warfarin and Chest-Pain

Coagulation panels are ordered for a variety of conditions in the emergency department (ED).. This narrative review evaluates specific conditions for which a coagulation panel is commonly ordered but has limited utility in medical decision-making.. Coagulation panels consist of partial thromboplastin time (PTT) or activated partial thromboplastin time (aPTT), prothrombin time (PT), and international normalized ratio (INR). These tests evaluate the coagulation pathway which leads to formation of a fibrin clot. The coagulation panel can monitor warfarin and heparin therapy, evaluate for vitamin K deficiency, evaluate for malnutrition or severe systemic disease, and assess hemostatic function in the setting of bleeding. The utility of coagulation testing in chest pain evaluation, routine perioperative assessment, prior to initiation of anticoagulation, and as screening for admitted patients is low, with little to no change in patient management based on results of these panels. Coagulation testing should be considered in systemically ill patients, those with a prior history of bleeding or family history of bleeding, patients on anticoagulation, or patients with active hemorrhage and signs of bleeding. Thromboelastography and rotational thromboelastometry offer more reliable measures of coagulation function.. Little utility for coagulation assessment is present for the evaluation of chest pain, routine perioperative assessment, initiation of anticoagulation, and screening for admitted patients. However, coagulation panel assessment should be considered in patients with hemorrhage, patients on anticoagulation, and personal history or family history of bleeding.

Topics: Anticoagulants; Blood Coagulation Tests; Chest Pain; Emergency Medicine; Emergency Service, Hospital; Heparin; Humans; International Normalized Ratio; Intraoperative Complications; Partial Thromboplastin Time; Prothrombin Time; Warfarin

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Aortic Valve; Aortic Valve Stenosis; Benzoates; Bicuspid Aortic Valve Disease; Bioprosthesis; Chest Pain; Craniotomy; Echocardiography; Echocardiography, Three-Dimensional; Echocardiography, Transesophageal; Enoxaparin; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hematoma, Subdural, Acute; Humans; Hydrazines; Immunologic Factors; Plasma Exchange; Purpura, Thrombocytopenic, Idiopathic; Pyrazoles; Recurrence; Rituximab; Stroke Volume; Thrombosis; Ventricular Dysfunction, Left; Warfarin

Topics: Anticoagulants; Antithrombins; Athletes; Baseball; Chest Pain; Computed Tomography Angiography; Dabigatran; Dyspnea; Female; Hemoptysis; Humans; Pulmonary Embolism; Warfarin; Young Adult

Topics: Anticoagulants; Chest Pain; Coronary Thrombosis; Electrocardiography; Heart Ventricles; Humans; Intestine, Small; Kidney; Male; Middle Aged; Splenic Infarction; Ventricular Function, Left; Warfarin

Topics: Adult; Anticoagulants; Cardiomyopathies; Chest Pain; Coronary Angiography; Coronary Occlusion; Drug-Eluting Stents; Dyspnea; Echocardiography; Electrocardiography; Heart Diseases; Heart Transplantation; Humans; Male; Myocardial Ischemia; ST Elevation Myocardial Infarction; Thrombosis; Ventricular Dysfunction, Left; Warfarin

Topics: Aged; Angiography; Anticoagulants; Aspirin; Chest Pain; Diagnosis, Differential; Dyspnea; Electrocardiography; Female; Heparin; Humans; Lower Extremity; Pulmonary Embolism; Tomography, X-Ray Computed; Ultrasonography; Venous Thrombosis; Warfarin

A 65-year-old Japanese man presented with acute myocardial infarction (AMI) and polycythemia. Biochemical studies of the patient's hemoglobin (Hb) and the sequencing of his globin genes revealed that the polycythemia was secondary to a high oxygen affinity Hb variant, Hb Fuchu-II. Hb variants with high oxygen affinity can be an additional thrombotic risk factor in older patients and/or those with other risk factors. The patient was diagnosed with hemoglobinopathy after the development of AMI and exemplifies the importance of recognizing such conditions and of taking appropriate prophylactic interventions.

