warfarin and Anemia

Anemia has been associated with a higher risk of major bleeding among atrial fibrillation patients on oral anticoagulation and is therefore included in most bleeding risk scores. In contrast, much less evidence exists regarding the association between anemia and stroke risk in atrial fibrillation patients. The purpose of this review was to re-evaluate the efficacy and safety of anticoagulant treatment, in particular of new oral anticoagulants, in patients with non-valvular atrial fibrillation and chronic anemia. Five observational studies were found in the literature that specifically investigated this issue; the results can be synthetized as follows: (i) the progressive decrease in hemoglobin level was associated with an increased incidence of major hemorrhages, already evident in mild anemia and very high in more severe anemia (hemoglobin level <~10 g/dl), up to >10% per year. In contrast, the association between anemia and stroke risk appears to be weak; (ii) warfarin seems to be effective in stroke prevention in patients with mild anemia, with a moderate increase in major hemorrhages, whereas it seems to be ineffective and associated with a high incidence of hemorrhagic complications in patients with more severe anemia; (iii) new oral anticoagulants, in particular apixaban, seem to induce a lower incidence of major hemorrhages in comparison with warfarin in patients with both mild and severe anemia. However, when hemoglobin level is <~10 g/dl, the incidence of major hemorrhages remains high, also in patients treated with the new anticoagulants. These data suggest that in patients with atrial fibrillation and mild anemia, anticoagulant treatment appears to be effective, but requires close monitoring during follow-up, whereas in patients with more severe anemia the choice of whether or not to prescribe an anticoagulant treatment should be made on a case by case basis, considering the thromboembolic risk, the etiology of chronic anemia and the history and general condition of the patient. New oral anticoagulants should be preferred to warfarin.

Topics: Administration, Oral; Anemia; Anticoagulants; Atrial Fibrillation; Humans; Pyridones; Stroke; Warfarin

Warfarin significantly reduces thromboembolic risk, but perceptions of associated bleeding risk limit its use. The evidence supporting the association between bleeding and individual patient risks factors is unclear. This systematic review aims to determine the strength of evidence supporting an accentuated bleeding risk when patients with risk factors listed in the warfarin prescribing information are prescribed the drug. A systematic literature search of MEDLINE and Cochrane CENTRAL was conducted to identify studies reporting multivariate relationships between prespecified covariates and the risk of bleeding in patients receiving warfarin. The prespecified covariates were identified based on patient characteristics for bleeding listed in the warfarin package insert. Each covariate was evaluated for its association with specific types of bleeding. The quality of individual evaluations was rated as 'good', 'fair' or 'poor' using methods consistent with those recommended by the Agency for Healthcare Research and Quality (AHRQ). Overall strength of evidence was determined using the Grading of Recommendations Assessment, Development (GRADE) criteria and categorised as 'insufficient', 'very low', 'low', 'moderate' or 'high'. Thirty-four studies, reporting 134 multivariate evaluations of the association between a covariate and bleeding risk were identified. The majority of evaluations had a low strength of evidence for the association between covariates and bleeding and none had a high strength of evidence. Malignancy and renal insufficiency were the only two covariates that had a moderate strength of evidence for their association with major and minor bleeding respectively. The associations between covariates listed in the warfarin prescribing information and increased bleeding risk are not well supported by the medical literature.

Topics: Alcohol Drinking; Anemia; Anticoagulants; Drug Labeling; Heart Diseases; Hemorrhage; Humans; Liver Diseases; Medication Adherence; Mental Disorders; Neoplasms; Prescription Drugs; Renal Insufficiency; Risk Factors; Warfarin

Topics: Analgesics, Non-Narcotic; Anemia; Anticoagulants; Antineoplastic Agents; Dietary Supplements; Female; Gastrointestinal Diseases; Humans; International Normalized Ratio; Middle Aged; Neoplasms; Thrombocytopenia; Warfarin

Topics: Aged; Aged, 80 and over; Anemia; Atrial Fibrillation; Cardiovascular Diseases; Family Practice; Female; Humans; Hypertension; Life Style; Male; Warfarin

Topics: Anemia; Anticoagulants; Biological Transport; Blood Coagulation Factors; Collagen; Enzymes; Membranes; Mitochondria; Oxidative Phosphorylation; Protein Biosynthesis; Solubility; Vitamin D; Vitamin E; Vitamin E Deficiency; Vitamin K; Warfarin

To determine whether point-of-care (POC) International Normalized Ratio (INR) test results correlate with plasma INR measures in intermittent hemodialysis (IHD) patients on warfarin. Anemia is thought to reduce the accuracy of POC INR assay results. Whether POC INR testing could be implemented for hemodialysis patients on chronic warfarin, who are often anemic despite hematopoietic therapy, has not been established.. Thirty-seven chronic hemodialysis patients on warfarin contributed sets of three consecutive blood samples for INR comparison immediately before hemodialysis: one finger stick, two from hemodialysis access (arteriovenous graft, fistula, or catheter). POC INR testing was performed using CoaguChek S device. Anemia was defined as hematocrit < 32%.. Pairwise comparison and correlation of 258 INR results showed high correlation for POC versus laboratory INR (r = 0.94; P < 0.001). Of these, 16 (6%) differed by >0.6 INR units, four (1.6%) differed by >0.8 INR units, and one differed by >1.0 INR units. Resulting pairwise correlation analyses between samples were: for anemic patients (0.96; P < 0.001), nonanemic patients (0.93; P < 0.001), and for those obtained from arteriovenous grafts (0.94; P < 0.001). POC INR samples from dialysis catheters correlated poorly with laboratory INR results.. POC INR correlates well with plasma INR measures in IHD patients requiring chronic warfarin, and anemia did not influence this reliability. Blood sampling from finger stick or arteriovenous graft or fistula showed excellent correlation with laboratory INR, whereas sampling from dialysis catheters was unsatisfactory, likely from heparin contamination.

