phenprocoumon and Heart-Failure

The purpose of this review article is to summarize the literature on diseases that are documented to have an effect on response to warfarin and other VKAs.. We searched the English literature from 1946 to September 2015 via PubMed, EMBASE, and Scopus for the effect of diseases on response vitamin K antagonists including warfarin, acenocoumarol, phenprocoumon, and fluindione.. Among many factors modifying response to VKAs, several disease states are clinically relevant. Liver disease, hyperthyroidism, and CKD are well documented to increase response to VKAs. Decompensated heart failure, fever, and diarrhea may also elevate response to VKAs, but more study is needed. Hypothyroidism is associated with decreased effect of VKAs, and obese patients will likely require higher initial doses of VKAs.. In order to minimize risks with VKAs while ensuring efficacy, clinicians must be aware of the effect of disease states when prescribing these oral anticoagulants.

Topics: Acenocoumarol; Administration, Oral; Anticoagulants; Cardiovascular Diseases; Diarrhea; Fibrinolytic Agents; Heart Failure; Humans; Hyperthyroidism; Kidney Failure, Chronic; Liver Diseases; Obesity; Phenindione; Phenprocoumon; Vitamin K; Warfarin

 The exact monitoring of the therapeutic-range international normalized ratio (INR) after left ventricular assist device (LVAD) implantation is an important aim to reduce the risk of thrombosis or bleeding complications. Service providers offer a telemedical anticoagulation service (CS)..  We compared LVAD patients using the CS (.  A total of 1,798 INR measurements were analyzed. The TTR.  We found that INR self-management is superior regarding the efficiency of post-LVAD anticoagulation therapy when compared with telemedical (CS)-based INR management in a small study cohort. Intensive training by experienced staff was able to replace CS.

Topics: Anticoagulants; Drug Monitoring; Germany; Heart Failure; Heart-Assist Devices; Hemorrhage; Humans; International Normalized Ratio; Patient Satisfaction; Phenprocoumon; Predictive Value of Tests; Prospective Studies; Prosthesis Implantation; Quality of Life; Self Care; Telemedicine; Thrombosis; Treatment Outcome; Ventricular Function, Left

Topics: Aged; Anticoagulants; Contrast Media; Diuretics; Drug Therapy, Combination; Echocardiography; Electrocardiography; Glucocorticoids; Heart Failure; Humans; Hypereosinophilic Syndrome; Magnetic Resonance Imaging, Cine; Male; Phenprocoumon; Treatment Outcome

Anticoagulation in patients with ventricular assist device (VAD) support is crucial and to date, no alternative to vitamin K antagonists (VKAs) can be safely used. Genetic variances of cytochrome p450 2C9 (CYP2C9) and vitamin K epoxide reductase (VKORC) have been recently connected with variation of VKA maintenance as well as loading doses. In this retrospective study, we assessed the incidence of genetic variations and the influence of different genotypes of CYP2C9 and VKORC1 in VAD patients.. A total of 161 patients received a VAD implant in our institution between January 2006 and July 2014. Of these, 63 consented to genetic analysis and completed an interview with standardized questions on phenprocoumon (PC) dosage, international normalized ratio and anticoagulation-related complications. Determination of VKORC (-1639 G > A; -1173 C > T) and of CYP2C9 (*2, 430 C > T; *3, 1075 A > C) polymorphisms was performed by polymerase chain reaction and restriction analysis.. The most common VKORC-1639 allele combination was wild-type GG (41%) followed by GA (32%) and AA (27%). Patients with VKORC1 polymorphisms AA and GA needed less PC in the maintenance phase of anticoagulation (P < 0.001) compared with wild-type GG patients. In contrast, CYP2C9 polymorphisms showed no effect on PC doses. Similar findings were observed in the initiation phase of PC therapy. High complications rates under PC therapy were observed particularly at the beginning.. VKORC polymorphism affects PC dosage in the initiation as well as the maintenance phase. High rates of bleeding complications and thromboembolic events were found at the beginning of PC therapy in VAD patients. Therefore, a genotype-guided dosage algorithm might be useful in VAD patients.