Topics: Aged; Anticoagulants; Aspirin; Chest Pain; Coronary Angiography; Hemoglobins, Abnormal; Humans; Male; Myocardial Infarction; Oxygen; Platelet Aggregation Inhibitors; Polycythemia; Treatment Outcome; Warfarin

Topics: Aged, 80 and over; Amiodarone; Anti-Arrhythmia Agents; Chest Pain; Coronary Artery Disease; Drug-Eluting Stents; Fibrinolytic Agents; Heart Failure; Humans; Hypertension; Male; Platelet Aggregation Inhibitors; Renal Insufficiency, Chronic; Tachycardia, Ventricular; Treatment Outcome; Warfarin

The relative effectiveness of vitamin K antagonists compared with novel oral anticoagulants in treating pulmonary embolism remains unclear. Recent trials comparing the efficacy of vitamin K antagonists with factor Xa inhibitors for the treatment of pulmonary emboli have been non-inferiority studies based primarily on risk reduction (such as bleeding events), rather than resolution of specific diseases such as pulmonary embolism. Consequently, there is a lack of evidence indicating which of these agents are more effective. Here, we present a case where pulmonary emboli were treated with novel oral anticoagulants followed by warfarin to discuss the potential limitations in the use of novel oral anticoagulants as prevention or treatment of thromboembolism and the continued role for warfarin in this setting.. A 34-year-old African American woman presented to our clinic with shortness of breath and pleuritic chest pain several months post-surgery. She was identified as having multiple bilateral pulmonary embolisms and was treated with several novel oral anticoagulants, which failed to resolve the clots. Complete resolution was achieved upon switching to warfarin.. The patient described in this report failed to respond to novel oral anticoagulant therapy, but her emboli resolved when she was treated with warfarin. This study challenges the notion that factor Xa inhibitors are better alternatives to vitamin K anticoagulants in the treatment of pulmonary emboli based on their safety profile and ease of use alone. As a result, further post-marketing investigations into the efficacy of these agents in the management of pulmonary emboli may be warranted.

Topics: Administration, Oral; Adult; Angiography; Anticoagulants; Chest Pain; Dyspnea; Female; Humans; Pulmonary Embolism; Treatment Failure; Vitamin K; Warfarin

The emergency department (ED) serves as the primary gateway for acute care and the source of health care of last resort. Emergency physicians are commonly expected to rapidly assess and treat patients with a variety of life-threatening conditions. However, patients do refuse recommended therapy, even when the consequences are significant morbidity and even mortality. This raises the ethical dilemma of how emergency physicians and ED staff can rapidly determine whether patient refusal of treatment recommendations is based on intact decision-making capacity and how to respond in an appropriate manner when the declining of necessary care by the patient is lacking a basis in informed judgment. This article presents a case that illustrates the ethical tensions raised by the refusal of life-sustaining care in the ED and how such situations can be approached in an ethically appropriate manner.

Topics: Adult; Anticoagulants; Cerebral Veins; Chest Pain; Chronic Pain; Emergency Service, Hospital; Fatal Outcome; Female; Flank Pain; Headache Disorders; Humans; Narcotics; Pulmonary Artery; Treatment Refusal; Venous Thrombosis; Vision Disorders; Warfarin

Topics: Aged; Aged, 80 and over; Anticoagulants; Australia; Chest Pain; Female; Heart Diseases; Hospital Mortality; Humans; Hypoxia; Male; Neoplasms; Neurodegenerative Diseases; Nursing Homes; Pulmonary Embolism; Retrospective Studies; Sex Distribution; Syncope; Warfarin

Intramural esophageal hematoma is part of a spectrum of esophageal injuries. Vomiting and straining, endoscopic procedures and bleeding disorders are the most common predisposing factors. However, it can also be an unusual complication of anticoagulation and/or thrombolysis therapy. The most common symptoms are retrosternal chest pain, dysphagia and hematemesis. Computed tomography is the modality of choice and treatment is medically conservative with the cessation of Warfarin and thrombolysis use. When anticoagulation and/or thrombolysis therapy is necessary, periodic reassessment for symptoms of intramural esophageal hematoma may be helpful for early identification and management. We described one case of intramural esophageal hematoma possibly resulting from anticoagulation and/or thrombolysis therapy in the setting of pulmonary embolism.

