Predicting international normalised ratio ≥ 4.5 in hospitalised patients

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Predicting international normalised ratio ≥ 4.5 in hospitalised patients using vitamin K antagonists

Vitamin K antagonists (VKAs) used for the prevention and treatment of thromboembolic disease, increase the risk of bleeding complications. This model was developed and validated to predict the risk of an international normalised ratio (INR) ≥4.5 during a hospital stay.

We developed and validated a clinical prediction model for an INR ≥4.5 in VKA-treated patients admitted to our hospital. The model includes factors that are collected during routine care and are extractable from electronic patient records, enabling easy use of this model to predict an increased bleeding
risk in clinical practice.

Research authors: Albert R. Dreijer, Joseph S. Biedermann, Jeroen Diepstraten, Anouk D. Lindemans, Marieke J.H.A. Kruip, Patricia M.L.A. van den Bemt, Yvonne Vergouwe

Clinical pharmacology
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Predicted risk of INR ≥ 4.5

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The prediction model can help physicians to identify patients at the lower spectrum of thromboembolic risk and those for whom the risk of bleeding during vitamin K antagonist (VKA) therapy is high. Using the prediction model may also help
when counselling and informing patients about their potential risk for haemorrhage while on anticoagulants, and in identifying those patients who might benefit from more careful management of anticoagulation. Alternatively, these patients can also be switched to direct oral anticoagulants (DOACs), which cause less major bleeding, such as intracranial haemorrhages, compared to VKAs

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Calculations alone should never dictate patient care, and are no substitute for professional judgement. See our full disclaimer.

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Additional information

Details

Model author

T. A. Hueting

Model ID

1221

Version

1.9

Revision date

2018-03-20

Specialty

Clinical pharmacology, Internal medicine

Model type

Logistic regression ^{(Calculation)}

MeSH terms

International Normalized Ratio

Ratio, International Normalized

Bleeding

Rating

Status

Public

Formula
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Condition	Formula

Study characteristics

Additional information

Adult patients admitted to a tertiary hospital and treated with VKAs between 2006 and 2010 were analysed. Bleeding risk was operationalised as an INR value ≥4.5. Multivariable logistic regression analysis was used to assess the association between potential predictors and an INR ≥4.5 and validated in an independent cohort of patients from the same hospital between 2011 and 2014.

8996 admissions of patients treated with VKAs were identified, of which 1507 (17%) involved an INR ≥4.5. The final model included the following predictors: gender, age, concomitant medication and several biochemical parameters. Temporal validation showed a c-statistic of 0.71.

The development cohort constisted of 8996 patients, and the validation cohort consisted of 9018 patients.

Study Population

Total population size: 8996

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Females: {{ model.numberOfFemales }}

Continuous characteristics

Name	Q1	Median	Q3	Unit
Alanine amino transferase	16	25	44	u/l
Aspartate amino transferase	22	30	44	u/l
Gamma-glutamyl transferase	33	61	131	u/l
Lactate dehydrogenase	357	442.5	589.8	u/l
Albumin	31	36	41	g/l
estimated Glomerular filtration rate	49	70	90	ml/min/1.73m2
Haemoglobin	100	116	134	g/l
Thyroid stimulation hormone	0.7	1.4	2.8	mu/l
Triiodothyronine	1.0	1.4	1.8	nmol/l
Thyroxin	83.5	104.5	132.0	nmol/l
C-reactive protein	8	30	82	mg/l
plateletcount	175	229	300.8	x10^9/l

Categorical characteristics

Name	Subset / Group	Nr. of patients
INR ≥4.5 during a previous admission	Yes	868
INR ≥4.5 during a previous admission	No	8128
VKA type	acenocoumarol	7978
VKA type	Other	1018
Ward type	Medical ward	5497
Ward type	Ither	3499
Use of concomitant medication	Miconazole	153
Use of concomitant medication	Cotrimoxazole	337
Use of concomitant medication	Fluconazole	119
Use of concomitant medication	Voriconazole	7
Use of concomitant medication	Amiodarone	724
Use of concomitant medication	Rifampicin	53
Use of concomitant medication	Carbamazepine	73
Use of concomitant medication	Phenytoin	89
Use of concomitant medication	Colestyramin	17
Use of concomitant medication	Anti-thyroid drugs	110

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Disclaimer: Calculations alone should never dictate patient care, and are no substitute for professional judgement.