Topics: Adolescent; Adult; Aged; Anticoagulants; Blood Coagulation; Cytochrome P-450 CYP2C9; DNA; Dose-Response Relationship, Drug; Female; Genetic Variation; Genotype; Germany; Heart Failure; Heart-Assist Devices; Hemorrhage; Humans; Incidence; Male; Middle Aged; Phenprocoumon; Polymorphism, Genetic; Retrospective Studies; Thromboembolism; Vitamin K Epoxide Reductases; Young Adult

Bleeding and thrombo-embolism are two of the most threatening adverse events associated with the use of continuous flow left ventricular assist devices (LVADs) in the treatment of severe heart failure. We analysed our LVAD patients treated with the HeartMate II (HM II) device by following a low anticoagulation regimen.. Between 2008 and February 2011, we implanted 40 HM II LVADs in our institution. Intention to treat was bridge to transplant in 25, destination therapy in 9, bridge to candidacy in 5 cases and bridge to recovery in 1 case. Heparin was started only after 24 h postoperatively, and Phenprocumon (Phen) was started after removal of all chest drains. International normalized ratio (INR) target in the years 2008-2009 was 2.5, and 2.0-2.5 since 2010. Acetyl salicylic acid (ASA) was prescribed 50-100 mg/day only in patients <55 years or in case of severe atherosclerotic disease of the right coronary artery. All data were analysed consecutively concerning thrombo-embolic and bleeding events.. Fifty-two percent of the patients were in INTERMACS level 1 or 2 at the time of implantation. The mean age was 58 ± 11 years, and the mean days under LVAD was 241 days (maximum: 1052 days). The survival rate was 87.5% after 30 years and 75% in the long term. Early postoperatively, no strokes or thrombo-embolic events occurred. In the long term, two patients suffered from ischaemic strokes, but recovered well. In both of these index events, the INR was lasting below 1.4. One of these two patients developed pump thrombosis additionally. Only three patients (ASA + Phen) developed gastrointestinal bleeding (7.5%). Two patients were withdrawn from Phen + ASA because of multiple angiodysplasia.. Compared with the literature, even a mild anticoagulation protocol does not increase the risk of thrombotic events, but reduces bleeding events in the use of an HM II LVAD.

Topics: Anticoagulants; Aspirin; Female; Heart Failure; Heart-Assist Devices; Heparin; Humans; Male; Middle Aged; Phenprocoumon; Stroke; Thromboembolism

Topics: Anticoagulants; Female; Heart Failure; Heart-Assist Devices; Humans; Male; Phenprocoumon; Stroke; Thromboembolism

Uhl's disease is a rare disorder characterized by aplasia of the right ventricular myocardium leading to its parchment-like appearance. The loss of right ventricular function causes massive dilation of the right heart with progressive right heart failure in severe cases.. A 70-year-old patient with progressive dyspnea and massive peripheral edema presented with an acute decompensation of chronic right heart failure. Previously, pulmonary arterial hypertension was suspected and therapy with sildenafil was initiated. Echocardiography and cardiac MRI (magnetic resonance imaging) showed marked hypoplasia of the right ventricular free wall and marked dilation of the right heart without pulmonary arterial hypertension. The diagnosis of Uhl's disease was confirmed by typical MRI morphology. A slow cardiac recompensation was achieved by medicinal treatment of heart insufficiency. Hence the patient remained stable for 9 months with medicinal therapy without signs of further decompensation.. Uhl's disease should be suspected in patients with massive right heart dilation without pulmonary hypertension even in the adult. The major diagnostic clue is hypoplasia of the right ventricular free wall, which can be demonstrated by echocardiography and cardiac MRI. There is no causal therapy for the disease. Besides medicinal therapy for heart failure, right ventricular cardiomyoplasty and, ultimately, transplantation might be undertaken successfully.

Topics: Aged; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Cardiomegaly; Diagnosis, Differential; Echocardiography; Heart Defects, Congenital; Heart Failure; Heart Ventricles; Hemodynamics; Humans; Magnetic Resonance Imaging; Male; Phenprocoumon

Topics: Anticoagulants; Equipment Design; Heart Failure; Heart-Assist Devices; Humans; Phenprocoumon; Pulsatile Flow

Restrictive cardiomyopathy is a rare heart muscle disease in childhood. By presenting a case report of a 15 year old adolescent, the aim of this article is to describe diagnosis, pathogenesis and therapy of restrictive cardiomyopathy. A review of the literature comprising pediatric studies on restrictive cardiomyopathy serves as a basis to discuss recommendations for therapeutic strategies in pediatric patients with this rare disease.

Topics: Adolescent; Anticoagulants; Cardiomegaly; Cardiomyopathy, Restrictive; Diuretics; Drug Therapy, Combination; Echocardiography; Electrocardiography; Endocardial Fibroelastosis; Female; Heart Failure; Humans; Phenprocoumon

Heart failure has been identified as a risk factor for increased coumarin anticoagulant responsiveness in several small-scale experiments. Epidemiological studies quantifying the risk of overanticoagulation by heart failure in a non-selected population on coumarins are scarce. Therefore, we investigated whether patients with heart failure have an increased risk of overanticoagulation and determined the effect of incidental heart failure on coumarin dose requirements. A cohort study of all patients was performed from an outpatient anticoagulation clinic treated with acenocoumarol or phenprocoumon between 1 January 1990 and 1 January 2000. All cohort members were followed until the first occurrence of an international normalized ratio (INR) > or = 6.0, the last INR assessment, death, loss to follow-up, or end of the study period. Of the 1077 patients in the cohort, 396 developed an INR > or = 6.0. The risk of overanticoagulation was 1.66 [95% confidence interval (CI): 1.33-2.07] for cases of prevalent heart failure and 1.91 (95%CI: 1.31-2.79) for incidental cases. The decrease in dose requirements in patients with incidental heart failure showed a significant trend from the fifth INR measurement preceding the date of incidental heart failure to the third measurement after this date. Heart failure is an independent risk factor for overanticoagulation. Therefore, patients with heart failure should be closely monitored to prevent potential bleeding complications.