Topics: Aged; Anticoagulants; Chest Pain; Deglutition Disorders; Diagnosis, Differential; Esophageal Diseases; Fatal Outcome; Hematemesis; Hematoma; Humans; Male; Pulmonary Embolism; Thrombolytic Therapy; Tomography, X-Ray Computed; Warfarin

Herein we report the clinical presentation and radiographic findings of a patient with a known history of multiple nonossifying fibromas, also known as the Jaffe-Campanacci syndrome, who presented with persistent pleuritic chest pain after a fall and was found to have a small pulmonary embolus. The presentation, pathophysiology and management of the syndrome are briefly discussed.

Topics: Angiography; Bone Neoplasms; Cafe-au-Lait Spots; Chest Pain; Female; Fibroma; Heparin; Humans; Pleurisy; Pulmonary Embolism; Syndrome; Treatment Outcome; Warfarin; Young Adult

Pulmonary embolism (PE) is a common cardiovascular emergency, by which occlusion of a part of the pulmonary arterial bed may lead to acute life threatening but potentially reversible right ventricular failure. Early diagnosis is fundamental to implement immediate effective treatment to reduce mortality. However, the diagnosis can be easily missed due to non-specific clinical presentation. We wish to present an unusual case whereby a patient with no risk factors for PE, symptoms suggestive of acute pericarditis and an ECG showing concave ST segment elevation was found to have multiple pulmonary emboli.

Topics: Anticoagulants; Chest Pain; Diagnosis, Differential; Female; Humans; Medical History Taking; Middle Aged; Pericarditis; Pulmonary Embolism; Treatment Outcome; Ventricular Dysfunction, Right; Warfarin

Shrinking lung syndrome is characterized by pulmonary compromise secondary to unilateral or bilateral paralysis of the diaphragm.. Shrinking lung syndrome was diagnosed in a patient with antiphospholipid syndrome after a cesarean delivery at 28 4/7 weeks of gestation. Signs and symptoms included unexplained right-side chest pain, dyspnea, tachypnea, and absent breath sounds at the right base of the lungs. After initiation of corticosteroids, her symptoms resolved.. Although seen in association with systemic lupus erythematosus, shrinking lung syndrome has not been described with antiphospholipid syndrome or during pregnancy. Diagnosis and awareness are important because treatment with moderate- to high-dose corticosteroids appears to improve the clinical outcome.

Topics: Adult; Antiphospholipid Syndrome; Aspirin; Cesarean Section; Chest Pain; Dyspnea; Female; Heparin; Humans; Hyperventilation; Lung Diseases; Oxygen; Prednisolone; Pregnancy; Pregnancy Complications; Radiography; Respiratory Paralysis; Respiratory Sounds; Syndrome; Treatment Outcome; Warfarin

Familial Mediterranean fever (FMF) is the autoinflammatory disease and hereditary periodic fever syndrome that most commonly affects people of Eastern Mediterranean origin. It is characterized by recurrent self-limited attacks of fever and serositis, with an increase in acute-phase reactant markers, and is transmitted in an autosomal recessive pattern. Inflammation shifts the hemostatic mechanisms favoring thrombosis. There are few reports of an increased risk of hypercoagulability in patients with FMF in the absence of amyloidosis and nephrotic syndrome. In this case report, we describe a 43-year-old Turkish patient who presented with right-sided pleuritic chest pain and pulmonary embolism. The patient described having prior similar attacks of serositis, but had never been diagnosed with FMF. Further workup revealed an increase in acute phase reactants, negative hypercoagulability studies and heterozygosity for the M694V mutation in the pyrin (MEFV) gene. We identified untreated FMF and chronic inflammation as his only risk factor for pulmonary embolism. With this case report, we support recent studies that have demonstrated that inflammation may lead to prothrombotic states in patients with FMF.

