ITEMS IN FPM WITH MESH TERM:
ABSTRACT: Family physicians should be familiar with the acute management of atrial fibrillation and the initiation of chronic therapy for this common arrhythmia. Initial management should include hemodynamic stabilization, rate control, restoration of sinus rhythm, and initiation of antithrombotic therapy. Part II of this two-part article focuses on the prevention of thromboembolic complications using anticoagulation. Heparin is routinely administered before medical or electrical cardioversion. Warfarin is used in patients with persistent atrial fibrillation who are at higher risk for thromboembolic complications because of advanced age, history of coronary artery disease or stroke, or presence of left-sided heart failure. Aspirin is preferred in patients at low risk for thromboembolic complications and patients with a high risk for falls, a history of noncompliance, active bleeding, or poorly controlled hypertension. The recommendations provided in this article are consistent with guidelines published by the American Heart Association and the Agency for Healthcare Research and Quality.
ABSTRACT: The Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy provides guidelines for outpatient management of anticoagulation therapy. The ACCP guidelines recommend short-term warfarin therapy, with the goal of maintaining an International Normalized Ratio (INR) of 2.5 +/- 0.5, after major orthopedic surgery. Therapy for venous thromboembolism includes an INR of 2.5 +/- 0.5, with the length of therapy determined by associated conditions. For patients with atrial fibrillation, the INR is maintained at 2.5 +/- 0.5 indefinitely; for most patients with mechanical valves, the recommended INR is 3.0 +/- 0.5 indefinitely. Use of outpatient low-molecular-weight heparin (LMWH) is as safe and effective as inpatient unfractionated heparin for treatment of venous thromboembolism. The ACCP recommends starting warfarin with unfractionated heparin or LMWH for at least five days and continuing until a therapeutic INR is achieved. Because patients with venous thromboembolism and cancer who have been treated with LMWH have a survival advantage that extends beyond their venous thromboembolism treatment, the ACCP recommends beginning their therapy with three to six months of LMWH. When invasive procedures require the interruption of oral anticoagulation therapy, recommendations for bridge therapy are determined by balancing the risk of bleeding against the risk of thromboembolism. Patients at higher risk of thromboembolization should stop warfarin therapy four to five days before surgery and start LMWH or unfractionated heparin two to three days before surgery.
ABSTRACT: Factors associated with an increased risk of thromboembolic events in patients with atrial fibrillation (AF) include increasing age, rheumatic heart disease, poor left ventricular function, previous myocardial infarction, hypertension and a past history of a thromboembolic event. Patients with AF should be considered for anticoagulation or antiplatelet therapy based on the patient's age, the presence of other risk factors for stroke and the risk of complications from anticoagulation. In general, patients with risk factors for stroke should receive warfarin anticoagulation, regardless of their age. In patients who are under age 65 and have no other risk factors for stroke, either aspirin therapy or no therapy at all is recommended. Aspirin or warfarin is recommended for use in patients between 65 and 75 years of age with no other risk factors, and warfarin is recommended for use in patients without risk factors who are older than 75 years of age.
ABSTRACT: Warfarin is the oral anticoagulant most frequently used to control and prevent thromboembolic disorders. Prescribing the dose that both avoids hemorrhagic complications and achieves sufficient suppression of thrombosis requires a thorough understanding of the drug's unique pharmacology. Warfarin has a complex dose-response relationship that makes safe and effective use a challenge. For most indications, the dose is adjusted to maintain the patient's International Normalized Ratio (INR) at 2 to 3. Because of the delay in factor II (prothrombin) suppression, heparin is administered concurrently for four to five days to prevent thrombus propagation. Loading doses of warfarin are not warranted and may result in bleeding complications. Interactions with other drugs must be considered, and therapy in elderly patients requires careful management. Current dosing recommendations are reviewed, and practical guidelines for the optimal use of warfarin are provided.
Painful Plaques Shortly After Hospital Discharge - Photo Quiz
ABSTRACT: Many physicians and other providers attempt therapeutic warfarin oversight without regularly scheduled anticoagulation appointments. Studies show that the risk of major bleeding or thromboembolic events due to warfarin therapy is between 2 percent and 12 percent per year. Point-of-care anticoagulation devices are convenient for patients and physicians and allow for patient-focused anticoagulation care.
A Systematic Approach to Managing Warfarin Doses - Improving Patient Care
Thromboembolism - Clinical Evidence Handbook
Management of Newly Detected Atrial Fibrillation - Editorials