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The authors present case studies of two patients, aged 76 and 77, who were diagnosed with fresh post-myocardial infarction ventricular septal defects (VSD) and were admitted for urgent surgical intervention. The report is a comment in the discussion concerning the optimal time for surgical intervention.
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BACKGROUND: Warfarin dose requirements are partly determined by common single nucleotide polymorphisms in VKORC1 and CYP2C9 genes. OBJECTIVES: The aim of this study was to investigate how the presence of allelic variants in CYP2C9 affects the stability of anticoagulation in patients within the first 3 months following elective heart valve replacement. MATERIAL AND METHODS: In a case-control study we compared 18 consecutive carriers of CYP2C9*2 and/or *3 and 25 well-matched patients with the wild type CYP2C9*1/*1 genotype. The former group was randomly assigned to use coagulometers or monitor international normalized ratio (INR) in local outpatient clinics. Subjects receiving drugs potently interfering with warfarin were ineligible. Anticoagulation with the baseline warfarin regimens based on pharmacogenetic algorithm was assessed by time in the therapeutic INR range (TTR) within the first 3 months following implantation. RESULTS: Carriers of the CYP2C9*2 and/or *3 genotypes were characterized by lower estimated warfarin dose (median, 21 [interquartile range, 21-35] vs. 35 [28-42] mg/week, p=0.02) and actual (27.8±13.2 vs. 46.3±13.9 mg/week, p<0.001), together with lower TTR values (56 [38.6-74.9] vs. 75.4 [58.1-83.6] %, p=0.03) and longer time above the therapeutic range (13.8 [4.9-34.5] vs. 4.5 [0-15.3]%, p=0.047) than patients with the CYP2C9*1/*1 genotype. There were no differences in the estimated and actual warfarin doses, TTR values and adverse events between the self-testing and standard-care subgroups. CONCLUSIONS: The presence of CYP2C9*2 and/or *3 genotypes is associated with unstable warfarin treatment in patients after heart valve replacement, regardless of the type of INR testing.
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Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Citocromo P-450 CYP2C9/genética , Monitoramento de Medicamentos/métodos , Implante de Prótese de Valva Cardíaca , Coeficiente Internacional Normatizado , Polimorfismo de Nucleotídeo Único , Varfarina/uso terapêutico , Idoso , Anticoagulantes/metabolismo , Citocromo P-450 CYP2C9/metabolismo , Procedimentos Cirúrgicos Eletivos , Feminino , Frequência do Gene , Genótipo , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Farmacogenética , Fenótipo , Polônia , Valor Preditivo dos Testes , Fatores de Tempo , Varfarina/metabolismoRESUMO
INTRODUCTION: Adherence to therapeutic recommendations, concerning in particular drug administration, diet and healthy life style, is essential to obtain optimal medical treatment effects. Elevated blood pressure is an extremely important risk factor for cardiovascular diseases such as coronary artery disease, chronic heart failure and stroke, as well as chronic kidney disease. AIM: The aim of the study was to assess the level of adherence among heart transplant recipients and to explain the reasons for non-adherence phenomenon. MATERIAL AND METHODS: The study was performed on 55 heart allograft recipients: 11 women (20%) and 44 men (80%), all hypertensive. Participation in the study was voluntary and the three-part questionnaire was anonymous to obtain reliable answers. The second part was designed using the Modified Morisky Scale (MMS) consisting of questions assessing motivation and knowledge among patients. The third included questions concerning lifestyle, reasons for non-adherence and methods to improve it. RESULTS: In self-assessment of the adherence to medical recommendations on a scale of 0 to 10 the analyzed population estimated their level of adherence to be on average 8.49 ± 1.33, which is a considerably high result. It was discovered that both the level of motivation (2.20) and knowledge (2.83) are high among heart transplant recipients. Still, the level of knowledge was significantly higher than the motivation (p < 0.005). Correlation analysis revealed that the self-assessed adherence level correlated positively with the level of motivation (r = 0.357; p < 0.007). CONCLUSIONS: Creation of an active attitude of the patient in the process of treatment is a crucial and at the same time often difficult task demanding cooperation of the patient, the patient's close family and the whole therapeutic team.
