THE IMPACT OF INR SELF-MONITORING (PATIENT SELF-TESTING AND SELF-MANAGEMENT) ON THE INCIDENCE OF THROMBOTIC AND HEMORRHAGIC COMPLICATIONS IN PATIENTS TREATED WITH VITAMIN K ANTAGONISTS: A LITERATURE REVIEW

Sylwia Wiktoria Kolano; Mikołaj Dubiel; Michał S. Bochenek; Wojciech Jakubowski; Jan T. Tomasik; Kinga Filip; Daria Wańczyk; Aleksandra Gródek

doi:10.31435/ijitss.1(49).2026.4690

Authors

Sylwia Wiktoria Kolano Independent Public Healthcare Institution of the Ministry of the Interior and Administration in Kraków, Kraków, Poland https://orcid.org/0009-0000-1180-1135
Mikołaj Dubiel Independent Public Healthcare Institution of the Ministry of the Interior and Administration in Kraków, Kraków, Poland https://orcid.org/0009-0009-0785-6681
Michał S. Bochenek Independent Public Healthcare Institution of the Ministry of the Interior and Administration in Kraków, Kraków, Poland https://orcid.org/0009-0009-3933-1548
Wojciech Jakubowski HCP Medical Center, Poznań, Poland https://orcid.org/0009-0004-6476-324X
Jan T. Tomasik Independent Public Healthcare Institution of the Ministry of the Interior and Administration in Kraków, Kraków, Poland https://orcid.org/0000-0003-1562-3051
Kinga Filip 5 Military Clinical Hospital with Polyclinic SPZOZ, Kraków, Poland https://orcid.org/0009-0008-3731-1087
Daria Wańczyk Centrum Stomatologii JuniorDent, Kraków, Poland https://orcid.org/0009-0001-5568-7263
Aleksandra Gródek 5 Military Clinical Hospital with Polyclinic SPZOZ, Kraków, Poland https://orcid.org/0009-0008-7820-3269

DOI:

https://doi.org/10.31435/ijitss.1(49).2026.4690

Keywords:

Patient Self-Managemen, Patient Self-Testing, Patient Self-Monitoring, PST, PSM, INR Monitoring, Warfarin, Vitamin K Antagonists, Thromboembolism, Hemorrhagic, TTR

Abstract

Vitamin K antagonists (VKAs) remain essential in the management of patients with mechanical heart valves, rheumatic mitral stenosis, and selected cases of atrial fibrillation. Because therapeutic effectiveness depends on maintaining the international normalized ratio (INR) within a narrow target range, strategies that improve INR stability are critical to reducing the risks of thromboembolic and hemorrhagic complications. Traditional clinic-based monitoring is limited by infrequent testing and delayed dose adjustments, prompting growing interest in patient self-testing (PST) and patient self-management (PSM).

This review assessed the impact of PST and PSM on anticoagulation quality and clinical outcomes in adults treated with VKAs. A targeted PubMed search (2015–2025) identified meta-analyses and randomized controlled trial evaluating INR self-monitoring. Three high-quality sources—a Cochrane review, a network meta-analysis, and a meta-analysis focused on telemedicine-supported PST—served as the primary evidence base.

Across studies, both PST and PSM significantly increased time in therapeutic range (TTR), typically by 5–10 percentage points compared with standard care. PSM and telemedicine-assisted PST demonstrated the greatest improvements. Enhanced TTR translated into reductions in thromboembolic events, particularly in high-intensity PSM strategies. Importantly, no increase in major bleeding was observed in any self-monitoring model, indicating a favorable safety profile.

In conclusion, INR self-monitoring, especially intensive PSM and telemedicine-enabled PST, offers an effective and safe approach to improving anticoagulation control in patients requiring long-term VKA therapy. These strategies address well-recognized limitations of traditional INR monitoring and support more responsive, patient-centered care.

References

Addisu, Z. D., Demsie, D. G., Tafere, C., Yazie, T. S., Endeshaw, D., Tefera, B. B., Berihun, M., & Beyene, D. A. (2025). Time in the therapeutic range, bleeding event, and their determinants in older patients with atrial fibrillation on warfarin in Ethiopia: Multicenter cross-sectional study. Frontiers in Pharmacology, 16, Article 1541592. https://doi.org/10.3389/fphar.2025.1541592

Agency for Healthcare Research and Quality. (2024). Making healthcare safer IV: Reducing adverse drug events related to anticoagulant use in adults (AHRQ Publication No. 23-XXXXX). U.S. Department of Health and Human Services.

