warfarin and Arrhythmias--Cardiac

Drugs are widely used and highly effective in the treatment of heart disease. Nevertheless, in some instances, even drugs effective in a population display lack of efficacy or adverse drug reactions in individual patients, often in an apparently unpredictable fashion. This review summarizes the genomic factors now known to influence variability in responses to widely used cardiovascular drugs such as clopidogrel, warfarin, heparin and statins. Genomic approaches being used to discover new pathways in common cardiovascular diseases and thus potential new targets for drug development are described. Finally, the way in which this new information is likely to be used in an electronic medical record environment is discussed.

Topics: Arrhythmias, Cardiac; Cardiovascular Agents; Clopidogrel; Genetic Variation; Genomics; Hematologic Agents; Heparin; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Pharmacogenetics; Ticlopidine; Warfarin

The incidence of cardiac arrhythmias is estimated et 1.2 per 1000 pregnancies, usually in the third trimester and 50% of them are asymptomatic. They may appear for the first time in pregnancy or have a recurring character An important risk factor related to their appearance is the presence of structural heart disease, which complicates < 1% of pregnancies. Generally the symptoms are mild and the treatment is not necessary but in some cases pharmacotherapy is necessary Pharmacotherapy must be a compromise between the potentially adverse effects of drugs on the fetus and the beneficial effects on the cardiovascular system of the mother. Due to the development of cardiac surgery many women with heart defects reach reproductive age and become pregnant. Therefore this problem will be faced more and more often in clinical practice. In addition to pharmacological methods some cardiac arrhythmias may require urgent, life-saving procedures. External electrical cardioversion is associated with the application of certain amount of energy via two electrodes placed on the thorax. It is used to treat hemodynamically unstable supraventricular tachycardias, including atrial fibrillation and atrial flutter Also in hemodynamically stable patients in whom drug therapy was ineffective elective electrical cardioversion can be use to convert cardiac arrhythmia to sinus rhythm. We present a case of a 33 years old patient with congenital heart disease surgically corrected in childhood who had first incident of atrial flutter in pregnancy. Arrhytmia occured in 26th week of gestation. The patient was hemodynamically stable and did not approve electrical cardioversion as a method of treatment therefore pharmacotherapy was started. Heart rate was controled with metoprolol and digoxin, warfarin was used to anticoagulation. Calcium and potassium were also given. Described therapy did not convert atrial flutter to sinus rhythm therefore in 33rd week of gestation after patient's approval electrical cardioversion was performed. Before cardioversion transesophageal echocardiogram was made to exclude the presence of thrombus inside atria. Energy of 50J was applied and sinus rhythm was restored. Cardiotocography during and after cardioversion did not show any significant fetal heart rate changes. Further pregnancy and puerperium were uneventful. Case report and review of the literature about cardiac arrhytmias and methods of its treatment especially in pregnant women. Analysis of medical do

Topics: Adult; Anti-Arrhythmia Agents; Anticoagulants; Arrhythmias, Cardiac; Digoxin; Electric Countershock; Female; Heart Rate, Fetal; Humans; Metoprolol; Pregnancy; Pregnancy Complications, Cardiovascular; Thromboembolism; Warfarin

Heart failure (HF) patients show high morbidity and mortality rate with increased risk of malignant arrhythmia and thromboembolism. Anticoagulation reduces embolic event and death rates in HF patients with atrial fibrillation, but if antithrombotic therapy is beneficial in patients with HF in sinus rhythm is still debated.. We conducted a systematic review of prospective, randomized controlled trials (RCTs) to assess the efficacy and safety of oral anticoagulant therapies (OATs) compared to antiplatelet treatment in HF patients in sinus rhythm. MEDLINE, Web of Science, CENTRAL and Scopus databases were searched up to May 2012. Four RCTs were identified and a total of 3663 patients were included in the meta-analysis. Patients with both ischemic and non-ischemic HF were included. There was no significant difference in mortality (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.86 to 1.19) between OATs group and antiplatelet drug group. OATs have reduced ischemic stroke risk (OR 0.49, 95% CI 0.32 to 0.74), but have increased major bleeding risk (OR 2.01, 95% CI 1.40 to 2.88) compared to antiplatelet treatment.. In HF patients in sinus rhythm OATs do not show a better risk-benefit profile compared to antiplatelet treatment in cardioembolism prevention. Warfarin and aspirin seem to be similar in reducing mortality. Warfarin reduces the incidence of ischemic stroke, but increases major bleedings. Thus, it is possible to speculate that aspirin prescription be indicated in patients with high risk of bleeding, whereas warfarin could be preferred in patients with high thromboembolic risk.

Topics: Administration, Oral; Anticoagulants; Arrhythmias, Cardiac; Aspirin; Fibrinolytic Agents; Heart Failure; Humans; Odds Ratio; Platelet Aggregation Inhibitors; Prospective Studies; Randomized Controlled Trials as Topic; Risk Factors; Thromboembolism; Warfarin

Optimal management of perioperative anticoagulation in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation is not yet established. We performed a meta-analysis of the published literature to assess the safety and efficacy of perioperative heparin-based bridging therapy versus uninterrupted warfarin therapy in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation. We performed a systematic review of MEDLINE (1950 to 2012), EMBASE (1988 to 2012), Cochrane Controlled Trials Register (fourth quarter 2011), and reports presented at scientific meetings (1994 to 2011). Randomized controlled trials, case-control, or cohort studies comparing the safety and efficacy of uninterrupted warfarin therapy to heparin-based bridging therapy were eligible. Outcomes reported in eligible studies were rates of bleeding and thromboembolic events. Of 3,195 reports initially reviewed, we identified 8 studies enrolling 2,321 patients for the meta-analysis. Maintenance of therapeutic warfarin was associated with significantly lower bleeding postoperatively compared to heparin-based bridging therapy (odds ratio 0.30, 95% confidence interval 0.18 to 0.50, p <0.01). There was no significant difference in risk of thromboembolic events between these 2 strategies (odds ratio 0.65, 95% confidence interval 0.14 to 3.02, p = 0.58). In conclusion, strategy of uninterrupted warfarin therapy throughout pacemaker or implantable cardioverter-defibrillator implantation is associated with decreased risk of bleeding without increasing risk of thromboembolic events. This strategy is a viable alternative to heparin-based bridging therapy.

