Avaliação da qualidade do controle da anticoagulação oral de acordo com o sexo: revisão sistemática e meta-análise.

Abstract

The increased prevalence of cardiovascular diseases observed in recent years has enhanced the number of people using oral anticoagulants (OAC). Warfarin is a vitamin K inhibitor with most experience use as an OAC, being the main coumarin derivative distributed in Brazil. Warfarin therapy presents difficult management related to its narrow therapeutic index and wide dose-response variability. Frequent laboratory monitoring becomes fundamental to guide dose adjustments. The time therapeutic range (TTR) is one of the methods used to evaluate the quality of anticoagulation, and it is recommended to be maintained above 60%. In this range, the risk of bleeding and thromboembolic complications is minimized. Previous studies have shown differences in the quality of oral anticoagulation control between men and women, although this evidence is controversial. Thus, the purpose of this study was to perform a systematic review and meta-analysis to assess the association between sex and oral anticoagulation control in patients on coumarin derivatives. The MEDLINE, BVS, CINAHL, EMBASE, Cochrane Library and Web of Science databases were consulted to analyze observational and experimental studies, involving patients of both sexes, aged over 18 years, on chronic oral anticoagulation with coumarin derivatives. Fourteen studies met the eligibility criteria and were included in the review. The data were synthesized and then compiled results were used to develop a meta-analysis. Odds ratios (OR) for binary variables and mean differences (MD) for continuous variables were grouped using randomized effect models. Nine studies were evaluated in the meta-analysis from binary variables (OR=0.89; CI 95%=0.80, 1.00; z=-1.96; p=0.05; I2=74%) and five studies with continuous variables (MD=-4.03; 95% CI=-5.74, -2.31; z=-4.61; p<0.0001; I2=49%). The combined estimates indicated that the female sex was associated with lower TTR than the male sex being a risk factor (mediator) for worse control of anticoagulation. Women in oral anticoagulation are often elderly, with poor health and dependent on caregivers. Our results signal the need for future studies designed to better understand the aspects involved in this worse control. Besides, our results may contribute to subsidize the development of patient-centered strategies and adaptation of care in order to increase the effectiveness and safety of treatment, contributing to reduce complications in this subgroup of patients.