According to this study, female patients exhibit poorer postoperative control of coagulation function compare to male patients. This difference may be a result of physiological and anatomical distinctions between the two genders, which affect the metabolism and anticoagulant effects of warfarin. For instance, females may have a higher clearance rate of warfarin than males, resulting in decreased sensitivity to the medication and inferior anticoagulant effects. Additionally, estrogen levels in females may impact the anticoagulant effects of warfarin14-16.
In a study conducted by Zhu, Chen17,18,it was found that female, atrial fibrillation, and compliance were linked to TTR of less than 60% among cardiac valve replacement patients receiving outpatient follow-up. However, our study findings revealed a significant improvement in patients' compliance and postoperative coagulation function control, particularly in individuals with atrial fibrillation, through the implementation of long-term home monitoring. This improvement can be attributed to the fact that home monitoring enables patients to monitor their INR values at home, eliminating the need for frequent hospital visits and reducing time and transportation costs. With home monitoring, patients can monitor their INR values at any time and provide timely feedback to doctors or caregivers, which in turn allows for adjustments to anticoagulant treatments and better control of blood coagulation19,20.
Moreover, patients were more involved in their treatment through education on self-monitoring at home, allowing them to take an active role in their anticoagulant therapy and increasing their accountability for their health. Additionally, increased monitoring and adjustments to warfarin dosage through home monitoring may decrease the risk of bleeding and blood clotting complications, leading to better patient outcomes. It is important to note that, based on lasso regression analysis, patients who were on novel anticoagulant medications before surgery had better control of their coagulation function after the surgery. Novel anticoagulant medications, such as rivaroxaban, have been found to have better anticoagulant effects compared to traditional medications like aspirin21. This is likely due to patients who were already taking novel anticoagulant medications before surgery also had higher awareness of anticoagulation management compared to those who started anticoagulant medications after surgery. Patients who take aspirin before surgery may have various underlying conditions, such as hypertension or diabetes, which could impact their coagulation function. This could potentially limit the anticoagulant effects of aspirin and result in differences in the anticoagulant effects of warfarin after surgery. Thus, the preoperative cultivation of patients' anticoagulation awareness is essential in cardiothoracic surgery. Educating and empowering patients will enhance their understanding and compliance, leading to safer surgeries and improved postoperative outcomes.
According to our study findings, despite warfarin dose adjustment for each hom monitoring patients based on their INR value, the average time in TTR was found to be only 59.2%. This could be attributed to some patients occasionally failing to report their target INR values. To ensure data integrity and reliability, we are currently designing a mobile application for long-term monitoring of patients' INR values. With this app, patients can easily measure and upload their INR values, and the healthcare providers will provide guidance on adjusting their warfarin dose. We will incorporate built-in checks to ascertain the accuracy of entered INR values, promptly flagging any outliers or irregular readings for further validation. This new method aims to be more efficient and convenient for both patients and healthcare providers.
In addition, nomogram charts are widely used in oncology and contribute to enhancing precision and offering intuitive prognosis assessment, which is beneficial for clinical decision-making22,23. Our research is the initial one to utilize the nomogram chart in evaluating the management of coagulation function in patients undergoing cardiac valve replacement.
We have created a valuable tool for predicting the risk of poor control of coagulation function in patients. This tool can assist doctors in early identification of high-risk patients with inadequate postoperative coagulation function control. For these patients, it is recommended to provide thorough education during their hospital stay and encourage long-term self-monitoring at home, with feedback to healthcare providers to adjust medication as needed to control their coagulation function. Home monitoring not only offers convenience, real-time monitoring, increased patient engagement, and reduced complication risks for postoperative coagulation function control, but also helps doctors gain a comprehensive understanding of patients' coagulation status and adjust treatment plans based on real-time data, enabling more personalized management of anticoagulant therapy for each patient. The developed nomogram chart will help researchers select suitable patients with stable coagulation function control for clinical trials. In retrospective studies, we can exclude patients exhibiting impaired coagulation function to mitigate the potential influence of complications, such as bleeding and thrombosis, on the trial outcomes.
There are some limitations in this study. Firstly, it is a retrospective research. Secondly, the TTR result in this study is sampled from a limited number of patients. These limitations might influence the generalizability of the findings and may not accurately reflect the entire population. Consequently, future studies with larger, prospective designs and a more diverse patient population are necessary to provide more comprehensive and reliable evidence in this area.