Topics: Anticoagulants; Arrhythmias, Cardiac; Defibrillators, Implantable; Dose-Response Relationship, Drug; Global Health; Heparin; Humans; Incidence; Odds Ratio; Pacemaker, Artificial; Prosthesis Implantation; Risk Factors; Thromboembolism; Warfarin

The article concerns the policy of anti-platelet treatment in patients with coronary heart disease exposed to transcutaneous coronary interventions. Patients with cardiac fibrillations are specially considered. International trials are reviewed.

Topics: Acute Coronary Syndrome; Anticoagulants; Arrhythmias, Cardiac; Contraindications; Coronary Angiography; Coronary Occlusion; Coronary Thrombosis; Disease Progression; Humans; Randomized Controlled Trials as Topic; Stents; Vitamin K; Warfarin

The majority of women with bioprosthetic valves do not require anticoagulation during pregnancy. In women with mechanical valves, a detailed discussion of the advantages and disadvantages of the three anticoagulant options (warfarin, unfractionated heparin and low molecular weight heparin) is indicated. The majority of women with arrhythmias during pregnancy have a benign increased rate of atrial or ventricular premature beats. Those women who are hemodynamically stable can be reassured and do not usually require treatment. Women with more ominous arrhythmias should be managed in collaboration with a cardiologist, usually using the same agents that would be chosen in the non-pregnant patient, including electrical cardioversion when necessary. This is the fifth and final article in a series reviewing in detail the assessment and management of specific cardiac disorders in pregnancy.

Topics: Anti-Arrhythmia Agents; Anticoagulants; Arrhythmias, Cardiac; Bioprosthesis; Electric Countershock; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heparin, Low-Molecular-Weight; Humans; Pregnancy; Pregnancy Complications, Cardiovascular; Treatment Outcome; Warfarin

Topics: Aged; Aged, 80 and over; Aging; Anticoagulants; Arrhythmias, Cardiac; Atrial Fibrillation; Female; Humans; Incidence; Japan; Male; Middle Aged; Prevalence; Ventricular Premature Complexes; Warfarin

Many patients with cardiac arrhythmias require concomitant therapy with warfarin and amiodarone. Beyond the predictable pharmacokinetic drug-drug interaction requiring a significant warfarin dose reduction, the iodine-rich amiodarone affects the thyroid gland, causing overt hypothyroidism or thyrotoxicosis in 14%-18% of cases. In turn, thyroid disorders may affect warfarin sensitivity, with hypothyroidism and thyrotoxicosis resulting in increased or decreased warfarin requirements, respectively. We describe 3 patients on concomitant amiodarone and warfarin who developed amiodarone-induced thyrotoxicosis heralded by a significant decrease in warfarin requirements. We review the literature on the mechanisms of the complex drug-drug and drug-disease interactions within the thyroid gland, warfarin, and amiodarone triad. Given that significant thyroid disorders may be only mildly symptomatic and thus may escape clinical detection, we suggest that thyroid function should be tested in any patient with otherwise unexplained changes in warfarin dose requirements, particularly if concomitantly treated with amiodarone.

Topics: Adult; Amiodarone; Anti-Arrhythmia Agents; Anticoagulants; Arrhythmias, Cardiac; Drug Interactions; Female; Humans; Male; Middle Aged; Risk Factors; Thyroid Gland; Thyrotoxicosis; Warfarin

Moricizine is well absorbed after oral administration and undergoes extensive first-pass metabolism. The drug has a large apparent volume of distribution (approximately 4 liters/kg), exhibits extensive plasma protein binding (approximately 95%) and produces at least 30 metabolites. Indirect evidence indicates that some of those metabolites may be pharmacologically active. The elimination half-life of moricizine is 2 to 6 hours, but its duration of antiarrhythmic action is much longer suggesting active metabolites. Moricizine induces its own metabolism with no change in pharmacologic effect. It also induces the metabolism of theophylline and specific pathways of antipyrine. Cimetidine reduces metabolism of moricizine but does not alter its pharmacologic effects. This observation provides further support for the hypothesis that the metabolites of moricizine contribute to the pharmacologic actions during therapy and indicate that plasma level monitoring is not likely to be of value. There are no known clinically significant pharmacokinetic interactions between moricizine and digoxin, warfarin or propranolol. Excessive prolongation of the PR interval has been seen in some patients receiving both digoxin and moricizine, probably due to additive electrophysiologic effects of the 2 drugs.

