We appreciate the comments of Escobar et al1 regarding our article.1 The introduction of alternatives to vitamin K antagonists (VKA) has demonstrated the importance of the early identification of patients who are most likely to exhibit poor International Normalized Ratio (INR) control.
The SAMe-TT2R2 score has been proposed as a predictor of poor anticoagulation control.2 Although it has been validated in a number of populations of patients with atrial fibrillation, this score could still be improved, as the C-statistic reported in these studies is low (0.55-0.6).3 Moreover, our results indicate that it is less useful in patients in unstable situations, such as recent decompensated heart failure.1
Factors such as a history of bleeding, multidrug therapy, and eating habits appear to show promise in terms of improving the predictive capacity of new scores that will better distinguish those patients who are less suitable to receive VKA.3 Other factors—such as abuse of alcohol or other drugs, chronic kidney disease, cancer, mental disorders,4 and even the experience of the physician adjusting the VKA dose—have also been shown to be capable of predicting an inadequate percentage of time in therapeutic range.5
However, although new scoring systems will probably enhance our capacity to predict poor INR control, they should not involve a degree of complexity that would limit their use in routine clinical practice, unless they offer a significant improvement.