warfarin and Coronary-Thrombosis

Patients with atrial fibrillation who undergo percutaneous coronary intervention are at increased risk for both coronary and cerebral thrombotic events. As a result, antithrombotic therapy for this patient population continues to pose a significant challenge. In this review, we discuss the development of warfarin triple therapy as the standard of care in the last century, the transition to dual therapy with warfarin and a P2Y12 inhibitor, the advent of NOACs, recent clinical trials, and new regimens with a NOAC and a P2Y12 inhibitor. We also discuss our current clinical practice, based on the available data.

Topics: Anticoagulants; Aspirin; Atrial Fibrillation; Cardiology; Coronary Thrombosis; Drug Therapy, Combination; Humans; Intracranial Thrombosis; Percutaneous Coronary Intervention; Purinergic P2Y Receptor Antagonists; Warfarin

This review aims to discuss the use of antithrombotic therapy in patients with atrial fibrillation who undergo coronary stenting with emphasis on the use of double vs triple therapy.. When combined with systemic anticoagulation, dual antiplatelet therapy results in an unacceptable increase in bleeding without any improvement in prevention of thrombotic events. Direct oral anticoagulants combined with single antiplatelet therapy have reduced bleeding compared with warfarin plus dual antiplatelet therapy. Triple anticoagulation therapy with warfarin or direct oral anticoagulants leads to an excess of bleeding and is not superior in preventing thrombotic events. Recent randomized, controlled trials have shown a significant reduction in major bleeding events in patients treated with dual antithrombotic therapy compared with triple therapy without any difference in efficacy. These findings call into question whether triple therapy should remain a part of standard practice.

Topics: Anticoagulants; Antithrombins; Atrial Fibrillation; Coronary Artery Disease; Coronary Thrombosis; Drug Therapy, Combination; Hemorrhage; Humans; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Stents; Stroke; Warfarin

The recently described complication of late and very late stent thrombosis with coronary stents has raised the question of when is it safe to stop antiplatelet therapy in the era of drug eluting stents? With several million patients having already had coronary stents implanted worldwide, the importance of an appreciation of stent thrombosis is not only critical to the cardiologist but also surgeon, physician, dentist and other specialists that perform procedures on patients which require with-holding antiplatelet agents. Currently there is great concern amongst medical professionals on how to manage this group of patients in the absence of clear guidelines. This article reviews the current data on coronary stents, in-stent restenosis and stent thrombosis and role of antiplatelet medication post percutaneous coronary intervention (PCI) to provide a concise and clear algorithm for managing perioperative antiplatelet therapy in patients having undergone recent PCI. The algorithm encourages a multidisciplinary approach and is based on the surgical bleeding risk, operative risk of adverse cardiac events and stent thrombosis risk to guide safe practice. Challenging areas including aspirin and clopidogrel hypersensitivity, clopidogrel resistance and concomitant vitamin K antagonist therapy are also addressed.

Topics: Coronary Thrombosis; Drug Hypersensitivity; Drug Resistance; Drug Therapy, Combination; Drug-Eluting Stents; Graft Occlusion, Vascular; Humans; Platelet Aggregation Inhibitors; 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

Patients with coronary artery aneurysms caused by Kawasaki disease are at increased risk of coronary thrombosis and ischemia. To prevent coronary thrombosis, long-term anti-thrombosis using anti-platelet drugs, such as aspirin, dipyridamole, ticlopidine, clopidogrel, and abciximab, with or without warfarin is recommended by official guidelines. In fact, aspirin or aspirin with warfarin are the most frequently administered regimen in these patients with coronary aneurysms. However, there has been paucity of data and no randomized controlled study to determine the efficacy of these drugs. This short article attempts to summarize the efficacy and safety of these drugs based on currently available literatures and our multi-institutional experience.

Topics: Aspirin; Child, Preschool; Coronary Aneurysm; Coronary Thrombosis; Humans; Infant; Mucocutaneous Lymph Node Syndrome; Platelet Aggregation Inhibitors; Warfarin

A 56-year-old man presented with sustained chest pain. Coronary angiography revealed total occlusion of the distal right coronary artery and left anterior descending branch. Left ventriculography depicted a mobile mass in the right sinus of Valsalva originating from the ostium of the right coronary artery. Transesophageal echocardiography (TEE) showed a mobile mass in the sinus of Valsalva and another mobile mass in the aortic arch. The mass at the right sinus of Valsalva was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study showed protein S deficiency. This is the first case of acute myocardial infarction as a result of multiple coronary embolism caused by thrombosis in the right sinus of Valsalva with a second aortic arch thrombosis, contributed by protein S deficiency.