Topics: Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Cimetidine; Clinical Trials as Topic; Digoxin; Drug Interactions; Humans; Moricizine; Phenothiazines; Propranolol; Theophylline; Warfarin

Topics: Angina Pectoris; Anticoagulants; Arrhythmias, Cardiac; Blood Coagulation; Blood Platelets; Clinical Trials as Topic; Coronary Disease; Drug Interactions; Drug Therapy, Combination; Female; Fibrinolytic Agents; Heparin; Humans; Male; Myocardial Infarction; Time Factors; Warfarin

Topics: Age Factors; Anticoagulants; Arrhythmias, Cardiac; Coumarins; Female; Heart Failure; Humans; Male; Middle Aged; Myocardial Infarction; Phenindione; Prothrombin Time; Shock; Time Factors; Warfarin

Anti-platelet therapy is commonly used in patients receiving oral anticoagulation and may increase bleeding risk among patients undergoing cardiac implantable electronic device (CIED) surgery. We sought to determine the proportion of anticoagulated patients who are concomitantly receiving anti-platelet therapy, the associated risk of clinically significant hematoma (CSH), and the proportion of patients in whom anti-platelet usage is guideline-indicated.. A secondary analysis of the Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial (BRUISE CONTROL). Patients who were receiving warfarin, had an annual predicted risk of thromboembolism of ≥5% and were scheduled to undergo non-emergent CIED surgery were randomized to continued warfarin versus heparin bridging. In the current analysis, patients were divided into those receiving anti-platelet therapy and those not receiving anti-platelet therapy. The incidence of CSH was compared in both groups. The proportion of patients on potentially inappropriate and potentially interruptible antiplatelet therapy was estimated.. All 681 patients enrolled in BRUISE CONTROL were included, of whom 280 received and 401 did not receive anti-platelet therapy. Anti-platelet therapy increased the risk of CSH (relative risk, 1.72; 95% confidence interval (CI), 1.09 to 2.72; P = 0.02). Of the 280 patients receiving anti-platelet therapy, 97 (34.6%) had no guideline indication for concomitant anti-platelet therapy and an additional 146 (52.1%) were on anti-platelet therapy that could potentially have been interrupted around CIED surgery.. Concomitant anti-platelet therapy in patients receiving anticoagulation is associated with a significant risk of CSH. The majority of concomitant anti-platelet therapy is potentially inappropriate or interruptible.. clinicaltrials.gov Identifier: (NCT00800137).

Topics: Administration, Oral; Anticoagulants; Arrhythmias, Cardiac; Aspirin; Canada; Defibrillators, Implantable; Drug Therapy, Combination; Follow-Up Studies; Hematoma; Incidence; Pacemaker, Artificial; Platelet Aggregation Inhibitors; Retrospective Studies; Risk Factors; Single-Blind Method; Thromboembolism; Warfarin

Patients who require perioperative anticoagulation during cardiac implantable electronic device surgery are at increased risk for bleeding complications. The BRUISE CONTROL trial demonstrated that continuing warfarin was safer than heparin bridging, reducing the incidence of clinically significant pocket hematoma. Novel oral anticoagulants are being increasingly prescribed in place of warfarin. The best perioperative management of these new anticoagulants is unknown.. A randomized controlled trial to investigate whether a strategy of continued vs interrupted novel oral anticoagulant (dabigatran, rivaroxaban, or apixaban) at the time of device surgery, in patients with moderate to high risk of arterial thromboembolic events, reduces the incidence of clinically significant hematoma (defined as a hematoma requiring reoperation and/or resulting in prolongation of hospitalization, and/or requiring interruption of anticoagulation). The secondary outcomes include components of the primary outcome, composite of all other major perioperative bleeding events, thromboembolic events, all-cause mortality, cost-effectiveness, patient quality of life, perioperative pain, and satisfaction. Planned analyses include descriptive statistics of all baseline variables. For the primary outcome, interrupted vs continued novel oral anticoagulant arms will be compared using the χ(2) test. If any clinically significant differences are identified, a logistic regression analysis will be conducted. Quality of life will be assessed using EuroQol-5D, and perioperative pain using a visual analog scale.. BRUISE CONTROL-2 is a randomized trial evaluating the best strategy to manage novel oral anticoagulants at the time of device surgery. We hypothesize that device surgery can be performed safely without interruption of these medications.

Topics: Administration, Oral; Anticoagulants; Arrhythmias, Cardiac; Canada; Cause of Death; Dabigatran; Defibrillators, Implantable; Dose-Response Relationship, Drug; Hemorrhage; Humans; Incidence; Pacemaker, Artificial; Practice Guidelines as Topic; Preoperative Care; Prospective Studies; Pyrazoles; Pyridones; Rivaroxaban; Survival Rate; Thromboembolism; Warfarin

Management of oral anticoagulation in patients undergoing pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) implantation remains controversial. Prior studies demonstrate that continuation of warfarin may be safer when compared with strategies requiring interruption and/or heparin bridging. Limited data from randomized trials exist.. We conducted a randomized trial to determine whether warfarin continuation is superior to warfarin interruption during PPM or ICD implantation.. Patients on oral anticoagulation referred for PPM or ICD implantation were randomized to warfarin continuation versus interruption. Patients randomized to warfarin interruption were further stratified into two groups based on their risk for thromboembolic events in the absence of warfarin. Moderate-risk patients were randomized to warfarin continuation versus warfarin interruption. High-risk patients were randomized to warfarin continuation versus warfarin interruption with heparin bridging. The primary combined outcome included thromboembolic events, anticoagulant-related complications, or any significant bleeding necessitating additional intervention or discontinuation of anticoagulation.. We studied 100 patients (average age 70.8 years, 21% female, mean body mass index 28.4) who underwent 64 ICD and 36 PPM implantations. Fifty patients were assigned to continue warfarin. The randomized groups were well matched. Among patients randomized to warfarin interruption, there were two pocket hematomas, one pericardial effusion, one transient ischemic attack, and one patient who developed heparin-induced thrombocytopenia. No events were noted among patients continuing warfarin (P = .056).. While the results were not statistically significant, there was a trend toward reduced complications in patients randomized to warfarin continuation. This strategy should be considered in patients undergoing PPM or ICD implantation.

