Genetic polymorphisms and dosing of vitamin K antagonist in Indian patients after heart valve surgery

  • Shiv Kumar ChoudharyEmail author
  • Arun Basil Mathew
  • Amit Parhar
  • Milind Padmakar Hote
  • Sachin Talwar
  • Palleti Rajashekhar
Original Article



Vitamin K antagonists (VKAs), such as warfarin and acenocoumarol, exert their anti-coagulant effect by inhibiting the subunit 1 of vitamin K epoxide reductase complex (VKORC1). CYP2C9 is a hepatic drug-metabolizing enzyme in the CYP450 superfamily and is the primary metabolizing enzyme of warfarin. Three single nucleotide polymorphisms, two in the CYP2C9 gene, namely CYP2C9*2 and CYP2C9*3, and one in the VKORC1 gene (c.− 1639G > A, rs9923231), have been identified to reduce VKA metabolism and enhance their anti-coagulation effect. The purpose of this study is to evaluate the prevalence of CYP2C9 and VKORC1 polymorphism in Indians receiving VKA-based anti-coagulation after valve surgery and to evaluate the usefulness of genetic information in managing VKA-based anti-coagulation.


In the current prospective observational study, 150 patients who underwent heart valve surgery and had stable INR were genotyped for VKORC1 (− 1639 G > A), CYP2C9*2, and CYP2C9*3. The VKA dosage was estimated from published algorithms and compared to the clinically stabilized dosage.


Out of 150 patients, 101 (67.33%) were on warfarin and 49 (32.66%) were on acenocoumarol. Majority of the patients, the 83 in warfarin group and the 40 in acenocoumarol group, had a wild CYP2C9 diplotype. The rest had a mutant (CYP2C9*2 or CYP2C9*3) diplotype. Similarly, 67 patients in the warfarin group and 35 patients in the acenocoumarol group had wild type (G/G) of VKORC1 genotype. The rest had a mutant (G/A or A/A) VKORC1 genotype. In the warfarin group, based on the genotype, 51.5% of the patients were extensive or normal metabolizers, and 47.4% of the patients were intermediate metabolizers of VKAs. In the acenocoumarol group, 61.2% of the patients were extensive or normal metabolizers, and 38.8% of the patients were intermediate metabolizers. Individually, alleles of VKORC1 (− 1639 G > A), CYP2C9*2, and CYP2C9*3 had mean dosage reduction effect on VKA dosage, which co-related to the clinically stabilized dosages (P < 0.0001). Among the VKORC1 (− 1639 G > A) cohort, the reduction in warfarin mean weekly dosage was 13.48 mg as compared to the wild-type category (P < 0.0001) and similarly, the reduction in the mean weekly acenocoumarol dose was 6.07 mg (P < 0.03) as compared to the wild type after adjusting for age, gender, and body mass index.


Single nucleotide polymorphism in the CYP2C9 gene and in the VKORC1 gene is present in nearly 40% of Indian patients. VKORC1 (− 1639 G > A), CYP2C9*2, and CYP2C9*3 genotypes have significant dosage-lowering effects on VKA-based anti-coagulation therapy. The trend in estimated dosages of VKAs co-related to that of observed the clinically stabilized dosage in the cohort. The pharmacogenomic calculators used in this study tend to overestimate the VKA dosages as compared to clinical dosage due to the limitations in the algorithms and in our study. A new algorithm based on a larger dataset capturing the vast genetic variability across the Indian population and relevant clinical factors could provide better results.


Vitamin K antagonist CYP2C9 VKORC1 



We acknowledge contributions of Dr. Dhananjay Raje and Ms. Moumita Chakraborty from MDS Bioanalytics, Pune, for conducting the statistical analysis. Blood samples for genotyping were analyzed free of cost at Mendelian Health Technologies Pvt. Ltd., Pune, India.

Compliance with ethical standards

Conflict of interest

Mathew A B, Hote MP, Talwar S, Rajashekhar P, and Choudhary SK have no conflict of interest. One of the authors (Parhar A) is employed with a commercial clinical genomic services organization (Mendelian Health Technologies, Pune, India) and was involved in the design, analysis, and discussion of findings. This study was a collaborative project between All India Institute of Medical Sciences, New Delhi, India, and Mendelian Health Technologies, Pune, India. No financial relationship exists between any organizations that might have interest in the submitted work.

Ethical approval for research involving human participants and/or animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval was obtained from institutional ethics committee.

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2019

Authors and Affiliations

  • Shiv Kumar Choudhary
    • 1
    Email author
  • Arun Basil Mathew
    • 1
  • Amit Parhar
    • 2
  • Milind Padmakar Hote
    • 1
  • Sachin Talwar
    • 1
  • Palleti Rajashekhar
    • 1
  1. 1.Department of Cardiothoracic and Vascular SurgeryAll India Institute of Medical SciencesNew DelhiIndia
  2. 2.Mendelian Health Technologies Pvt. LtdPuneIndia

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