Topics: Anticoagulants; Coronary Angiography; Coronary Thrombosis; Echocardiography, Transesophageal; Embolism; Humans; Male; Middle Aged; Myocardial Infarction; Sinus of Valsalva; Warfarin

Intracardiac thrombosis and cardioembolisms may have impressive effects on quality of life, prognosis and therapeutic costs in patients with valve disease or replacement devices. Distinct pathophysiological differences exist regarding intracardiac thrombus formation in low-versus high-pressure areas. Important cardiac confounders for low-pressure areas are left atrial geometry and function, including atrial fibrillation or loss of active atrial contraction. In high-pressure areas, flow velocity and shear stress are raised, and this may result in flow turbulence, for example when blood passes a stenotic area. Other major factors which correlate with intracardiac thrombus formation are implantation of polymer material and the degree of endocardial damage resulting for example, from infective or rheumatic endocarditis. Because of the interaction of platelets and the plasma clotting system, a combination of oral anticoagulation therapy and antiplatelet drugs should prevent more thromboembolic events than might anticoagulation alone. Recent studies in patients with prosthetic heart valves have indicated a positive risk-benefit profile if low-dose antiplatelet drugs are added to moderate intensive oral anticoagulation therapy. Thromboembolic events and bleeding complications due to oral anticoagulation therapy are accepted key parameters to demonstrate the superiority of one replacement device over another. However, there is no consistent system for reporting morbid events. In order to organize low and narrow target INR ranges, point-of-care patient self-testing modalities have been introduced and used effectively in large sample sizes. In the near future, some promising new drugs--including direct thrombin or factor Xa inhibitors with broader therapeutic ranges and thus fewer side effects--will become available. The test for these drugs will be their potential to prevent intracardiac thrombosis and cardioembolism in a patient population which is under significant risk.

Topics: Anticoagulants; Coronary Thrombosis; Drug Therapy, Combination; Embolism; Heart Valve Diseases; Humans; Platelet Aggregation Inhibitors; Thrombolytic Therapy; Warfarin

Sub-acute thrombosis is a serious complication of coronary artery stenting. Clopidogrel plus aspirin is the accepted prophylactic regimen, but has yet to be proven superior to ticlopidine plus aspirin, and a new regimen combining cilostazol and aspirin has been introduced.. We conducted a meta-analysis of all trials that compared >or=2 oral anti-thrombotic strategies in patients undergoing coronary stent placement to determine which treatment optimally prevents adverse cardiac events in the 30 days following stent insertion. We used meta-regression to compare all strategies to a shared control strategy: ticlopidine plus aspirin. We also compared randomized trials to historically controlled and other non-randomized trials. We conducted sensitivity analysis and subgroup analysis to assess for possible heterogeneity.. In comparison to ticlopidine plus aspirin the odds-ratios for cardiac events, with 95% confidence intervals were: aspirin alone, 4.29 (3.09-5.97), coumadin plus aspirin, 2.65 (2.18-3.21), clopidogrel plus aspirin, 1.06 (0.86-1.31), cilostazol plus aspirin, 0.73 (0.47-1.14). Among trials that compared clopidogrel plus aspirin to ticlopidine plus aspirin, historically controlled trials were statistically distinct from randomized trials. The analysis of cilostazol was sensitive to the small size of the included studies.. Neither clopidogrel plus aspirin nor cilostazol plus aspirin can be statistically distinguished from ticlopidine plus aspirin for the prevention of adverse cardiac events in the 30 days after stenting. A randomized trial including cilostazol is warranted.