Topics: Aged; Aged, 80 and over; Anemia; Anticoagulants; Arteriovenous Shunt, Surgical; Blood Coagulation; Blood Specimen Collection; Blood Vessel Prosthesis Implantation; Catheterization, Central Venous; Catheters, Indwelling; Clinical Laboratory Techniques; Drug Monitoring; Feasibility Studies; Female; Fingers; Hematinics; Hematocrit; Humans; International Normalized Ratio; Male; Point-of-Care Systems; Predictive Value of Tests; Prospective Studies; Renal Dialysis; Reproducibility of Results; Warfarin

We studied association of laboratory testing beyond the international normalised ratio (INR) with bleeding and stroke/transient ischaemic attack (TIA) outcomes in patients with atrial fibrillation treated with warfarin.. This was a retrospective nested case-control study from the Finnish Warfarin in Atrial Fibrillation (FinWAF) registry (n=54 568), reporting the management and outcome in warfarin-anticoagulated patients. Associations of blood count test frequency and results were assessed together with risk of bleeding or stroke/TIA during 5-year follow-up.. National FinWAF registry, with data from all six hospital districts. Follow-up period for complications was 1 January 2007-31 December 2011.. A total of 54 568 warfarin-anticoagulated patients.. The number of patients with bleeding was 4681 (9%) and stroke/TIA episodes, 4692 (9%). In patients with bleeds, lower haemoglobin (within 3 months) preceded the event compared with the controls (median 126 vs 135 g/L; IQR 111-141 g/L vs 123-147 g/L, p<0.001), while patients with stroke/TIA had only modestly lower INR (median 2.2 vs 2.3; 1.8-2.6 vs 2.1-2.7, p<0.001). When the last measured haemoglobin was below the reference value (130 g/L for men, 120 g/L for women), the OR for a bleeding complication was 2.9 and stroke/TIA, 1.5. If the haemoglobin level was below 100 g/L, the complication risk increased further by 10-fold. If haemoglobin values were repeatedly (more than five times) low during the preceding 3 months, future OR was for bleeds 2.3 and for stroke/TIA 2.4.. The deeper the anaemia, the higher the risk of bleeding and stroke/TIA. However, INR remained mainly at its target and only occasionally deviated, failing to detect the complication risk. Repeated low haemoglobin results, compatible with persistent anaemia, refer to suboptimal management and increased the complication risk in anticoagulated patients.

Topics: Anemia; Anticoagulants; Atrial Fibrillation; Case-Control Studies; Female; Hemoglobins; Hemorrhage; Humans; Ischemic Attack, Transient; Male; Registries; Retrospective Studies; Stroke; Thrombosis; Treatment Outcome; Warfarin

Hemoglobin levels and platelet counts have been associated with adverse clinical outcomes in patients with cardiovascular conditions. We aimed to assess the impact of oral anticoagulant use for patients with atrial fibrillation and concomitant anemia or thrombocytopenia.. We used medical data from a multicenter health care system in Taiwan including 37,074 patients with atrial fibrillation. Patients were categorized into 3 groups based on hemoglobin and platelet levels: Group 1 (hemoglobin >10g/dL and platelet>100 K/µL; n = 29,147), Group 2 (hemoglobin<10 g/dL or platelet<100 K/µL; n = 7078), and Group 3 (hemoglobin <10 g/dL and platelet <100 K/µL; n = 849). Patients in each category were further stratified as 3 groups according to their stroke prevention strategies: no oral anticoagulant use (non-OAC), warfarin, or nonvitamin K antagonist oral anticoagulants (NOACs).. A higher hemoglobin or platelet level was associated with a higher risk of ischemic stroke/systemic embolism but lower risks of intracranial hemorrhage and major bleeding. The composite risks of ischemic stroke/systemic embolism, intracranial hemorrhage and major bleeding were higher in Group 3 or Group 2, compared with Group 1 (6.79% a year vs 6.41% year vs 4.13% year). Compared to non-OACs, warfarin was not associated with a lower composite risk in the 3 groups. NOACs were associated with a lower composite risk in Group 1 (adjusted hazard ratio:0.68, [95% confidence interval:0.60-0.76]) and Group 2 (adjusted hazard ratio:0.73, [95% confidence interval:0.53-0.99]) but was nonsignificant in Group 3.. Patients with atrial fibrillation with anemia or thrombocytopenia were a high-risk population. Compared with no OAC use, NOACs were associated with better clinical outcomes for patients with atrial fibrillation and advanced anemia (hemoglobin <10g/dL) or thrombocytopenia (platelet <100 K/µL) but not for those with both conditions.

