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Intern Emerg Med. 2017 Dec;12(8):1109-1119. doi: 10.1007/s11739-017-1678-9. Epub 2017 May 13.

Vitamin K antagonist therapy: changes in the treated populations and in management results in Italian anticoagulation clinics compared with those recorded 20 years ago.

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Cardiovascular Diseases, University of Bologna, Coordinator of the START-Register, Bologna, Italy.
Arianna Anticoagulazione Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy.
Dip Medicina di Laboratorio, Patologia Clinica-Merate, Asst Lecco, Lecco, Italy.
UO Medicina Interna ed Emocoagulopatie, Policlinico Univeristario, Cagliari, Italy.
Department of Cardiothoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy.
Thrombosis Centre, Department Heart and Vessels, University Hospital of Florence, Florence, Italy.
Haemostasis and Thrombosis Center, Department of Laboratory Medicine, AO Istituti Ospitalieri, Cremona, Italy.
Department of Hematology, S. Bortolo Hospital, Vicenza, Italy.
Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, IRCCS Cà Granda Maggiore Hospital Foundation, Milan, Italy.


Vitamin K antagonists (VKA) are the most widely used anticoagulants in the world. An appropriate management of treated patients is crucial for their efficacy and safety. The prospective, observational, multicenter, inception-cohort FCSA-START Register, a branch of START Register (NCT02219984) included VKA-treated patients managed by centers of Italian Federation of anticoagulation clinics (AC). Baseline patient characteristics and data during treatment were analyzed and compared with those of ISCOAT study, performed by the Federation and published in 1996/7. 5707 naïve patients [53% males, mean age 73.0 years (28.1% >80 years)], 61.6% treated for atrial fibrillation (AF), and 28.0% for venous thromboembolism were included. During the 8906 patient-years (pt-yrs) of observation, 123 patients had major bleeding (MB) (1.38% pt-yrs; fatal: 0.11% pt-yrs), while non-major clinically relevant bleeds were 144 (1.62% pt-yrs). Bleeding was more frequent in elderly (≥70 years; p = 0.04), and during initial 3-month therapy (p = 0.02). Bleeding rate was 2.5% pt-yrs for temporally related INR results <3.0, increasing to 12.5% for INR ≥ 4.5. Thrombotic events were 47 (0.53% pt-yrs; 4 fatal 0.04% pt-yrs). Compared with ISCOAT-1996/7 results, patients older than 80 y are increased from 8 to 28% (p < 0.01), and those treated for AF are increased from 17 to 61%. The quality of anticoagulation control and incidence of MB are not different. However, thrombotic complications fell drastically from 3.5 to 0.53% pt-yrs (p < 0.01), with lower mortality (p = 0.01). VKA-treated patients monitored in Italian AC have good clinical results, with low bleeding and thrombotic complications rates. Important changes in the treated population and improvement in thrombotic complications are detected compared with the ISCOAT-1996/7 study.


Atrial fibrillation; Bleeding; Thrombotic; Venous thromboembolism; Warfarin

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