Outpatient Low-Molecular Weight Heparin for Conversion to Warfarin in Non-Valvular Atrial Fibrillation
Background: Patients with non-valvular atrial fibrillation (NVAF) are often hospitalized on IV heparin until target INRs are achieved. SQ LMWH has been shown to be safe and effective for OP treatment of DVT, but has not been widely used in NVAF. We discharged 35 patients with NVAF on SQ LMWH and analyzed safety, cost and satisfaction. Methods:Patients with NVAF who were being held in the hospital only for conversion of heparin to warfarin and who met other entry criteria were enrolled. Baseline CBC, coagulation profile, neurologic exam and demographic data were obtained. Patients were instructed in the use of LMWH and warfarin and then discharged on dalteparin 100 units/kgm BID. Ten patients also chose to monitor their own INRs with a point of care testing device (Coagucheck). Eight patients elected to have a home health nurse administer the dalteparin. When two consecutive INRs were therapeutic, dalteparin was discontinued. Actual cost of outpatient care was calculated. Inpatient costs were projected based on the number of days it took to reach the therapeutic INR values. Ten days after enrollment patients responded to a phone survey regarding thrombotic and/or bleeding complications, readmission to ED or hospital and satisfaction. Results: 31 patients completed the entire process. 51%(18/35) were >70 years old. There were no significant thrombotic or bleeding complications, no readmissions and one ED visit for minor bleeding at a venupuncture site (INR=2.5). 71%(22/31) reported minor bruising. Patients using Coagucheck monitored INRs 2x as frequently as patients using the lab. Outpatient costs including the cost of dalteparin, INR testing, home health visits, coagucheck supplies and 1 ED visit totaled $20,324 or $616 per patient. Projected inpatient costs including the cost of room, IV heparin, PTT and INR testing totaled $123,261 or $3,735 per patient. This represented a cost saving of $3,119 per patient. 91%(28/31) were satisfied or very satisfied with the OP treatment and 87%(27/31)reported they would use it again. Conclusions: Outpatient SQ LMWH is a safe, cost-effective and attractive alternative to inpatient IV heparin in patients with NVAF.