Topics: Administration, Oral; Anemia; Anticoagulants; Atrial Fibrillation; Embolism; Hemoglobins; Hemorrhage; Humans; Intracranial Hemorrhages; Ischemic Stroke; Risk Factors; Stroke; Thrombocytopenia; Warfarin

To determine whether anemia is an independent risk factor for ischemic stroke and major bleeding in patients with non-valvular atrial fibrillation (NVAF).. Anemia in patients with NVAF increase risk of clinical complications related to atrial fibrillation.. We conducted a prospective multicenter registry of patients with NVAF in Thailand. Demographic data, medical history, comorbid conditions, laboratory data, and medications were collected and recorded, and patients were followed-up every 6 months. The outcome measurements were ischemic stroke or transient ischemic attack (TIA), major bleeding, heart failure (HF), and death. All events were adjudicated by the study team. We analyzed whether anemia is a risk factor for clinical outcomes with and without adjusting for confounders.. There were a total of 1562 patients. The average age of subjects was 68.3 ± 11.5 years, and 57.7% were male. The mean hemoglobin level was 13.2 ± 1.8 g/dL. Anemia was demonstrated in 518 (33.16%) patients. The average follow-up duration was 25.8 ± 10.5 months. The rate of ischemic stroke/TIA, major bleeding, HF, and death was 2.9%, 4.9%, 1.8%, 8.6%, and 9.2%, respectively. Anemia significantly increased the risk of these outcomes with a hazard ratio of 2.2, 3.2, 2.9, 1.9, and 2.8, respectively. Oral anticoagulants (OAC) was prescribed in 74.8%; warfarin accounts for 89.9% of OAC. After adjusting for potential confounders, anemia remained a significant predictor of major bleeding, heart failure, and death, but not for ischemic stroke/TIA.. Anemia was found to be an independent risk factor for major bleeding, heart failure, and death in patients with NVAF.

Topics: Administration, Oral; Anemia; Anticoagulants; Atrial Fibrillation; Humans; Male; Prospective Studies; Registries; Risk Factors; Stroke; Warfarin

Many factors influence international normalized ratio (INR); however, few studies have examined the impact of anemia in warfarin patients. The primary objective of this study was to explore the relationship between in-clinic anemia and the control of INR within an anticoagulation clinic.. A retrospective chart review was performed on a random sample of patients seen in an academic medical center pharmacy-managed anticoagulation clinic. Hemochron® Signature Elite machine was utilized to monitor point-of-care (POC) INR. In-clinic anemia was defined as hematocrit <32%. Statistical analyses were conducted using STATA MP a webbased platform ( https://www.stata.com/statamp/ ).. Of the 300 patients analyzed, 45 (15%) patients had in-clinic anemia. Patients with in-clinic anemia were more likely to be younger (. Study results suggest that in-clinic anemia may be more prevalent among younger, female patients prescribed warfarin, and patients diagnosed with in-clinic anemia may be a risk factor for out-of-range INR. Pharmacists practicing in anticoagulation clinics can incorporate this information into patient care practice in efforts to maintain optimal management.

Topics: Adult; Aged; Ambulatory Care Facilities; Anemia; Anticoagulants; Female; Humans; International Normalized Ratio; Male; Middle Aged; Point-of-Care Testing; Retrospective Studies; Warfarin

 Many patients on warfarin therapy often present with supratherapeutic international normalized ratio (INR) levels, resulting from the influence of several patient-specific factors, which have been associated with adverse outcomes..  This article aims to identify risk factors for over-anticoagulation (INR levels ≥4) in a cohort of patients taking warfarin..  A cohort of warfarin users aged 18 to 85 years from January 2005 to April 2013 was identified in The Health Improvement Network U.K. primary care database (.  Among the factors examined, the strongest predictors of over-anticoagulation were warfarin indication (in particular, valvular atrial fibrillation and valve replacement), renal failure (with the risk increasing steeply with decreasing estimated glomerular filtration rate), cancer, anaemia, respiratory infections treated with antibiotics, chronic obstructive pulmonary disease treated with β2-agonists, polypharmacy (≥10 medications), low socio-economic status and residency in rural areas. Similar results were obtained when supratherapeutic levels were defined as INR ≥5 or, alternatively, as INR > 3..  Predictors of supratherapeutic INR levels found in this study might help physicians identify patients where closer INR monitoring is warranted.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anemia; Anticoagulants; Blood Coagulation; Case-Control Studies; Databases, Factual; Female; Glomerular Filtration Rate; Humans; International Normalized Ratio; Male; Medical Overuse; Middle Aged; Neoplasms; Odds Ratio; Poverty; Primary Health Care; Pulmonary Disease, Chronic Obstructive; Regression Analysis; Renal Insufficiency; Respiratory Tract Infections; Rural Population; United Kingdom; Warfarin; Young Adult

The use and range of indications for anticoagulation therapy are steadily growing. The objective of this study was to develop a scoring model to predict the occurrence of significant bleeding in patients taking warfarin with a supra-therapeutic international normalized ratio.. Data were collected from the medical records of patients taking warfarin with an international normalized ratio > 3.5. The characteristics of bleeding episodes and the need for transfusion of blood products were recorded. Regression models were constructed to predict the occurrence of significant bleeding (requiring a transfusion of more than 2 units of packed red blood cells, intrapericardial or intracranial hemorrhage). The predictive values of previously published scores (ATRIA: anemia, hypertension, severe renal disease, age ≥ 75 years, or prior bleeding history; and ORBIT: old, reduced hemoglobin, bleeding history, kidney insufficiency or antiplatelet treatment) were compared with our New Bleeding Score (NBLDSCOR); the areas under the curve for the receiver-operating characteristic plots were compared using a non-parametric DeLong test.. Significant bleeding was reported in 87 out of 389 admitted patients. With an area under the curve of 0.736 ± 0.032, NBLDSCOR was the best predictor of significant bleeding in this population. Neither ATRIA nor ORBIT was a good predictor of significant bleeding, where the area under the curve for the receiver-operating characteristic plot for ATRIA was 0.654 ± 0.034 and for ORBIT was 0.604 ± 0.033. The predictive power of NBLDSCOR was superior to ATRIA and ORBIT (p < 0.001), while there was no meaningful difference in the predictive powers of ATRIA and ORBIT.. The NBLDSCOR including age, negative Rhesus factor, low hemoglobin, renal impairment, and concomitant peptic ulcer and disseminated cancer is a good predictor of significant bleeding in this patient population.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anemia; Anticoagulants; Cross-Sectional Studies; Female; Hemorrhage; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Retrospective Studies; Risk Assessment; Warfarin