Topics: Acetaminophen; Adult; Analgesics, Non-Narcotic; Anticoagulants; Chest Pain; Colchicine; Diagnosis, Differential; Familial Mediterranean Fever; Follow-Up Studies; Heparin; Humans; Male; Pulmonary Embolism; Serositis; Tubulin Modulators; Turkey; Warfarin

Topics: Abdominal Pain; Adolescent; Anticoagulants; Chest Pain; Competitive Behavior; Contraceptives, Oral; Enoxaparin; Female; Gymnastics; Humans; Pulmonary Embolism; Warfarin

Topics: Anticoagulants; Chest Pain; Coloring Agents; Drug Hypersensitivity; Drug-Related Side Effects and Adverse Reactions; Humans; Male; Middle Aged; Skin Diseases; Warfarin

A case of malabsorption- associated warfarin resistance is reported.. A 42-year-old, 111-kg, Caucasian man arrived at the emergency department with atypical pleuritic chest pain. The chest pain was associated with shortness of breath, diaphoresis, nausea, vomiting, and tachycardia. The patient's medical history was significant for multiple episodes of deep venous thrombosis (DVT) in the left upper extremity and both lower extremities, a right above-the-knee amputation due to complications of a previous DVT, insertion of a vena cava filter, pulmonary embolism (PE), asthma, hypertension, and multiple myocardial infarctions. During admission, he was diagnosed presumptively with PE. All potential causes of interference with warfarin absorption were investigated and ruled out. I.V. warfarin therapy at a conventional initial dosage of 5 mg once daily was started on hospital day 2. The International Normalized Ratio (INR) reached the therapeutic range after increasing the i.v. warfarin dosage to 7.5 mg once daily on hospital day 6. The ability to obtain a therapeutic INR on a relatively low dosage of i.v. warfarin but not high dosages of oral warfarin strongly suggests an inherent warfarin malabsorption defect in this patient.. A 42-year-old man with a history of recurrent thromboembolisms demonstrated resistance to oral warfarin therapy due to warfarin malabsorption.

Topics: Adult; Anticoagulants; Chest Pain; Drug Resistance; Humans; Injections, Intravenous; International Normalized Ratio; Malabsorption Syndromes; Male; Obesity; Pulmonary Embolism; Venous Thrombosis; Warfarin

Patent foramen ovale provides a passage from venous circulation to arterial circulation. This may allow passage of a thrombus formed in the venous system into the systemic circulation. We present a case in which a thrombus was entrapped in a patent foramen ovale. A 45-year-old woman presented with complaints of atypical chest pain and pretibial edema. Transthoracic echocardiography showed normal systolic function and grade I diastolic dysfunction. Pulmonary artery pressure was 43 mmHg. There was a mobile multilobular mass in the right atrium, attached to the interatrial septum via a thin pedicle. Transesophageal echocardiography showed a biatrial mass. It was 7-10 mm thick, multilobular, homogeneously echogenic, and highly mobile. It passed through the patent foramen ovale into the left atrium. The left atrial part was 6-8 mm thick, relatively shorter, and less mobile. The patient denied any symptoms related to a cerebrovascular accident. Heparin was initiated and an urgent operation was decided. Intraoperative transesophageal echocardiography showed that the mass was a thrombus which had become smaller due to anticoagulation. She had no neurologic symptoms postoperatively. Venous Doppler examination revealed deep vein thrombosis and warfarin was started.