Topics: Aged; Anticoagulants; Arrhythmias, Cardiac; Defibrillators, Implantable; Dose-Response Relationship, Drug; Female; Follow-Up Studies; Humans; Intraoperative Care; Male; Pacemaker, Artificial; Postoperative Complications; Prospective Studies; Prosthesis Implantation; Stroke; Treatment Outcome; Warfarin

Implantable cardioverter defibrillator (ICD) therapy with backup ventricular pacing increases survival in patients with life-threatening ventricular arrhythmias. Most currently implanted ICD devices provide dual-chamber pacing therapy. The most common comorbid cause for mortality in this population is congestive heart failure.. To determine the efficacy of dual-chamber pacing compared with backup ventricular pacing in patients with standard indications for ICD implantation but without indications for antibradycardia pacing.. The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial, a single-blind, parallel-group, randomized clinical trial.. A total of 506 patients with indications for ICD therapy were enrolled between October 2000 and September 2002 at 37 US centers. All patients had a left ventricular ejection fraction (LVEF) of 40% or less, no indication for antibradycardia pacemaker therapy, and no persistent atrial arrhythmias.. All patients had an ICD with dual-chamber, rate-responsive pacing capability implanted. Patients were randomly assigned to have the ICDs programmed to ventricular backup pacing at 40/min (VVI-40; n = 256) or dual-chamber rate-responsive pacing at 70/min (DDDR-70; n = 250). Maximal tolerated medical therapy for left ventricular dysfunction, including angiotensin-converting enzyme inhibitors and beta-blockers, was prescribed to all patients.. Composite end point of time to death or first hospitalization for congestive heart failure.. One-year survival free of the composite end point was 83.9% for patients treated with VVI-40 compared with 73.3% for patients treated with DDDR-70 (relative hazard, 1.61; 95% confidence interval [CI], 1.06-2.44). The components of the composite end point, mortality of 6.5% for VVI-40 vs 10.1% for DDDR-70 (relative hazard, 1.61; 95% CI, 0.84-3.09) and hospitalization for congestive heart failure of 13.3% for VVI-40 vs 22.6% for DDDR-70 (relative hazard, 1.54; 95% CI, 0.97-2.46), also trended in favor of VVI-40 programming.. For patients with standard indications for ICD therapy, no indication for cardiac pacing, and an LVEF of 40% or less, dual-chamber pacing offers no clinical advantage over ventricular backup pacing and may be detrimental by increasing the combined end point of death or hospitalization for heart failure.

Topics: Adrenergic beta-Antagonists; Aged; Amiodarone; Angiotensin-Converting Enzyme Inhibitors; Anti-Arrhythmia Agents; Anticoagulants; Arrhythmias, Cardiac; Cardiac Pacing, Artificial; Cardiovascular Agents; Catheter Ablation; Defibrillators, Implantable; Digoxin; Diuretics; Female; Heart Failure; Humans; Male; Middle Aged; Pacemaker, Artificial; Single-Blind Method; Survival Analysis; Tachycardia, Ventricular; Ventricular Dysfunction, Left; Warfarin

Moricizine is well absorbed after oral administration and undergoes extensive first-pass metabolism. The drug has a large apparent volume of distribution (approximately 4 liters/kg), exhibits extensive plasma protein binding (approximately 95%) and produces at least 30 metabolites. Indirect evidence indicates that some of those metabolites may be pharmacologically active. The elimination half-life of moricizine is 2 to 6 hours, but its duration of antiarrhythmic action is much longer suggesting active metabolites. Moricizine induces its own metabolism with no change in pharmacologic effect. It also induces the metabolism of theophylline and specific pathways of antipyrine. Cimetidine reduces metabolism of moricizine but does not alter its pharmacologic effects. This observation provides further support for the hypothesis that the metabolites of moricizine contribute to the pharmacologic actions during therapy and indicate that plasma level monitoring is not likely to be of value. There are no known clinically significant pharmacokinetic interactions between moricizine and digoxin, warfarin or propranolol. Excessive prolongation of the PR interval has been seen in some patients receiving both digoxin and moricizine, probably due to additive electrophysiologic effects of the 2 drugs.

Topics: Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Cimetidine; Clinical Trials as Topic; Digoxin; Drug Interactions; Humans; Moricizine; Phenothiazines; Propranolol; Theophylline; Warfarin

In a prospective trial, 99 patients with a history of AMI of less than 12 hours were allocated at random to treatment with subcutaneous heparin, 5 000 IU twice daily, (51 patients) or warfarin (48 patients). In a subsample of 21 patients, 11 in the warfarin group and 10 in the heparin group, fasting FFA analyses were performed before and 2 hours after administration of anticoagulants on days 1 and 2. No measurable increase in FFA concentrations was demonstrated in the heparin-treated patients, in spite of a significant influence on the thrombin clotting time. The frequency of ventricular arrhythmias as detected by continuous tape recordings was equal in the two groups. It is concluded that subcutaneous heparin, 5 000 IU every 12 hours, can be administered to patients with AMI without increasing the risk of arrhythmias as compared with warfarin.

Topics: Aged; Arrhythmias, Cardiac; Fatty Acids, Nonesterified; Female; Heparin; Humans; Myocardial Infarction; Prospective Studies; Warfarin

Topics: Angina Pectoris; Anticoagulants; Arrhythmias, Cardiac; Blood Coagulation; Blood Platelets; Clinical Trials as Topic; Coronary Disease; Drug Interactions; Drug Therapy, Combination; Female; Fibrinolytic Agents; Heparin; Humans; Male; Myocardial Infarction; Time Factors; Warfarin

Topics: Acute Disease; Adult; Aged; Anticoagulants; Arrhythmias, Cardiac; Clinical Trials as Topic; Electrocardiography; Female; Heart Block; Heart Failure; Hemorrhage; Heparin; Humans; Male; Middle Aged; Myocardial Infarction; Placebos; Prothrombin Time; Pulmonary Embolism; Sampling Studies; Sodium; Thrombosis; Warfarin

Topics: Aged; Arrhythmias, Cardiac; Blood Loss, Surgical; Hip Fractures; Humans; Male; Perioperative Care; Risk Factors; Venous Thromboembolism; Warfarin

The concurrence of atrial fibrillation and acute coronary syndrome poses a conundrum in the antithrombotic management as intensification of anticoagulation or antiplatelet therapy inevitably comes at the price of an increased bleeding risk. Various antithrombotic combinations have been attempted to prevent the recurrent cardiovascular events, however, there has been limited success in effective risk reduction for this high risk population. Given the overarching effect of interleukin 1β-driven inflammation on the arrhythmogenesis, thrombogenesis, and hypercoagulability, we hypothesize that the triple-pathway strategy (i.e., incorporating antiinflammatory therapy into anticoagulant and antiplatelet therapy) would grant incremental cardiovascular benefits for atrial fibrillation patients with coexisting acute coronary syndrome and stent placement.