Background Major randomized trials assessing non-vitamin K antagonist oral anticoagulants ( NOAC s) for stroke prevention in atrial fibrillation generally excluded patients with hemoglobin <10 g/dL. This study evaluated the safety and effectiveness of NOAC s in patients with atrial fibrillation and anemia. Methods and Results A cohort study based on electronic medical records was conducted from 2010 to 2017 at a multicenter healthcare provider in Taiwan. It included 8356 patients with atrial fibrillation who had received oral anticoagulants (age, 77.0±7.3 years; 48.0% women). Patients were classified into 2 subgroups: 7687 patients with hemoglobin ≥10 g/ dL and 669 patients with hemoglobin <10 g/ dL . A Cox regression analysis was performed to assess the risks of ischemic stroke/systemic embolism, bleeding, and death associated with NOAC versus warfarin in both subgroups, respectively. In patients with hemoglobin ≥10 g/ dL , NOAC (n=4793) was associated with significantly lower risks of ischemic stroke/systemic embolism, major bleeding, and gastrointestinal tract bleeding than warfarin (n=2894); there was no difference in the risk of death. In patients with hemoglobin <10 g/ dL , NOAC (n=390) was associated with significantly lower risks of major bleeding (adjusted hazard ratio, 0.43; 95% CI, 0.30-0.62) and gastrointestinal tract bleeding than warfarin (n=279), but there was no difference in the risk of ischemic stroke/systemic embolism (adjusted hazard ratio, 0.79; 95% CI , 0.53-1.17) or death. Subgroup analyses suggested that NOAC was associated with fewer bleeding events, irrespective of cancer or peptic ulcer disease history. Conclusions In patients with atrial fibrillation with hemoglobin <10 g/ dL , NOAC was associated with lower bleeding risks than warfarin, with no difference in the risk of ischemic stroke/systemic embolism or death.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anemia; Anticoagulants; Antithrombins; Atrial Fibrillation; Biomarkers; Electronic Health Records; Female; Hemoglobins; Hemorrhage; Humans; Male; Retrospective Studies; Risk Assessment; Risk Factors; Stroke; Taiwan; Time Factors; Warfarin

The oral anticoagulant warfarin is a vitamin K antagonist and is considered the first line anticoagulant in valvular atrial fibrillation. However prothrombin time should be closely monitored, drug interactions checked and compliance regarding diet ensured when the patient is on warfarin therapy. Anaemia should be looked for, evaluated for the cause and corrected since it is an independent predictor of bleeding and thrombotic episodes during warfarin therapy for atrial fibrillation We present an interesting case of anaemia which developed during warfarin therapy for atrial fibrillation. The patient was on amiodarone and was consuming leafy vegetables resulting in frequent raise in prothrombin time during which time she developed bleeding into the right femoral pseudoaneurysm which had developed following catheterisation for thrombectomy. Surgical correction of pseudoaneurysm was done, comedication was changed and diet compliance ensured which resulted in the subsequent maintenance of prothrombin time in the therapeutic range and steady haemoglobin levels.

Topics: Anemia; Aneurysm, False; Anticoagulants; Atrial Fibrillation; Cardiac Catheterization; Directive Counseling; Female; Humans; Middle Aged; Prothrombin Time; Spinacia oleracea; Treatment Outcome; Vitamin K; Warfarin

Patients with atrial fibrillation (AF) are prone to cardiovascular events and anticoagulation-related bleeding complications. We hypothesized that patients with anemia are at increased risk for these outcomes.. We performed a post hoc analysis of the ARISTOTLE trial, which included >18,000 patients with AF randomized to warfarin (target international normalized ratio, 2.0-3.0) or apixaban 5 mg twice daily. Multivariable Cox regression analysis was used to determine if anemia (defined as hemoglobin <13.0 in men and <12.0 g/dL in women) was associated with future stroke, major bleeding, or mortality.. Anemia was present at baseline in 12.6% of the ARISTOTLE population. Patients with anemia were older, had higher mean CHADS. Chronic anemia is associated with a higher incidence of bleeding complications and mortality, but not of stroke, in anticoagulated patients with AF. Apixaban is an attractive anticoagulant for stroke prevention in patients with AF with or without anemia.