Topics: Anticoagulants; Chest Pain; Echocardiography, Transesophageal; Female; Foramen Ovale, Patent; Heparin; Humans; Middle Aged; Treatment Outcome; Venous Thrombosis; Warfarin

Pulmonary arterial hypertension (PAH) remains a debilitating and life-threatening disease despite improvements in hemodynamics, exercise capacity and survival with recent therapeutic advances. Health-related quality of life (HRQOL) has, therefore, been proposed as an important outcome for evaluating care. Relatively little, however, is known regarding HRQOL or its determinants in PAH. The Minnesota Living with Heart Failure questionnaire was recently adapted and validated for HRQOL measurement in PAH. We applied this pulmonary hypertension-specific version (MLHF-PH) to a larger population of PAH patients.. Ninety-three consecutive outpatients with PAH completed the MLHF-PH. Scores were assessed for correlations with demographics, symptoms, hemodynamics and treatments.. Patients with PAH had significantly impaired HRQOL as assessed by the disease-specific MLHF-PH. Each physical and emotional component, as well as total scores on the MLHF-PH indicated severely depressed HRQOL. As compared to other diagnoses, PAH associated with scleroderma had the worst HRQOL. Patients with WHO functional Class II symptoms reported better HRQOL than Class III patients. Fatigue, weakness and abdominal discomfort were each associated with more severely depressed HRQOL, as was current epoprostenol use. With the sole exception of the right atrial pressure, hemodynamic measurements did not correlate with HRQOL scores. Simultaneous evaluation of HRQOL with a non-disease-specific questionnaire (SF-36) revealed a similarly impaired status, although identified fewer associations with patient-specific factors.. Severely impaired HRQOL is present in this population of patients with PAH evaluated with a disease-specific questionnaire. The availability of a pulmonary hypertension-specific HRQOL questionnaire may enable further targeted investigations of factors that might improve outcomes.

Topics: Activities of Daily Living; Adolescent; Adult; Aged; Aged, 80 and over; Analysis of Variance; Chest Pain; Epoprostenol; Fatigue; Female; Health Status; Hemodynamics; Humans; Hypertension, Pulmonary; Male; Middle Aged; Quality of Life; Sickness Impact Profile; Warfarin; Young Adult

Topics: Adrenergic beta-Antagonists; Amiodarone; Anticoagulants; Atrial Fibrillation; Cardiomyopathies; Chest Pain; Humans; Perfusion; Vasodilator Agents; Warfarin

A 54-year old man presented with multiple pulmonary emboli and an incidental finding of a huge left ventricular thrombus. Transthoracic echo images demonstrated a globally dilated heart with very poor left ventricular function. It was elected to manage the patient medically, and he was commenced on warfarin therapy, resulting in completed resolution of the thrombus over 10 weeks. No underlying cause was found and he did not experience any further embolic events. This illustrates a rare case of a large ventricular thrombus in a patient with no underlying risk factors.

Topics: Anticoagulants; Chest Pain; Dyspnea; Heart Ventricles; Humans; Incidental Findings; Male; Middle Aged; Pulmonary Embolism; Thromboembolism; Ultrasonography; Ventricular Dysfunction, Left; Warfarin

Topics: Aged; Anticoagulants; Arm; Chest Pain; Dyspnea; Edema; Enoxaparin; Exercise; Factor V; Humans; Male; Methylenetetrahydrofolate Reductase (NADPH2); Mutation; Ultrasonography, Doppler; Venous Thrombosis; Warfarin

Topics: Chest Pain; Coronary Artery Bypass; Finland; Follow-Up Studies; Hemorrhage; Humans; Male; Middle Aged; Myocardial Infarction; Pharmacogenetics; Point Mutation; Postoperative Complications; Radiography; Risk Assessment; Warfarin

The risk/benefit ratio of warfarin therapy changes in the over 75s, when haemorrhagic side-effects become more common. These may not always be reported in the literature.. A woman of 80 years, on long-term warfarin therapy presented with an acute dissecting thoracic aortic aneurysm; on investigation the only precipitating factor found was an international normalised ratio of 4.8. This patient, who also had an abdominal aortic aneurysm, survived, on discontinuation of her anticoagulant therapy.. We describe a previously unreported complication of warfarin therapy in a patient over 75 years of age, to add to the cautions in prescribing this drug in patients of this age group.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aorta; Aortic Aneurysm, Thoracic; Aortic Dissection; Atrial Fibrillation; Chest Pain; Female; Follow-Up Studies; Humans; Smoking; Tomography, X-Ray Computed; Warfarin

