title: Prognostic Value of Prothrombin Time International Normalized Ratio in Acute Decompensated Heart Failure　- A Combined Marker of Hepatic Insufficiency and Hemostatic Abnormality.
abstract: BACKGROUND
  There are limited studies regarding the prognostic value of coagulation abnormalities in heart failure patients. The clinical significance of prothrombin time international normalized ratio (INR), a widely accepted marker assessing coagulation abnormalities, in acute decompensated heart failure (ADHF) remains unclear.
  
  
  RESULTS
  Among 561 consecutive patients admitted for ADHF, INR was assessed in 294 patients without prior anticoagulation therapy, acute coronary syndrome, liver disease, or overt disseminated intravascular coagulation. Increased INR on admission was positively associated with increased levels of thrombin-antithrombin complex, C-reactive protein, total bilirubin, γ-glutamyl transpeptidase, inferior vena cava diameter, tricuspid regurgitation severity, markers of neurohormonal activation, and also negatively associated with decreased albumin, cholinesterase, and total cholesterol. In contrast, there was no significant association with left ventricular ejection fraction, serum sodium or blood urea nitrogen. Multivariate analysis showed that increased INR was independently associated with increased all-cause mortality (hazard ratio 1.89 per 0.1 increase, 95% confidence interval 1.14-3.13, P=0.013) during the median follow up of 284 days. Increased INR also had a higher prognostic value compared to risk score models including the Model for End-Stage Liver Disease (MELD) score or the MELD excluding INR (MELD-XI) score.
  
  
  CONCLUSIONS
  Increased INR is an independent predictor of all-cause mortality in ADHF patients without anticoagulation, reflecting coagulation abnormalities and hepatic insufficiency, possibly through systemic inflammation, neurohormonal activation and venous congestion.
authors.affiliation: Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.
authors.forename: Atsushi
authors.initials: A
authors.lastname: Okada
authors.forename: Yasuo
authors.initials: Y
authors.lastname: Sugano
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Nagai
authors.forename: Seiji
authors.initials: S
authors.lastname: Takashio
authors.forename: Satoshi
authors.initials: S
authors.lastname: Honda
authors.forename: Yasuhide
authors.initials: Y
authors.lastname: Asaumi
authors.forename: Takeshi
authors.initials: T
authors.lastname: Aiba
authors.forename: Teruo
authors.initials: T
authors.lastname: Noguchi
authors.forename: Kengo F
authors.initials: KF
authors.lastname: Kusano
authors.forename: Hisao
authors.initials: H
authors.lastname: Ogawa
authors.forename: Satoshi
authors.initials: S
authors.lastname: Yasuda
authors.forename: Toshihisa
authors.initials: T
authors.lastname: Anzai
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D000990:Antithrombin III; D001663:Bilirubin / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism; D005260:Female; D006333:Heart Failure / Q000097:blood* / Q000401:mortality*; D048550:Hepatic Insufficiency / Q000097:blood* / Q000401:mortality*; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D010447:Peptide Hydrolases / Q000097:blood; D011517:Prothrombin Time; D012042:Registries; D005723:gamma-Glutamyltransferase / Q000097:blood
chemical_list: C046193:antithrombin III-protease complex; D000990:Antithrombin III; D002097:C-Reactive Protein; D005723:gamma-Glutamyltransferase; D010447:Peptide Hydrolases; D001663:Bilirubin