Topics: Aged; Aged, 80 and over; Anemia; Anticoagulants; Atrial Fibrillation; Embolism; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Incidence; Male; Middle Aged; Mortality; Multivariate Analysis; Proportional Hazards Models; Pyrazoles; Pyridones; Randomized Controlled Trials as Topic; Stroke; Thromboembolism; Warfarin

Gastrointestinal bleeding is a well-known risk of systemic anticoagulation. However, bleeding in the setting of supratherapeutic anticoagulation may have a milder natural history than unprovoked bleeding. It is a common clinical gestalt that endoscopy is common, but bleeding source identification or intervention is uncommon, yet few data exist to inform this clinical impression. Consequently, we sought to examine our institutional experience with gastrointestinal bleeding in the setting of supratherapeutic international normalized ratio (INR) with the aim of identifying predictors of endoscopically identifiable lesions, interventions, and outcomes.. A retrospective review was conducted at a tertiary referral academic medical center to identify patients presenting with gastrointestinal bleeding in the setting of warfarin and a supratherapeutic INR (>3.5) who underwent an endoscopic procedure. Relevant clinical covariates, endoscopic findings, need for intervention, and outcomes were collected by review of the medical record. Logistic regression adjusting for potential confounders identified predictors of endoscopically significant lesions as well as intervention and outcomes.. A total of 134 patients with INR 3.5 or greater (mean 5.5, range 3.5-17.1) presented with symptoms of gastrointestinal bleeding, most commonly as melena or symptomatic anemia. Antiplatelet agents were used by 54% of patients, and 60% of patients were on concomitant acid suppression on admission. Procedures included esophagogastroduodenoscopy (upper endoscopy; EGD) (n = 128), colonoscopy (n = 73), and video capsule endoscopy (n = 32). Active bleeding at first EGD or colonoscopy was found in only 19 patients (18%), with endoscopic intervention in only 26 patients (25%). At a critical threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion fell to <20%. On multivariate logistic regression, concomitant antiplatelet therapy (odds ratio [OR] 2.59; 95% confidence interval [CI], 1.13-5.94), timing of EGD within 12 hours of presentation (OR 3.71; 95% CI, 1.05-13.08), and INR level (OR 0.79; 95% CI, 0.64-0.98) were the only significant independent predictors of identifying a source of bleeding. A risk score incorporating these covariates performed modestly in identifying risk of significant finding on EGD (area under the curve 0.68). We found no association between identification of a significant lesion at EGD and future readmission for gastrointestinal bleeding.. This study demonstrates that the relationship between INR elevation and identification of a bleeding source or endoscopic intervention at EGD are indeed antiparallel. Concomitant antiplatelet therapy increases the likelihood of bleeding source identification and intervention, as does EGD within 12 hours of presentation. However, regardless of source identification or endoscopic intervention, important clinical outcomes were unchanged, suggesting that decisions about endoscopy should be made on a case-by-case basis, particularly in patients with INR > 7.5. Future prospective studies on appropriate indications and timing of endoscopy in such patients are warranted.

Topics: Academic Medical Centers; Aged; Anemia; Anticoagulants; Capsule Endoscopy; Drug Therapy, Combination; Electronic Health Records; Endoscopy, Gastrointestinal; Female; Gastrointestinal Hemorrhage; Humans; International Normalized Ratio; Logistic Models; Male; Melena; Platelet Aggregation Inhibitors; Retrospective Studies; Risk Assessment; Warfarin

Results from the J-ROCKET AF study revealed that rivaroxaban was non-inferior to warfarin with respect to the principal safety outcomes in patients with non-valvular atrial fibrillation. This subgroup analysis evaluated whether non-major clinically relevant bleeding (NMCRB) could be a predictive factor for major bleeding (MB). Other predictive factors for MB were also obtained in both rivaroxaban and warfarin treatment groups.. The temporal incidence of MB was compared between the rivaroxaban and warfarin treatment groups. Assessment was made whether MB events were often preceded by NMCRB. Univariate and multivariate analyses were carried out to identify any independent predictive factors for MB in both treatment groups.. The incidences of MB and NMCRB were 18.04% (138/639 patients) in the rivaroxaban arm, and 16.42% in the warfarin arm (124/639 patients). NMCRB preceded MB in only four patients in each treatment group (rivaroxaban: 4/117 and warfarin: 4/98). Multivariate analysis identified predictive factors for bleeding events: anemia with warfarin treatment and concomitant use of antiplatelet agents with rivaroxaban treatment.. Results from this subgroup analysis, particularly the fact that there was no repeated or sequential pattern between NMCRB and MB occurrences in both treatment groups, suggests that NMCRB might not be a predictive factor for MB. On the contrary, anemia and concomitant use of antiplatelet therapy were likely predictive factors for bleeding with warfarin and rivaroxaban treatment, respectively.

Topics: Aged; Anemia; Anticoagulants; Atrial Fibrillation; Female; Hemorrhage; Humans; Japan; Male; Multivariate Analysis; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Rivaroxaban; Stroke; Warfarin

The balance between the efficacy and safety of anticoagulant therapy in patients aged ≥100years receiving anticoagulant therapy for venous thromboembolism (VTE) is uncertain.. We used data from the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to assess the rate of VTE recurrences, bleeding events, and mortality appearing during the course of anticoagulant therapy in VTE patients aged ≥100years.. Of 61,173 patients enrolled in RIETE as of January 2016, 47 (0.08%) were aged ≥100years. Of these, 10 (21%) were men, 21 (45%) presented with pulmonary embolism (PE), and 26 with deep vein thrombosis alone. Overall, 35 patients (74%) had severe renal insufficiency, 14 (30%) chronic heart failure, 30 (64%) anemia, 16 (34%) were taking antiplatelets, and 6 (13%) corticosteroids or non-steroidal anti-inflammatory drugs. Most patients (95%) were treated initially with low-molecular-weight heparin (LMWH) (mean daily dose, 168±42IU/kg). Then, 14 (30%) switched to vitamin K antagonists and 29 (62%) kept receiving long-term LMWH therapy (mean, 148±51IU/kg/day). During the course of anticoagulant therapy (mean duration, 139days), mortality was high (15/47; 32%). Two patients died of PE (initial PE one, recurrent PE one) and 5 (11%) had minor bleeding, but no major bleeding was reported.. Among patients with acute VTE aged ≥100years, the risk of VTE recurrences during the course of anticoagulation outweighed the risk of bleeding. Our data suggest the use of standard anticoagulant therapy in this patient population, even if they have severe renal insufficiency.