Topics: Acute Coronary Syndrome; Anti-Inflammatory Agents; Anticoagulants; Arrhythmias, Cardiac; Aspirin; Atrial Fibrillation; Cardiovascular System; Comorbidity; Drug Therapy, Combination; Fibrinolytic Agents; Hemorrhage; Humans; Interleukin-1beta; Models, Theoretical; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Stents; Stroke; Warfarin

Uninterrupted anticoagulation is important for patients at high risk for thromboembolism. Bridging with heparin/enoxaparin increases the risk of hematoma and infection. There are no published data on the feasibility of transvenous lead extraction (TLE) during uninterrupted anticoagulation.. The purpose of this study was to examine the feasibility and safety of TLE during uninterrupted warfarin therapy with therapeutic international normalized ratio (INR).. We performed a retrospective study of patients undergoing TLE while receiving uninterrupted warfarin therapy with INR ≥2.0 at a high-volume center.. Between March 2011 and December 2016, 1212 patients underwent TLE. Of these patients, 62 underwent TLE during uninterrupted warfarin therapy with therapeutic INR (mean 2.5 ± 0.5; range 2.0-4.5). The cohort was 85% male, mean age 65 years, CHA. TLE during uninterrupted warfarin therapy with therapeutic INR may be considered in patients at high risk for thromboembolism if performed by experienced operators at high-volume centers.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Arrhythmias, Cardiac; Defibrillators, Implantable; Device Removal; Feasibility Studies; Female; Follow-Up Studies; Humans; Male; Middle Aged; Retrospective Studies; Risk Factors; Thromboembolism; Treatment Outcome; Warfarin

Objective In modern cardiology practice, implantation of cardiac electronic devices in patients taking anticoagulant or antiplatelet therapy is a common clinical scenario. Bleeding complications are of particular concern in this patient population and pocket haematoma is one of the most frequent complications. We sought to determine the relationship between periprocedural antiplatelet/anticoagulant therapy and pocket haematoma formation in patients undergoing cardiac implantable electronic device (CIED) implantation. Methods We conducted a retrospective study including 232 consecutive patients undergoing CIED implantation in the department of cardiology of the Medipol University Hospital. Patients were divided into six groups: clopidogrel group (n = 12), acetylsalicylic acid (ASA) group (n = 73), ASA + clopidogrel group (n = 29), warfarin group (n = 34), warfarin + ASA group (n = 21) and no antiplatelet-anticoagulant therapy group as the control group (n = 63). CIED implantations were stratified under four subtitles including implantable cardioverter/defibrillator (ICD), cardiac resynchronization therapy (CRT), permanent pacemaker and the last group as either device upgrade or generator replacement. Results The mean age of the patients was 63 ± 14 years and 140 patients were male (60.3%). A pocket haematoma was documented in 6 of 232 patients (2.6%). None of the patients with pocket haematoma needed pocket exploration or blood transfusion. The type of the device did not have a significant effect on pocket haematoma incidence (P = 0.250). Univariate logistic regression showed that platelet level and ASA plus clopidogrel use were significantly associated with haematoma frequency after CIED implantations, respectively (OR: 0.977, CI 95% [0.958-0.996]; OR: 16.080, CI 95% [2.801-92.306]). Multivariate analysis revealed that dual antiplatelet treatment (β = 3.016, P = 0.002, OR: 2.410, 95% CI [3.042-136.943]) and baseline platelet level (β = -0.027, p:0.025, OR: 0.974, 95% CI [0.951-0.997]) were independent risk factors for pocket haematoma formation. Conclusion Dual antiplatelet therapy and low platelet levels significantly increased the risk of pocket haematoma formation in patients undergoing CIED implantations.

Topics: Anticoagulants; Arrhythmias, Cardiac; Aspirin; Defibrillators, Implantable; Drug Therapy, Combination; Female; Hematoma; Humans; Male; Middle Aged; Pacemaker, Artificial; Platelet Aggregation Inhibitors; Retrospective Studies; Risk Factors; Warfarin

Calumenin, a molecular chaperone, exerts a regulatory effect on the vitamin K-dependent γ-carboxylation redox cycle that inhibits transfer of the reduced vitamin K from VKORC1, the pharmacological target of warfarin, to the γ-carboxylase. Because of its polymorphic structure and central role in the warfarin metabolic pathway, a contributory role for calumenin to warfarin dose variability has been posited. The current study sought to validate modulation of therapeutic dosing requirements by a single nucleotide polymorphisms (SNP) occurring in the calumenin gene (CALU) reported in previous studies. The CALU SNP was further modeled to detect interaction with SNPs occurring in VKORC1, CYP2C9, and CYP4F2 genes and characterize any additional contribution to variability in therapeutic warfarin dose requirement.. The study was undertaken in an established, well-characterized cohort of subjects treated with warfarin in the Anticoagulation Clinic of Marshfield Clinic in Marshfield, Wisconsin.. Subjects (N=491) previously genotyped for SNPS known to contribute variability to therapeutic warfarin dose requirement were genotyped for CALU SNP rs1043550, using TaqMan assays. Contribution of CALU SNP rs1043550 was modeled relative to other genotypic and phenotypic characteristics including gender, diagnosis, age, body surface area, underlying indication for warfarin, comorbidities, and pharmacological exposures. Interaction between SNPs impacting on warfarin dose requirements and calumenin SNPs was also modeled.. Small differences in warfarin dosing requirements detected among individuals encoding the mutant G allele in the calumenin SNP were not statistically or clinically significant relative to therapeutic warfarin dose requirement and did not independently contribute significantly to the warfarin dosing model. Interaction between calumenin and VKORC1 SNPs contributed only minor additional variability to that ascribed to the wild type VKORC1 genotype.. The impact of the CALU SNP on warfarin dose variability was minor and did not contribute significantly to therapeutic warfarin dose requirement in our study cohort. While no contribution was noted for the SNP examined in the present study, further examination of interaction between genetic elements contributing major impact on therapeutic warfarin dose requirements and genes exhibiting a lesser contribution is warranted.

