic care vs primary care), self-testing alone versus self-management, and sex. We analysed patients with mechanical heart valves or atrial fibrillation separately. We used a random-effect model method to calculate pooled hazard ratios and did tests for interaction and heterogeneity, and calculated a time-specific number needed to treat.
Findings:
Of 1357 abstracts, we included 11 trials with data for 6417 participants and 12,800 person-years of follow-up. We reported a significant reduction in thromboembolic events in the self-monitoring group (hazard ratio 0·51; 95% CI 0·31-0·85) but not for major haemorrhagic events (0·88, 0·74-1·06) or death (0·82, 0·62-1·09). Participants younger than 55 years showed a striking reduction in thrombotic events (hazard ratio 0·33, 95% CI 0·17-0·66), as did participants with mechanical heart valve (0·52, 0·35-0·77). Analysis of major outcomes in the very elderly (age ≥85 years, n=99) showed no significant adverse effects of the intervention for all outcomes.
Interpretation:
Our analysis showed that self-monitoring and self-management of oral coagulation is a safe option for suitable patients of all ages. Patients should also be offered the option to self-manage their disease with suitable health-care support as back-up.
Comentario del Dr. Juan Carlos Souto
En este metaanálisis se analiza el potencial beneficio del autocontrol de la anticoagulación oral (fármacos antivitamina K). Se incluyeron los datos de 11 ensayos clínicos, con un total de 6417 participantes y un seguimiento de 12 800 personas/año.
Se reportó una reducción significativa en los eventos tromboembólicos en el grupo del autocontrol [HR 0,51; IC 95% (0,31-0,85)], pero no hubo significación estadística para la reducción del evento hemorrágico grave [0,88; (0,74-1,06)] ni para la reducción de muerte [0,82; (0,62-1,09)]. En los pacientes menores de 55 años, la reducción de eventos tromboembólicos fue aún más llamativa [0,33; (0,17-0,66)]. También, se redujo muy significativamente la incidencia de eventos tromboembólicos en los pacientes con válvulas cardíacas mecánicas [0,52; (0,35-0,77)]. En los pacientes mayores de 85 años no se observó una mayor tasa de complicaciones.
Según la conclusión del metaanálisis, el autocontrol se puede considerar en pacientes de cualquier edad. Disminuye significativamente la incidencia de eventos tromboembólicos, manteniendo la misma mortalidad y el mismo riesgo hemorrágico. Los grupos que más se beneficiarían serían los menores de 55 años y aquellos con válvulas cardíacas mecánicas.