Topics: Anticoagulants; Aspirin; Cilostazol; Clopidogrel; Coronary Thrombosis; Drug Therapy, Combination; Humans; Odds Ratio; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Stents; Tetrazoles; Ticlopidine; Warfarin

In patients suffering from acute myocardial infarction (AMI), new cardiovascular events can be prevented by aspirin or warfarin or a combination of both. Results from studies examining this issue have been published in recent years. We have evaluated the study results together with other factors that are decisive for implementation of the findings in clinical practice.. The following four studies were evaluated: the Coumadin Aspirin Reinfarction Study (CARS); the Combination Hemotherapy and Mortality Prevention (CHAMP) Study; the Warfarin, Aspirin Reinfarction Study (WARIS)-II; the Antithrombotics in the Secondary Prevention of Events in Coronary Thrombosis (ASPECT)-2 Study.. The studies had somewhat different design, particularly with regard to the intensity of anticoagulation. CARS and CHAMPS did not show any benefit with combined therapy. WARIS II concluded that warfarin had better preventive effect than aspirin; so had the two drugs in combination. ASPECT-2 suggested a benefit with the combined treatment (coumadin and aspirin) but had limited study power. In all studies, bleedings occurred most frequently in groups of patients treated with anticoagulants. In clinical practice, relatively few AMI patients would be candidates for warfarin treatment, as this drug is not recommended for the oldest patients. Adverse event profile, guidance of treatment and relation to invasive treatment procedures are factors in favour of aspirin.. Aspirin should be the antithrombotic agent of choice in secondary prevention after acute myocardial infarction. Warfarin could be used when there are specific additional indications. Combining these two agents is not recommended as a routine treatment.

Topics: Anticoagulants; Aspirin; Cardiovascular Diseases; Coronary Thrombosis; Drug Therapy, Combination; Fibrinolytic Agents; Humans; Myocardial Infarction; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Recurrence; Warfarin

Acute coronary syndromes (unstable angina and acute myocardial infarction) are generally caused by thrombosis over a disrupted atherosclerotic plaque. During the acute phase, antithrombotic therapy (including aspirin and heparin) has been shown to reduce the risk of death or myocardial infarction (MI). The purpose of this review is to examine the high-risk period for clinical thrombotic events that extends for several weeks after presentation and to review the treatments aimed at reducing these events.. More than half of clinical events reported during the first month occur after the first 3 to 5 days that comprise the standard in-hospital treatment period. Several different antithrombotic approaches have been tested, including longer duration of antiplatelet therapy, anticoagulant treatment, and oral glycoprotein (GP) IIb/IIIa inhibitors. Aspirin is effective at reducing risk, and clopidogrel provides additional benefit, as does dalteparin for at least the first month. Warfarin in addition to aspirin, while generally disappointing, has not been adequately tested at higher doses. Oral GP IIb/IIIa inhibitors cause a paradoxic increased risk of death for unclear reasons.. Further reduction of risk during the weeks after presentation with acute coronary syndromes remains an important therapeutic goal.

Topics: Angina, Unstable; Aspirin; Clopidogrel; Coronary Thrombosis; Heparin, Low-Molecular-Weight; Humans; Myocardial Infarction; Platelet Glycoprotein GPIIb-IIIa Complex; Randomized Controlled Trials as Topic; Thrombolytic Therapy; Ticlopidine; Time Factors; Warfarin

The goal of anticoagulant therapy in unstable angina is to prevent progression of a subocclusive coronary thrombus to complete occlusion of the coronary artery, thereby preventing myocardial infarction and death. Although these have been many advances in therapy with anticoagulants, considerable morbidity and mortality remains. Also, although combination therapy with potent novel anticoagulants and antiplatelet agents may be an alternative strategy, this needs to be balanced against the risks of hemorrhagic complications. More precise and biologically relevant methods of monitoring anticoagulant effect, along with appropriately modified doses given in combination offers promise.

Topics: Angina, Unstable; Anticoagulants; Antithrombins; Arginine; Clinical Trials as Topic; Coronary Thrombosis; Disease Progression; Heparin; Heparin, Low-Molecular-Weight; Hirudin Therapy; Hirudins; Humans; Myocardial Infarction; Peptide Fragments; Pipecolic Acids; Recombinant Proteins; Sulfonamides; Warfarin