Topics: Alleles; Anticoagulants; Arrhythmias, Cardiac; Calcium-Binding Proteins; Cohort Studies; Dose-Response Relationship, Drug; Female; Genotype; Heart Valve Diseases; Humans; Male; Models, Genetic; Pharmacogenetics; Polymorphism, Single Nucleotide; Thromboembolism; Treatment Outcome; Warfarin

To evaluate the impact of stopping anticoagulant medications prior to transurethral resection of the prostate on peri-operative cardiovascular complications.. Retrospective series (305 patients) undergoing TURP at a tertiary hospital between 2006 and 2010. All men were evaluated in preadmission clinics with defined protocols, with a low threshold for cardiovascular investigation. Incidence of postoperative bleeding and cardiovascular and cerebrovascular events was determined for 3 patient cohorts: group A--where anticoagulants were ceased preoperatively; group B--who were not receiving any anticoagulants; and group C--who underwent TURP while taking aspirin.. Of 305 patients, 194 (64%) did not receive anticoagulation therapy, 108 (35%) stopped receiving anticoagulation therapy pre-TURP, and 3 (0.98%) underwent TURP while taking aspirin. Anticoagulants used were aspirin (22.6%), warfarin (4.9%), antiplatelets (4.9%), and combination treatments (3.9%). Incidence of postoperative hemorrhage (early and delayed) was not significant (P = .69) between group A (10/108) and group B (7/194). Transfusion rate was 0.6% (2/305). Overall incidence of cardiovascular events was 0.98% (group A, n = 1 vs group B, n = 2), and incidence of deep vein thrombosis (0.32%; group A, n = 0 vs group B, n = 1) was not statistically significant (P = .30 and P = .37, respectively). Overall incidence of cerebrovascular events (0.65%; group A, n = 1 vs group B, n = 1) was not significant (P = 1.00). There were no deaths.. Men who have discontinue anticoagulation therapy before TURP do not appear to have a higher incidence of cardiovascular or cerebrovascular events, or bleeding-associated morbidity. It is possible that the morbidity attributed to discontinuing anticoagulation in this population may be overemphasized. Larger prospective studies are needed to better evaluate this clinical problem.

Topics: Aged; Angina Pectoris; Anticoagulants; Arrhythmias, Cardiac; Aspirin; Blood Transfusion; Humans; Ischemic Attack, Transient; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Preoperative Care; Prostatectomy; Retrospective Studies; Stroke; Venous Thrombosis; Warfarin

Characteristics of the amiodarone-warfarin interaction during long-term follow-up were studied.. Medical records from patients seen in the anticoagulation clinic at the Hennepin County Medical Center between April 1998 and March 2003 were retrospectively reviewed. Patients were included if they were older than 18 years, used the anticoagulation clinic as their primary clinic for anticoagulation therapy, and were receiving combined amiodarone and warfarin therapy for at least one month. The primary study endpoint was the occurrence of International Normalized Ratios (INRs) of >5 at any time during combined warfarin-amiodarone therapy. The secondary endpoint was the frequency of warfarin dosage changes.. A total of 70 patients met study inclusion criteria. Of these 70, 7 had amiodarone started before warfarin initiation. Of the 2434 INR values analyzed, 43% (n = 1043) were in the target therapeutic range, 34% (n = 820) were below target range, and 23% (n = 571) were above target range. A total of 102 INR values (4%) were above 5. The relative risk of having an INR of >5 for patients on concurrent warfarin and amiodarone versus those on warfarin alone was 1.366 (p = 0.005). INRs of >5 were most common during the first 12 weeks of combined therapy, with no subsequent large peaks evident.. Among patients treated in an anticoagulation clinic, INR values of >5 were most common during the first 12 weeks of combined therapy with amiodarone and warfarin and necessitated reduction in warfarin dosage. No other notable changes in INR or amiodarone or warfarin dosage occurred throughout the remainder of the 80-week study period.

Topics: Adult; Aged; Amiodarone; Anti-Arrhythmia Agents; Anticoagulants; Arrhythmias, Cardiac; Dose-Response Relationship, Drug; Drug Interactions; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Male; Middle Aged; Retrospective Studies; Warfarin

Topics: Adult; Anticoagulants; Arrhythmias, Cardiac; Aspirin; Fontan Procedure; Heart Diseases; Humans; Postoperative Care; Risk Factors; Thromboembolism; Warfarin

Topics: Anticoagulants; Arrhythmias, Cardiac; Atrial Fibrillation; Cerebrovascular Disorders; Heart Diseases; Humans; Risk; Thrombolytic Therapy; Thrombosis; Warfarin

Topics: Aortic Valve; Arrhythmias, Cardiac; Aspirin; Digitalis; Echocardiography; Electrocardiography, Ambulatory; Heart Valve Diseases; Hemodynamics; Mitral Valve; Plants, Medicinal; Plants, Toxic; Warfarin