Topics: Acenocoumarol; Aged; Anticoagulants; Blood Coagulation; Drug Administration Schedule; Drug Monitoring; Female; Follow-Up Studies; Heart Failure; Humans; International Normalized Ratio; Male; Middle Aged; Phenprocoumon; Risk Factors

A 48-year-old patient with dilated cardiomyopathy complained of dyspnea at rest, severe sleeplessness and a slight pain in the stomach. The clinical examination was normal except for a murmur at the apex of the heart. There was no evidence of edema or congestion of the jugular veins.. The echocardiography demonstrated a dilated left ventricle with severely compromised function. No ventricular thrombi were present at this time. Coronary artery disease was excluded by coronary angiography. Endomyocardial biopsies were obtained from the right ventricular septum. The immunohistological analysis of the endomyocardial biopsy specimens revealed pathologically increased lymphocytic infiltrates and increased expression of interstitial and endothelial MHC I and II antigens. Flow cytometric analysis of platelets surface antigens (P-selectin, GP53, thrombospondin) was performed as a measure for intravasal platelet activation. Our patient compared to a healthy control group (> 4 SD) and to other patients with dilated cardiomyopathy (> 2 SD). A high grade increase of platelet activation was found.. ACE inhibitor, diuretics, spironolactone and digitalis were used to treat the heart insufficiency. Due to the severe left ventricular dysfunction phenprocoumone and aspirin were also prescribed. A follow-up echocardiography was performed 6 months later. Comparable to the first examination left ventricular contractility was found to be severely reduced. In addition, a marginal thrombus was now present in the left ventricle despite antithrombotic therapy.. An increased platelet activation was found in the peripheral circulation of our patient with dilated cardiomyopathy. After 6 months, ventricular thrombi were found in the dilated ventricle, although aspirin and phenprocoumone had been administred. We speculate that an additional thrombotic treatment with clopidogrel is necessary in patients with dilated cardiomyopathy and increased platelet activation.

Topics: Anticoagulants; Aspirin; Cardiomyopathy, Dilated; Cardiovascular Agents; Drug Therapy, Combination; Heart Failure; Heart Ventricles; Humans; Male; Middle Aged; Phenprocoumon; Platelet Activation; Risk Factors; Thrombosis; Treatment Failure; Ultrasonography

A 39-year-old woman complained of dyspnoea and increasing abdominal pressure sensation. A Greenfield filter had been implanted into her inferior vena cava (IVC) 4 years previously because of pulmonary embolism from a deep vein thrombosis after a hysterectomy with abscess formation. Physical examination revealed neck vein congestion, jaundiced sclerae, a tense abdominal wall, ascites and a soft machinery murmur in the paraumbilical region.. Transaminase activities were slightly raised (GOT 38 U/I, GPT 20 U/I), but total bilirubin and direct bilirubin were markedly elevated (2.9 mg/dl and 1.1 mg/dl, respectively). There was no evidence of cholestasis or decreased liver synthesis. Ultrasound showed marked dilatation of the IVC and hepatic veins, and echocardiography revealed right ventricular enlargement with grade II tricuspid regurgitation. Calculated pulmonary arterial systolic pressure averaged 50 mmHG. Colour-coded Doppler sonography demonstrated an aorto-caval shunt at the level of the filter in the IVC and penetration of a filter strut into the aortic lumen.. After removing the ascitic fluid by fluid and sodium restriction, and administration of an aldosterone antagonist and a loop diuretic, the A-V fistula was closed surgically and the filter removed. Three months after operation she was put on phenprocoumon (Quick value 20-30%). At the latest outpatient examination, 6 months after the operation, she was free of symptoms.. As filter implantation in the IVC may produce severe complications, indications for it need to be demonstrated by further studies of its efficacy.

Topics: Adult; Anticoagulants; Aorta, Abdominal; Aortic Diseases; Arteriovenous Fistula; Chronic Disease; Echocardiography; Female; Follow-Up Studies; Heart Failure; Humans; Phenprocoumon; Time Factors; Ultrasonography, Doppler, Color; Vena Cava Filters; Vena Cava, Inferior