The basic mechanisms of atherosclerotic progression leading to the acute coronary syndromes (ACS) have been elucidated during the last few years. In this brief presentation, we outline 1) Definition of Atherosclerotic Lesions: eight morphologically different lesions are defined (Type I to VI) in various phases of disease. 2) Vulnerable Lipid-Rich Plaques and the ACS: The type IV and Va lesions tend to be relatively small in size, but soft or vulnerable to a "passive" phenomenon of plaque disruption; in addition, an "active" macrophage-dependent enzymatic (genesis of metalloproteinase) phenomenon of plaque disruption is evolving. 3) Thrombosis: we have shown that monocytes/macrophages in lipid-rich plaques may play a detrimental role after plaque disruption, promoting thrombin generation and thrombosis through the tissue factor pathway that can be prevented by tissue factor pathway inhibition; such pathway of thrombosis appears to be critical in the development of the ACS. 4) Effect of Lipid-Modifying Strategies and other Risk Factors on the Vulnerable Lipid-Rich Plaques: when high LDL-cholesterol is reduced therapeutically, efflux from the plaques of the liquid or sterified cholesterol, and also its hydrolysis into cholesterol crystals depositing in the vessel wall, predominate over the influx of LDL-cholesterol; consequently, there is a decrease in the softness of the plaque and so, presumably in the "passive" phenomenon of plaque disruption; modification of other risk factors presumably also favorably affect LDL-cholesterol influx and efflux. 5) Antithrombotic Strategies: the evolving antithrombotic approaches under investigation are briefly outlined.

Topics: Anticoagulants; Arteriosclerosis; Aspirin; Clinical Trials as Topic; Coronary Thrombosis; Disease Progression; Drug Therapy, Combination; Endothelium, Vascular; Fibrinolytic Agents; Humans; Lipids; Models, Biological; Platelet Aggregation Inhibitors; Rupture, Spontaneous; Thromboembolism; Thromboplastin; Warfarin

Topics: Adult; Angioplasty; Animals; Anticoagulants; Antithrombin III; Aspirin; Blood Coagulation Tests; Coronary Thrombosis; Fibrinolysis; Heart Diseases; Humans; Middle Aged; Platelet Aggregation Inhibitors; Rabbits; Swine; Thrombin; Thrombolytic Therapy; Thrombosis; Time Factors; Warfarin

Prevention offers the best approach to limiting morbidity and mortality from deep vein thrombosis and pulmonary embolism in obstetric patients. The use of anticoagulant drugs during pregnancy, however, can be problematic, from the maternal or the fetal point of view. Deciding on the best management is further limited by the lack of controlled clinical trials in the obstetric setting. From the data available, it can be recommended that anticoagulant prophylaxis should be targeted at groups of patients at high risk of thrombosis during pregnancy and the puerperium. Heparin is the agent of choice in most situations during pregnancy for the prophylaxis of venous thrombosis, while warfarin is still the most effective agent for the prevention of systemic embolism from artificial cardiac valves. Prophylactic measures against venous thrombosis are probably underused in the puerperium. Controlled clinical studies are urgently required to optimize prophylaxis of venous thromboembolism associated with pregnancy, and large studies may be more feasible in the puerperium when the incidence of thromboembolism is highest.

Topics: Coronary Thrombosis; Female; Heparin; Humans; Pregnancy; Pregnancy Complications, Cardiovascular; Risk Factors; Thromboembolism; Thrombophlebitis; Warfarin

The importance of the thrombotic component of coronary heart disease is increasingly recognised, and in particular the role of the coagulation system in this process. The Northwick Park Heart study was the first major prospective study to identify both fibrinogen and factor VIIc as risk factors, as powerful as total cholesterol in predicting ischaemic events. Since then, a number of epidemiological studies have confirmed the importance of fibrinogen, not just in CHD but in stroke as well. A variety of environmental factors are known to influence levels of factor VII and fibrinogen and therefore support their role in the development of coronary thrombosis. Both are known to increase with age and body weight and are relatively elevated in diabetes. Fibrinogen is strongly related to smoking habit and a substantial proportion of the IHD risk associated with smoking is mediated through this relationship. There is a dose response effect between number of cigarettes smoked and level of fibrinogen and an inverse relationship with time since cessation of the habit. Factor VII is known to correlate with total cholesterol level, and there is a relationship between dietary variability of fat intake and factor VII, which is likely to play an important role in the risk of CHD. The case for using either anticoagulation or anti platelet agents in secondary prevention of myocardial infarction is now clear, but there are still uncertainties in primary prevention which relate to the ideal dose intensity of either aspirin or anti-coagulation and the type of patient most likely to benefit. The ongoing Thrombosis Prevention Trial identifies middle-aged males at high risk of a myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Aspirin; Blood Coagulation; Coronary Thrombosis; Dietary Fats; Drug Therapy, Combination; Factor VII; Fibrinogen; Humans; Intracranial Embolism and Thrombosis; Male; Middle Aged; Risk Factors; Smoking; Warfarin