Topics: Aged; Aged, 80 and over; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Cardiac Pacing, Artificial; Cerebral Infarction; Coronary Disease; Electrocardiography, Ambulatory; Humans; Hyperkalemia; Hypertension; Middle Aged; Warfarin

To assess the incidence of adverse effects associated with long-term amiodarone therapy, we reviewed the records of 217 consecutive patients who were treated for refractory arrhythmia. After an average of 11.8 months of therapy, one or more side effects occurred in 113 patients (52%). These were considered clinically significant in 42 patients (19.3%), mandating discontinuation of amiodarone in 18 (8.3%). The untoward reactions requiring discontinuation of amiodarone included thyroid dysfunction, visual disturbances, pulmonary infiltrates, ataxia, cardiac conduction abnormalities, and drug interactions. The mild side effects included corneal microdeposits, skin rashes, and gastrointestinal symptoms. There was a weak correlation between blood levels of amiodarone, the daily dose, and the cumulative dose (r = 0.23, p = 0.015). Drug levels were higher in symptomatic patients (p less than 0.03), although they received lower doses of amiodarone. While amiodarone is associated with frequent side effects, they are generally mild and do not necessitate drug discontinuation. Careful monitoring of therapy is essential to detect the potentially serious adverse reactions which are encountered in nearly 20% of patients.

Topics: Amiodarone; Arrhythmias, Cardiac; Ataxia; Benzofurans; Drug Eruptions; Drug Interactions; Female; Gastrointestinal Diseases; Humans; Male; Middle Aged; Respiratory Tract Diseases; Thyroid Diseases; Time Factors; Vision Disorders; Warfarin

Topics: Amiodarone; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Benzofurans; Blood Coagulation Disorders; Dose-Response Relationship, Drug; Drug Interactions; Heart Atria; Heart Ventricles; Humans; Tachycardia; Warfarin

The clinical efficacy of amiodarone in the management of complex cardiac arrhythmias refractory to therapy with two or more conventional or other investigational antiarrhythmic agents was determined by long-term follow-up in patients who had received the drug for at least 3 months. A total of 181 patients, classified into four groups (group 1, supraventricular arrhythmias, n = 42; group 2, frequent ventricular premature complexes, n = 46; group 3, nonsustained ventricular tachycardia, n = 16; and group 4, sustained ventricular tachycardia, n = 77) received a daily maintenance dose of 200 to 800 mg amiodarone for up to 30 months. There was a total of 26 deaths (14%). Ten of these were probably attributable to arrhythmia, although all patients had either good or excellent response to therapy over a mean follow-up of 14.9 months prior to death. The drug had to be permanently discontinued because of side effects in only three patients, and in the majority of patients with side effects, symptoms could be alleviated with adjustment of dosage, thyroid replacement therapy, or temporary cessation of therapy. We conclude that amiodarone is highly effective in high-risk patients with complex refractory cardiac arrhythmias, and that close monitoring and prompt recognition of side effects and appropriate adjustment of dosage or institution of supplemental or replacement therapy (in less than 5% of patients) will allow continuation of amiodarone. The benefit of suppression of symptomatic arrhythmias and the potential of prevention of sudden death clearly outweigh the modest incidence of severe side effects.

Topics: Aged; Amiodarone; Arrhythmias, Cardiac; Benzofurans; Digoxin; Dose-Response Relationship, Drug; Drug Interactions; Drug Resistance; Female; Follow-Up Studies; Humans; Male; Middle Aged; Warfarin

The potentiation of the anticoagulant effect of sodium warfarin by amiodarone is reported in 10 patients. Amiodarone appears to augment the depression of vitamin K-dependent coagulation factors caused by warfarin by an uncertain mechanism, and may lead to serious bleeding. The maintenance dose of warfarin should be halved when amiodarone and warfarin are prescribed together.

Topics: Aged; Amiodarone; Arrhythmias, Cardiac; Benzofurans; Blood Coagulation; Blood Coagulation Factors; Drug Synergism; Female; Humans; Male; Middle Aged; Prothrombin Time; Vitamin K; Warfarin

Topics: Adult; Aged; Anti-Arrhythmia Agents; Aortic Valve; Arrhythmias, Cardiac; Death, Sudden; Female; Heart Valve Prosthesis; Heart Ventricles; Humans; Male; Middle Aged; Postoperative Complications; Stroke Volume; Tachycardia; Time Factors; Warfarin

Topics: Arrhythmias, Cardiac; Coronary Angiography; Coronary Disease; Embolism; Female; Heart Aneurysm; Hemodynamics; Humans; Male; Middle Aged; Myocardial Infarction; Warfarin

Topics: Arrhythmias, Cardiac; Blood Coagulation Tests; Humans; Prospective Studies; Prothrombin Time; Thromboembolism; Warfarin

Replacement of the mitral valve with the Björk-Shiley tilting disc valve prosthesis was performed in 203 consecutive patients with isolated mitral valvular disease at Karolinska Sjukhuset, Stockholm, Sweden, during the 6-year period ending December 1975. Results with the Delrin and pyrolytic carbon disc prostheses were analysed with actuarial techniques and compared in terms of mortality rate, incidence of thrombo-embolism and frequency of re-operation. Early (4%) and late mortality rates (7.5 deaths per 100 patient years) were similar with both types of prostheses. No case of primary mechanical prosthetic failure was encountered. The pyrolytic carbon disc prostheses have obviously decreased the incidence of systemic emboli from 9.6 to 5.3 per 100 patient years and so far eliminated mortality due to embolization. This benefit is probably related to the increased opening angle from 50 degrees to 60 degrees in the pyrolytic carbon disc model, which causes less resistance to blood flow. Thrombotic obstruction of the prosthetic valve, however, has been a persistent problem in the order of 3.3 incidences per 100 patient years. Only one patient in twelve involved was referred to our clinic and could be saved by an emergency re-operation. The development of the ring-shaped radiopaque marker in the tilting disc occluder provides a valuable tool for instant diagnosis of partly or completely obstructed disc motion caused by thrombosis. Disc motion can be easily visualized by cineradiography or fluoroscopy. Early diagnosis of and emergency operation for thrombotic obstruction of the prosthesis will reduce the mortality due to this dangerous complication.