Topics: Aged, 80 and over; Anemia; Anticoagulants; Comorbidity; Female; Heart Failure; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Male; Pulmonary Embolism; Recurrence; Registries; Renal Insufficiency; Spain; Treatment Outcome; Venous Thromboembolism; Venous Thrombosis; Warfarin

Topics: Abdominal Pain; Aged; Anemia; Anticoagulants; Erythrocyte Transfusion; Female; Hematoma; Humans; International Normalized Ratio; Muscular Diseases; Rectus Abdominis; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Aged, 80 and over; Anemia; Antibiotics, Antitubercular; Anticoagulants; Drug Interactions; Hematoma; Humans; Male; Muscular Diseases; Polypharmacy; Rifampin; Risk; Warfarin

This study aimed to describe the contemporary aetiology, clinical characteristics and mortality and its predictors in heart failure (HF) in Tanzania.. Design; Prospective observational study. Setting; Cardiovascular Center of the Muhimbili National Hospital in Dar es Salaam, Tanzania. Patients ≥18 years of age with HF defined by the Framingham criteria.. All-cause mortality.. Among 427 included patients, 217 (51%) were females and the mean (SD) age was 55 (17) years. HF aetiologies included hypertension (45%), cardiomyopathy (28%), rheumatic heart disease (RHD) (12%) and ischaemic heart disease (9%). Concurrent atrial fibrillation (AF), clinically significant anaemia, diabetes, tuberculosis and HIV were found in 16%, 12%, 12%, 3% and 2%, respectively, while warfarin was used in 3% of the patients. The mortality rate, 22.4 per 100 person-years over a median follow-up of 7 months, was independently associated with AF, HR 3.4 (95% CI 1.6 to 7.0); in-patient 3.2 (1.5 to 6.8); anaemia 2.3 (1.2 to 4.5); pulmonary hypertension 2.1 (1.1 to 4.2) creatinine clearance 0.98 (0.97 to 1.00) and lack of education 2.3 (1.3 to 4.2).. In HF in Tanzania, patients are younger than in the developed world, but aetiologies are becoming more similar, with hypertension becoming more and RHD less important. Predictors of mortality possible to intervene against are anaemia, AF and lack of education.

Topics: Anemia; Atrial Fibrillation; Comorbidity; Diabetes Mellitus; Educational Status; Female; Heart Failure; HIV Infections; Humans; Kidney Function Tests; Male; Middle Aged; Mortality; Prognosis; Prospective Studies; Tanzania; Tertiary Care Centers; Tuberculosis; Warfarin

Topics: Aged, 80 and over; Anemia; Anticoagulants; Atrial Fibrillation; Hemorrhage; Humans; Male; Platelet Aggregation Inhibitors; Stroke; Warfarin

An 81-year-old man on warfarin was admitted to hospital after 3 days of constipation, straining and mild rectal bleeding. A large, boggy mass was felt posteriorly on direct rectal examination. Investigations revealed a normocytic anaemia and a supratherapeutic international normalised ratio (INR). Fearing a late presentation of malignancy, an urgent CT of abdomen and pelvis was arranged which showed a homogeneous mass arising between the sacrum and the rectum. Given the anaemia in the presence of anticoagulation, and subsequent widespread perineal and scrotal ecchymosis, the patient was diagnosed with atraumatic presacral haematoma. Following resuscitation, the patient was managed non-operatively and was discharged several days later following stabilisation of the haemoglobin and INR. At 3 months, he had complete clinical and radiological resolution of this haematoma.

Topics: Aged, 80 and over; Anemia; Anticoagulants; Hematoma; Humans; International Normalized Ratio; Male; Rectal Diseases; Rectal Neoplasms; Sacrum; Tomography, X-Ray Computed; Warfarin

The prevalence and etiology of occult bleeding among patients on warfarin who are screened systematically for new anemia is largely unknown. We aimed to estimate the usefulness of following hemoglobin and mean red cell volume (MCV) with INR in order to screen for developing anemia as an indicator of occult bleeding.. All patients on warfarin controlled at our institution had measurements of complete blood count (CBC) with INR during 18 months. Patients who fell>25 g/L and/or decrease of MCV over 5 fL or MCV<80 fL were contacted with instructions to undergo evaluation of anemia.. Overall 3218 patients on warfarin were monitored at our institution and 442 (13.7%) had anemia and 235 (7.3%) had unexplained anemia. A total of 163/235 (69%) who were notified contacted their doctors and 82/163 (50%) were referred for investigation with upper and/or lower endoscopies. Gastrointestinal malignancies were found in 11 patients (10 colorectal cancers, 1 esophageal) and pre-cancerous lesions among 14 other patients. Additional 25/82 patients (30%) had upper and/or lower bleeding lesions such as ulcers and angiodysplasia. Based on 3669 years of observation, 73 patients needed to be screened for one year in order to identify one gastrointestinal lesion causing occult bleeding.. Thirty percent of those endoscoped had malignant or pre-malignant diseases. Regular measurement of CBC concomitantly with INR in patients on warfarin therapy led to detection of otherwise asymptomatic diseases in a significant proportion of patients and might lead to earlier diagnosis of malignant and premalignant disease.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anemia; Anticoagulants; Blood Cell Count; Child; Drug-Related Side Effects and Adverse Reactions; Female; Gastrointestinal Neoplasms; Humans; Iceland; Incidence; International Normalized Ratio; Male; Mass Screening; Middle Aged; Precancerous Conditions; Prevalence; Risk Assessment; Warfarin; Young Adult