Topics: Adrenal Cortex Hormones; Angioplasty, Balloon, Coronary; Aspirin; Coronary Artery Disease; Coronary Thrombosis; Coronary Vasospasm; Fish Oils; Heparin; Humans; Platelet-Derived Growth Factor; Recurrence; Risk Factors; Warfarin

Angioplasty procedures with balloons, cutters or lasers all may greatly enlarge the arterial lumen, but luminal diameter may decrease because of mural thrombus in 70% to 80%, smooth muscle proliferation, vasoconstriction or recoil. Thrombin binds to arterial wall matrix and fibrin within a thrombus. Heparin dose-dependently decreases platelet and thrombus deposition but does not eliminate these even at high doses. Specific thrombin inhibition started before angioplasty experimentally prevents mural thrombus and limits platelet deposition to a single layer or less. Experimentally, anticoagulant and antifibrin effects occur at lower antithrombin blood levels and lower activated partial thromboplastin times (1.7 times control). Because platelets are so sensitive to thrombin, the higher level of thrombin inhibition required may occur at a specific level (activated partial thromboplastin time greater than or equal to 2 times control); this is not defined in humans. The duration of therapy is not defined in animals or humans. Thrombus and thrombin may be related to cellular proliferation.

Topics: Angioplasty, Balloon, Coronary; Antithrombins; Coronary Thrombosis; Coronary Vessels; Heparin; Heparin, Low-Molecular-Weight; Hirudin Therapy; Humans; Muscle, Smooth, Vascular; Platelet Aggregation Inhibitors; Recurrence; Warfarin

Left atrial appendage closure with the WATCHMAN device is an alternative to anticoagulation for stroke prevention in selected patients with atrial fibrillation (AF). LA device-related thrombus (DRT) is poorly defined and understood. We aimed to (1) develop consensus echocardiographic diagnostic criteria for DRT; (2) estimate the incidence of DRT; and (3) determine clinical event rates in patients with DRT. In phase 1 (training), a training manual was developed and reviewed by 3 echocardiographers with left atrial appendage closure device experience. All available transesophageal (TEE) studies in the WATCHMAN left atrial appendage system for embolic protection in patients with atrial fibrillation (PROTECT-AF) trial patients with suspected DRT were reviewed in 2 subsequent phases. In phase 2 (primary blind read), each reviewer independently scored each study for DRT, and final echo criteria were developed. Unanimously scored studies were considered adjudicated, whereas all others were reevaluated by all reviewers in phase 3 (group adjudication read). DRT was suspected in 35 of 485 patients by the site investigator, the echocardiography core laboratory, or both; 93 of the individual TEE studies were available for review. In phase 2, 3 readers agreed on 67 (72%) of time points. Based on phases 1 and 2, 5 DRT criteria were developed. In phase 3, studies without agreement in phase 2 were adjudicated using these criteria. Overall, at least 1 TEE was DRT positive in 27 (5.7%) PROTECT-AF patients. Stroke, peripheral embolism, or cardiac/unexplained death occurred in subjects with DRT at a rate of 3.4 per 100 patient-years follow-up. In conclusion, DRT were identified on at least 1 TEE in 27 PROTECT-AF patients, indicating a DRT incidence of 5.7%. Primary efficacy events in patients with DRT occurred at a rate of 3.4 per 100 patient-years follow-up, intermediate in frequency between event rates previously reported for the overall device and warfarin arms in PROTECT-AF.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Coronary Thrombosis; Embolic Protection Devices; Female; Follow-Up Studies; Humans; Incidence; Male; Middle Aged; Stroke; Treatment Outcome; Warfarin