Topics: Aged; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Aspirin; Biomarkers; Cardiomyopathies; Chest Pain; Echocardiography; Electrocardiography; Heart Diseases; Heart Ventricles; Heparin; Humans; Male; Platelet Aggregation Inhibitors; Syndrome; Thrombosis; Tomography, X-Ray Computed; Treatment Outcome; Troponin; Warfarin

A 57-year-old woman was hospitalized because of gait disturbance and dysuria. Close examination revealed a cauda equina tumor at the level of L2 and L3. Tumor resection was performed, with posterolateral fusion and spinal instrumentation. On the eleventh day after the surgery, she experienced dyspnea and chest pain during standing and walking exercise. Pulmonary thromboembolism was diagnosed, based on: (1) blood gas analysis findings of hypoxemia and (2) defective images in both of the upper lobes on urgent pulmonary blood flow scintigram. Her clinical status improved with urgent thrombolytic therapy (with tisokinase and urokinase) and anticoagulation therapy (with heparin and warfarin), and her life was saved. When pulmonary thromboembolism occurs, early diagnosis by pulmonary blood flow scintigram and early thrombolytic and anticoagulative therapies are necessary. Special attention should be paid to symptoms of pulmonary thromboembolism in patients after spinal surgery.

Topics: Anticoagulants; Cauda Equina; Chest Pain; Dyspnea; Female; Heparin; Humans; Hypoxia; Lumbar Vertebrae; Middle Aged; Peripheral Nervous System Neoplasms; Plasminogen Activators; Postoperative Complications; Pulmonary Embolism; Spinal Fusion; Thrombolytic Therapy; Tissue Plasminogen Activator; Urokinase-Type Plasminogen Activator; Warfarin

We report about the history of a 53-year-old female who suffered from dyspnea as well as leg and chest pain for six months; in addition she experienced two syncopal events. Recurrent pulmonary embolism was suspected, which was subsequently confirmed by positive scintigraphical findings. Acute cor pulmonale may have caused the syncopes. Therapy with heparin and oral warfarin was started. Within few days the patients condition improved markedly. Signs of pulmonary hypertension disappeared within five months.

Topics: Chest Pain; Dyspnea; Female; Humans; Hypertension, Pulmonary; Leg; Middle Aged; Pulmonary Embolism; Thrombosis; Warfarin

Topics: Aftercare; Algorithms; Cardiac Catheterization; Catheterization, Swan-Ganz; Chest Pain; Clinical Protocols; Decision Trees; Diagnosis, Differential; Echocardiography; Electrocardiography; Female; Heparin; Humans; Medical History Taking; Middle Aged; Physical Examination; Pulmonary Embolism; Radionuclide Imaging; Recurrence; Ventilation-Perfusion Ratio; Warfarin

Pulmonary embolism remains a frequent and often fatal disorder. For the majority of patients, anticoagulation with heparin followed by warfarin represents the primary mode of treatment. Thrombolytic therapy is recommended for the patient with massive pulmonary embolism that has produced hypotension. Embolectomy is reserved for the patient with post embolic systemic hypotension who has an absolute contraindication to thrombolysis or who deteriorates despite thrombolytic therapy. Following successful embolectomy the surgeon must treat the complications of the surgery and prevent recurrence. Complications include cerebral infarction, pulmonary infarction and endobronchial hemorrhage, right ventricular failure, local or systemic bleeding and venous stasis. A case of successful pulmonary embolectomy with a complicated postoperative course is presented and the pathophysiology and treatment of the complications are discussed.

Topics: Adrenal Gland Diseases; Chest Pain; Dyspnea; Female; Heparin; Humans; Hypotension; Middle Aged; Pain; Postoperative Complications; Pulmonary Embolism; Syncope; Warfarin