A case of a baby born preterm with an antenatal diagnosis of aortic coarctation for which prostin was electively started at birth. The baby was found to be profoundly anaemic with no clear obstetric cause. Features consistent with antenatal intracerebral haemorrhage were noted on cranial ultrasonography in the context of severe coagulopathy, prompting investigations which confirmed fetal-maternal haemorrhage. It transpired that, following aortic and mitral valve replacements, the mother was anticoagulated with warfarin at conception, having misunderstood her cardiologist's advice that: 'you cannot get pregnant whilst on warfarin'. Following conversion to low molecular weight heparin, she suffered a stroke, thus warfarin was restarted, with an international normalised ratio of 3-4.7 during pregnancy. Following transfer to the paediatric intensive care unit, fetal warfarin syndrome was diagnosed. The coagulopathy and anaemia were corrected and aortic coarctation was excluded. The baby returned to the neonatal intensive care unit for ongoing care and was discharged home in good condition around his due date. At the present time, there is no clinically overt neurological deficit.

Topics: Abnormalities, Drug-Induced; Anemia; Anticoagulants; Aortic Coarctation; Blood Coagulation; Blood Coagulation Disorders; Female; Fetal Diseases; Heart Valves; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Infant, Newborn; Infant, Premature; Maternal-Fetal Exchange; Nasal Bone; Postoperative Complications; Pregnancy; Premature Birth; Stroke; Warfarin

Topics: Aged, 80 and over; Anemia; Atrial Fibrillation; Chronic Disease; Erythema; Esophagitis, Peptic; Female; Humans; Iron, Dietary; Practice Patterns, Physicians'; Warfarin

Risk factors for cancer-associated VTE include certain cancer types (e.g. pancreatic adenocarcinoma), chemotherapy, and the use of erythropoiesis-stimulating agents, central venous catheters, and surgery. We studied the risk factors for cancer-associated VTE in our institution.. Retrospective analysis of patients with solid cancers treated with chemotherapy at King Khalid University Hospital from 2000 to 2010.. We assessed risk factors responsible for VTE, including performance status, age, chemotherapy, use of erythropoietin (EPO), stage of disease and use of a central venous catheter. Patients with other co-morbidities such as diabetes were excluded.. Forty of 306 patients were identified as having VTE, including 111 males and 195 females with a median age of 38 years (range, 13-18 years). Thirty-nine patients had proximal deep vein thrombosis (DVT) and, 4 had pulmonary embolism with no evidence of DVT. Of the 43 patients, 40 patients had stage III or IV at the time of VTE. Thirty patients were taking erythropoietin (40 000 units/ week); 25 had a hemoglobin level higher than 12 g/L. All patients were treated with low molecular weight (LMW) heparin and maintained on LMW heparin or warfarin for minimum of 6 months.. VTE imposes a great risk to life in cancer patients. Risk factors include age more than 40 years, advanced cancer stage, chemotherapy, use of EPO for anemia and underuse of DVT prophylaxis.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Anemia; Anticoagulants; Catheterization, Central Venous; Erythropoietin; Female; Hemoglobins; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Neoplasm Staging; Pancreatic Neoplasms; Retrospective Studies; Risk Factors; Venous Thromboembolism; Warfarin; Young Adult

The aim of this analysis was to evaluate the roles of anemia, hypoalbuminemia, and renal impairment as independent predictors of bleeding in patients with nonvalvular atrial fibrillation (NVAF) receiving anticoagulation therapy with warfarin.. This was a previously published prospective, observational study conducted between November 1999 and July 2001. Patients with NVAF newly started on warfarin and referred to an anticoagulation clinic at a large university hospital (Northern General Hospital, Sheffield, United Kingdom), either at the time of hospital discharge or by their general practitioner, were eligible. Patients were divided into 2 groups: those aged <75 years; and those aged > or =75 years. Patients were seen at the clinic for an initial visit, and baseline information, including age, sex, employment status, medical history, and medication list, was obtained. Patients were also interviewed regarding episodes of bleeding (classified as minor bleeding events or major bleeding events) at the initial patient visit and by telephone every 4 to 6 weeks thereafter.. A total of 402 patients (mean [SD] age, 72.3 [10.3] years [range, 34-94 years]; 224 men [55.7%], 178 women [44.3%]) were included. Follow-up was complete for all patients (mean follow-up, 19.0 [8.1] months [range, 1.0-31.0 months]). A total of 107 minor and 11 major bleeding events were reported. Hypoalbuminemia was a significant predictor of all bleeding in patients aged <75 years (adjusted odds ratio [AOR] = 2.60; 95% CI, 1.26-5.33; P = 0.01), while renal impairment was a significant predictor in patients aged > or = 75 years (AOR = 2.65; 95% CI, 1.71-6.49; P = 0.01). After stratification by bleeding type, renal impairment was a significant predictor of major bleeding in patients aged > or = 75 years (AOR = 2.93; 95% CI, 1.03-9.58; P = 0.001). Anemia was not associated with bleeding.. Hypoalbuminemia and renal impairment were identified as patient-related predictive factors for bleeding, whereas anemia did not appear to increase this risk.