Brasen, C. L., Madsen, J. S., Parkner, T., & Brandslund, I. (2019). Home management of warfarin treatment through a real-time supervised telemedicine solution: A randomized controlled trial. Telemedicine Journal and E-Health, 25(2), 109–115. https://doi.org/10.1089/tmj.2017.0260

Corrochano, M., Jiménez, B., Millón, J., Gich, I., Rambla, M., Gil, E., Caparrós, P., Macho, R., & Souto, J. C. (2020). Patient self-management of oral anticoagulation with vitamin K antagonists in everyday practice: Clinical outcomes in a single centre cohort after long-term follow-up. BMC Cardiovascular Disorders, 20(1), Article 166. https://doi.org/10.1186/s12872-020-01448-7

Dalmau Llorca, M. R., Hernández Rojas, Z., Castro Blanco, E., Carrasco-Querol, N., Gonçalves, A. Q., Espuny Cid, A., Fernández Sáez, J., García-Goñi, M., Pérez-Villacastín, J., & Aguilar Martín, C. (2025). Clinical outcome and costs based on the degree of vitamin K antagonist control for non-valvular atrial fibrillation. Journal of Clinical Medicine, 14(3), Article 998. https://doi.org/10.3390/jcm14030998

Dhippayom, T., Boonpattharatthiti, K., Kategeaw, W., Hong, H., Chaiyakunapruk, N., Barnes, G. D., & Witt, D. M. (2024). Comparative effectiveness of warfarin management strategies: A systematic review and network meta-analysis. eClinicalMedicine, 74, Article 102712. https://doi.org/10.1016/j.eclinm.2024.102712

Dhippayom, T., Boonpattharatthiti, K., Thammathuros, T., Dilokthornsakul, P., Sakunrag, I., & Devine, B. (2022). Clinical outcomes of different warfarin self-care strategies: A systematic review and network meta-analysis. Thrombosis and Haemostasis, 122(4), 492–505. https://doi.org/10.1055/a-1677-9608

Gerfer, S., Wahlers, T., & Kuhn, E. (2024). Is there an alternative oral anticoagulation to vitamin-K-antagonists for patients with mechanical aortic valve replacement? A literature review. Cardiology and Therapy, 13(3), 453–463. https://doi.org/10.1007/s40119-024-00371-8

Gharib, S. K., Sadiq, A. M., Raza, F. M., Muhali, S. S., Marandu, A. A., Kyala, N. J., Ndale, E. K., Maro, V. P., Howlett, W. P., Mkwizu, E. W., Chamba, N. G., Lyamuya, F. S., Shao, E. R., & Kilonzo, K. G. (2025). Vitamin K antagonist use and level of anticoagulation control among patients at a tertiary hospital in northern Tanzania. Journal of Cardiovascular Pharmacology and Therapeutics, 30, Article 10742484251315104. https://doi.org/10.1177/10742484251315104

Heneghan, C. J., Garcia-Alamino, J. M., Spencer, E. A., Ward, A. M., Perera, R., Bankhead, C., Alonso-Coello, P., Fitzmaurice, D., Mahtani, K. R., & Onakpoya, I. J. (2016). Self-monitoring and self-management of oral anticoagulation. Cochrane Database of Systematic Reviews, 2021(4). https://doi.org/10.1002/14651858.CD003839.pub3

Holbrook, A., Schulman, S., Witt, D. M., Vandvik, P. O., Fish, J., Kovacs, M. J., Svensson, P. J., Veenstra, D. L., Crowther, M., & Guyatt, G. H. (2012). Evidence-based management of anticoagulant therapy. Chest, 141(2 Suppl.), e152S–e184S. https://doi.org/10.1378/chest.11-2295

Huang, Y., Xie, Y., Huang, L., & Han, Z. (2023). The value of anticoagulation management combining telemedicine and self-testing in cardiovascular diseases: A meta-analysis of randomized controlled trials. Therapeutics and Clinical Risk Management, 19, 279–290. https://doi.org/10.2147/TCRM.S395578