Topics: Adolescent; Adult; Arrhythmias, Cardiac; Child; Dicumarol; Evaluation Studies as Topic; Female; Follow-Up Studies; Heart Failure; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Myocardial Infarction; Thromboembolism; Time Factors; Warfarin

Topics: Acute Disease; Aged; Arrhythmias, Cardiac; Bradycardia; Cardiac Complexes, Premature; Coronary Care Units; Electrocardiography; Female; Humans; Male; Middle Aged; Morphine; Myocardial Infarction; Oxygen Inhalation Therapy; Retrospective Studies; Shock, Cardiogenic; Tachycardia; Time Factors; Warfarin

Topics: Aged; Arrhythmias, Cardiac; Blood Transfusion; Coronary Disease; Diverticulum, Colon; Gastrointestinal Hemorrhage; Hematocrit; Humans; Hypertension; Intracranial Embolism and Thrombosis; Middle Aged; Prothrombin Time; Pulmonary Embolism; Thrombophlebitis; Vitamin K; Warfarin

Topics: Aged; Alcoholism; Allopurinol; Arrhythmias, Cardiac; Chloral Hydrate; Colchicine; Digoxin; Drug Synergism; Gastrointestinal Hemorrhage; Gout; Hospitals, Teaching; Humans; Liver Diseases; Male; Middle Aged; Nitroglycerin; Patient Care Team; Pharmacists; Pharmacy Service, Hospital; Quinidine; Warfarin; Washington

Topics: Acute Disease; Adult; Anticoagulants; Arrhythmias, Cardiac; Chronic Disease; Coronary Disease; Dicumarol; Female; Heart Failure; Humans; Male; Middle Aged; Myocardial Infarction; Prognosis; Prothrombin Time; Thrombelastography; Thrombosis; Warfarin

Topics: Anxiety; Arrhythmias, Cardiac; Barbiturates; Chloral Hydrate; Chlordiazepoxide; Diphenhydramine; Drug Combinations; Female; Hospitalization; Humans; Male; Medical Records; Meprobamate; Middle Aged; Myocardial Infarction; Phenothiazines; Warfarin

Topics: Adult; Aged; Angina Pectoris; Arrhythmias, Cardiac; Cholesterol; Cholestyramine Resin; Clofibrate; Diet; Female; Heart Failure; Humans; Hyperlipidemias; Hyperthyroidism; Male; Middle Aged; Myocardium; Oxygen Consumption; Pacemaker, Artificial; Propranolol; Warfarin

Topics: Adolescent; Adult; Aged; Anticoagulants; Arrhythmias, Cardiac; Child; Coumarins; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Prothrombin Time; Thromboembolism; Warfarin

Aortic valve replacement with the University of Cape Town lenticular prosthesis was performed in 149 patients during a six-year period, almost all patients being severely disabled with advanced heart disease. There was a hospital mortality of 12 per cent. Bacterial endocarditis was a serious complication and accounted for three hospital and five long-term deaths. The survivors were followed for periods of up to 72 months (average 24), the minimum period of observation being six months. There were 23 late deaths due to heart disease, of which 5 where due to myocardial failure. Myocardial failure unrelieved or only temporarily alleviated by the operation occurred in three surviving patients. The main problems have been sudden death and systemic embolism. Some of the cases of sudden death were due to coronary artery embolism, but in a number the cause could not be determined even at necropsy, and they were presumed to be due to arrhythmia. Both complications appeared to be related to valve design. A bare steel seat was associated with a high incidence of both complications, whereas a woven Dacron-velour cloth-covered seat almost eliminated embolism and reduced the incidence of sudden death. Long-term anticoagulant therapy appears to be of no real value with the cloth-covered valve. Gratifying results were obtained in the surviving patients with loss of all symptoms in 80 per cent and improvement in almost all patients. This improvement or relief of symptoms was maintained in most patients throughout the period of study.

Topics: Adolescent; Adult; Aged; Alloys; Anemia, Hemolytic; Angina Pectoris; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Arrhythmias, Cardiac; Cardiovascular Diseases; Child; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Phenindione; Polymers; Postoperative Complications; Thromboembolism; Warfarin

Topics: Anticoagulants; Arrhythmias, Cardiac; Coronary Disease; Geriatrics; Heart Diseases; Heart Failure; Humans; Thromboembolism; Warfarin

Topics: Aged; Aortic Valve; Aortic Valve Stenosis; Arrhythmias, Cardiac; Cardiac Catheterization; Cardiac Surgical Procedures; Digoxin; Endocarditis; Endocarditis, Bacterial; Heart Failure; Heart Valve Diseases; Heart Valve Prosthesis; Heart, Artificial; Humans; Isoproterenol; Methicillin; Middle Aged; Postoperative Complications; Psychoses, Substance-Induced; Psychotic Disorders; Thoracic Surgery; Warfarin

Topics: Anticoagulants; Arrhythmias, Cardiac; Blood Cell Count; Cerebrovascular Disorders; Coronary Disease; Diabetes Mellitus; Dicumarol; Heart Failure; Heparin; Humans; Hypertension; Kidney Diseases; Liver Diseases; Myocardial Infarction; Peptic Ulcer; Pulmonary Embolism; Shock; Thromboembolism; Thrombophlebitis; Thrombosis; Varicose Veins; Warfarin