Topics: Adult; Aged; Aged, 80 and over; Anemia; Anticoagulants; Atrial Fibrillation; Controlled Clinical Trials as Topic; Female; Follow-Up Studies; Hemorrhage; Humans; Hypoalbuminemia; Male; Middle Aged; Renal Insufficiency; Risk Factors; Warfarin

Evidence regarding the use of dual antiplatelet therapy and oral anticoagulation (i.e., triple therapy) in acute coronary syndromes (ACS) is limited. We evaluated the characteristics associated with the choice of triple therapy in ACS. Using the Get With The Guidelines (GWTG) Coronary Artery Disease national registry, we studied patients with ACS at 361 sites in the United States from 2004 to 2007. Both univariate analysis and multivariate logistic regression analysis were used to assess the factors associated using triple therapy on discharge. The Generalized Estimating Equation method was used to account for within-hospital clustering in modeling. A total of 86,304 patients presented with ACS during the study period. At discharge, 3,933 patients (4.6%) were prescribed triple therapy, 60,716 patients (70.4%) received dual antiplatelet therapy, 2,348 patients (2.7%) received single antiplatelet therapy plus oral anticoagulation, 19,065 patients (22.1%) received antiplatelet monotherapy, and 242 patients (0.3%) received oral anticoagulation alone. Patients with a history of atrial fibrillation (odds ratio 7.01, 95% confidence interval 6.06 to 8.12; p <0.001), documented new-onset atrial fibrillation (odds ratio 3.76, 95% confidence interval 2.87 to 4.93; p <0.001), or history of atrial flutter (odds ratio 3.38, 95% confidence interval 2.15 to 5.32; p <0.001) were more frequently discharged with triple therapy. In conclusion, for patients with ACS, atrial fibrillation and atrial flutter were most strongly associated with the use of triple therapy; however, this therapy was used less often than dual or single antiplatelet therapy.

Topics: Acute Coronary Syndrome; Aged; Anemia; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Atrial Fibrillation; Atrial Flutter; Clopidogrel; Diabetes Mellitus; Drug Therapy, Combination; Drug Utilization; Female; Humans; Logistic Models; Male; Middle Aged; Patient Discharge; Platelet Aggregation Inhibitors; Registries; Smoking; Stents; Stroke; Stroke Volume; Ticlopidine; United States; Warfarin

Topics: Aged; Anemia; Anticoagulants; Diagnosis, Differential; Erythropoietin; Granulomatosis with Polyangiitis; Humans; Leg Ulcer; Male; Recombinant Proteins; Renal Insufficiency; Thrombosis; Treatment Outcome; Warfarin

Topics: Aged; Anemia; Anticoagulants; Antifungal Agents; Atrial Fibrillation; Drug Interactions; Ecchymosis; Female; Hemorrhage; Humans; Hypothyroidism; Melena; Miconazole; Stomatitis; Thyroxine; Warfarin

Topics: Anemia; Anticoagulants; Dalteparin; Delivery, Obstetric; Dextrans; Enoxaparin; Female; Hemorrhage; Humans; Length of Stay; Pregnancy; Pregnancy Complications, Hematologic; Puerperal Disorders; Sweden; Thrombophilia; Thrombosis; Uterine Hemorrhage; Warfarin

A 30-year-old woman with primary antiphospholipid syndrome (PAPS) presented with cerebral ischemia, thrombocytopenia, anemia and proteinuria. Administration of warfarin potassium, without concomitant corticosteroid administration, significantly improved all of these symptoms along with a decrease in the titers of antiCL-beta2-GP-I antibodies and a shortening of prolonged APTT. Therefore, the antiphospholipid antibodies in this patient could have been evoked by vitamin-K-dependent coagulation factors or plasma proteins which are assumed to undergo conformational changes exposing cryptic epitopes. This case report provides clues to the mechanisms underlying the production of antiphospholipid antibodies in patients with PAPS.

Topics: Adult; Anemia; Anticoagulants; Antiphospholipid Syndrome; beta 2-Glycoprotein I; Brain Ischemia; Cardiolipins; Female; Glycoproteins; Humans; Partial Thromboplastin Time; Proteinuria; Thrombocytopenia; Warfarin

Topics: Adult; Anemia; Dyspnea; Hemorrhage; Humans; Lung Diseases; Male; Pulmonary Alveoli; Warfarin

A young woman presented with a 2 year history of a severe bleeding disorder and marked deficiencies in all four vitamin-K-dependent factors. Metabolic studies with tracer doses of tritium-labelled vitamin K1 suggested that the patient might be taking an oral anticoagulant; and subsequently her plasma was found to contain a substance identical to phenindione in its spectrophotometric and chromatographic properties. The half-disappearance times of factors II, IX, X were measured after the administration of a concentrate of these factors and were found to conform with published figures. The concentrate controlled the patient's excessive bruising and prolonged skin and gingival bleeding. It would therefore seem that factor VII may not be essential in reversal of the bleeding disorder induced by anticoagulant overdose.

Topics: Adult; Anemia; Blood Coagulation Disorders; Blood Coagulation Factors; Blood Coagulation Tests; Chromatography, Gas; Chromatography, Thin Layer; Diabetes Complications; Female; Glucosephosphate Dehydrogenase; Hematemesis; Hematuria; Humans; Menorrhagia; Phenindione; Self Medication; Spectrum Analysis; Substance-Related Disorders; Vitamin K; Warfarin

Topics: Anemia; Hemorrhage; Humans; Oxymetholone; Warfarin

Topics: Anemia; Anemia, Sickle Cell; Humans; Warfarin