Krittayaphong, R., Chantrarat, T., Rojjarekampai, R., Jittham, P., Sairat, P., & Lip, G. Y. H. (2020). Poor time in therapeutic range control is associated with adverse clinical outcomes in patients with non-valvular atrial fibrillation: A report from the nationwide COOL-AF registry. Journal of Clinical Medicine, 9(6), Article 1698. https://doi.org/10.3390/jcm9061698

Mack, C. A., Lau, C., & Girardi, L. N. (2025). There is still no alternative to warfarin for mechanical valves: It remains the most effective anticoagulant. The Journal of Thoracic and Cardiovascular Surgery, 170(2), 489–494. https://doi.org/10.1016/j.jtcvs.2024.07.011

Otto, C. M., Nishimura, R. A., Bonow, R. O., Carabello, B. A., Erwin, J. P., III, Gentile, F., Jneid, H., Krieger, E. V., Mack, M., McLeod, C., O’Gara, P. T., Rigolin, V. H., Sundt, T. M., III, Thompson, A., & Toly, C. (2021). 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 143(5). https://doi.org/10.1161/CIR.0000000000000923

Pradhan, A., Mahalawat, S., & Perrone, M. A. (2024). From the INVICTUS trial to current considerations: It’s not time to retire vitamin K inhibitors yet! Pharmaceuticals, 17(11), Article 1459. https://doi.org/10.3390/ph17111459

Refaai, M. A., Shah, V., & Fernando, R. (2020). Performance of the microINR point-of-care system: A multicenter clinical trial. Thrombosis and Haemostasis, 120(4), 687–691. https://doi.org/10.1055/s-0040-1708034

Riva, N., Meli, S., Borg Xuereb, C., Vella, K., Ageno, W., Makris, M., & Gatt, A. (2020). Anticoagulation control with the point-of-care INR: A retrospective pre-/post-analysis. Thrombosis Research, 196, 21–24. https://doi.org/10.1016/j.thromres.2020.07.050

Romero-Arana, A., Romero-Sibajas, N., Arroyo-Bello, E., Romero-Ruiz, A., & Gómez-Salgado, J. (2025). Monitoring and follow-up of patients on vitamin K antagonist oral anticoagulant therapy using artificial intelligence: The AIto-Control project. Journal of Clinical Medicine, 14(20), Article 7191. https://doi.org/10.3390/jcm14207191

Sae-Lim, P., & Saelue, P. (2025). Appropriate target range of INR and predictive factors of recurrent thrombosis and bleeding in patients with venous thromboembolism on warfarin. Scientific Reports, 15(1), Article 23463. https://doi.org/10.1038/s41598-025-08229-2

Sharma, P., Scotland, G., Cruickshank, M., Tassie, E., Fraser, C., Burton, C., Croal, B., Ramsay, C. R., & Brazzelli, M. (2015). Is self-monitoring an effective option for people receiving long-term vitamin K antagonist therapy? A systematic review and economic evaluation. BMJ Open, 5(6), Article e007758. https://doi.org/10.1136/bmjopen-2015-007758

Shi, R., Wei, W., Yang, Y., Yang, S., Yan, L., & Zhu, Z. (2025). Study of target INR achievement, incidence of hemorrhagic complications and affecting factors after during warfarin treatment in western area of China. Scientific Reports, 15(1), Article 18200. https://doi.org/10.1038/s41598-025-03434-5

Thrombosis Canada. (2025). Warfarin: Point-of-care INR monitoring (Clinical guide). Thrombosis Canada. https://thrombosiscanada.ca

Van Beek, A., Bowers, M., Hall, B., & Meyer, B. (2021). Implementation of home-based international normalized ratio testing in adult patients treated with warfarin. Journal of the American Association of Nurse Practitioners, 33(7), 563–569. https://doi.org/10.1097/JXX.0000000000000339

Van Beek, A., Moeyaert, M., Ragheb, B., Price, E., MacEwan, J. P., Ahmed, N., & Ansell, J. (2024). Outcomes of warfarin home INR monitoring vs office-based monitoring: A retrospective claims-based analysis. Journal of General Internal Medicine, 39(7), 1127–1134. https://doi.org/10.1007/s11606-023-08348-4

Wolfes, J., Ellermann, C., Frommeyer, G., & Eckardt, L. (2025). Comparison of the latest ESC, ACC/AHA/ACCP/HRS, and CCS guidelines on the management of atrial fibrillation. JACC: Clinical Electrophysiology, 11(4), 836–849. https://doi.org/10.1016/j.jacep.2024.12.018