Antithrombotic management of patients with atrial fibrillation (AF) undergoing coronary stenting is complicated by the need for anticoagulant therapy for stroke prevention and dual antiplatelet therapy for prevention of stent thrombosis and coronary events. Triple antithrombotic therapy, typically comprising warfarin, aspirin, and clopidogrel, is associated with a high risk of bleeding. A modest-sized trial of oral anticoagulation with warfarin and clopidogrel without aspirin showed improvements in both bleeding and thrombotic events compared with triple therapy, but large trials are lacking. The RE-DUAL PCI trial (NCT 02164864) is a phase 3b, a strategy of prospective, randomized, open-label, blinded-endpoint trial. The main objective is to evaluate dual antithrombotic therapy with dabigatran etexilate (110 or 150 mg twice daily) and a P2Y12 inhibtor (either clopidogrel or ticagrelor) compared with triple antithrombotic therapy with warfarin, a P2Y12 inhibtor (either clopidogrel or ticagrelor, and low-dose aspirin (for 1 or 3 months, depending on stent type) in nonvalvular AF patients who have undergone percutaneous coronary intervention with stenting. The primary endpoint is time to first International Society of Thrombosis and Hemostasis major bleeding event or clinically relevant nonmajor bleeding event. Secondary endpoints are the composite of all cause death or thrombotic events (myocardial infarction, or stroke/systemic embolism) and unplanned revascularization; death or thrombotic events; individual outcome events; death, myocardial infarction, or stroke; and unplanned revascularization. A hierarchical procedure for multiple testing will be used. The plan is to randomize ∼ 2500 patients at approximately 550 centers worldwide to try to identify new treatment strategies for this patient population.

Topics: Anticoagulants; Antithrombins; Atrial Fibrillation; Clinical Protocols; Coronary Artery Disease; Coronary Thrombosis; Dabigatran; Drug Therapy, Combination; Hemorrhage; Humans; Myocardial Infarction; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Prospective Studies; Purinergic P2Y Receptor Antagonists; Research Design; Risk Factors; Stents; Stroke; Time Factors; Treatment Outcome; Warfarin

In the Thrombosis Prevention Trial (TPT), low-intensity warfarin reduced the risk of first coronary events only when the achieved international normalized ratio (INR) was > or =1.4. To validate the likely mechanism of action of low-intensity warfarin we measured its effects on plasma markers of thrombin generation, fibrin turnover and low-grade inflammation in TPT participants. D-dimer and prothrombin fragment F1.2 levels were lower at INRs > or =1.4 (P = 0.02 and 0.03 respectively); levels fell as INR increased (P for trend 0.04 and 0.002 respectively). C-reactive protein did not vary with INR. The efficacy of warfarin is related to reductions in thrombin generation and fibrin turnover.

Topics: Anticoagulants; Coronary Thrombosis; Fibrin; Fibrin Fibrinogen Degradation Products; Humans; International Normalized Ratio; Male; Middle Aged; Myocardial Infarction; Peptide Fragments; Prothrombin; Risk Factors; Thrombin; Warfarin

The antithrombotic benefit of the conventional treatment with coumadin after coronary stenting is limited by bleeding complications. However, the superiority of an antiplatelet therapy with aspirin alone compared with coumadin plus aspirin has not been proven by randomized studies. The efficacy and safety of treatment with aspirin alone in comparison to coumadin plus aspirin were evaluated in this randomized study.. Out of 164 patients aged 59.7 +/- 9.2 years, 79 patients were randomly assigned to receive 100 mg aspirin daily (group A) and 85 patients randomly assigned to coumadin plus aspirin (group CA) after provisional coronary stenting with a high-pressure technique. The primary end point was defined as the absence of death, subacute closure of the target vessel, myocardial infarction, urgent coronary bypass surgery, repeated coronary angioplasty, and peripheral vascular complications requiring transfusion or surgery. High-pressure inflation technique was used, but ultrasound guidance was not.. During hospitalization (median 8 days), 135 patients (82. 3%) were free of events (A, 84.8%; CA, 80.8%; P =.42). Eleven (6.7%) subacute closures occurred (A, 10.1%; CA, 3.5%; P =.09); 2 of them were lethal in the aspirin group. Emergency bypass surgery was performed in 1 patient in each group. Peripheral vascular complications were observed in 13 patients (7.9%) (A, 1.3%; CA, 14. 1%; P <.01). At 3-month follow-up, 15 (9.1%) elective revascularization procedures (A, 7.6%; CA, 10.6%; P =.51) were performed.. Aspirin alone at the low dose of 100 mg administered or the combination of coumadin and aspirin after high-pressure coronary stenting does not prevent adverse clinical events when ultrasound guidance is not used.

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Coronary Angiography; Coronary Disease; Coronary Thrombosis; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Safety; Stents; Ultrasonography, Interventional; Warfarin

Topics: Anticoagulants; Aspirin; Coronary Thrombosis; Humans; Male; Myocardial Ischemia; Smoking; Smoking Cessation; Warfarin

Topics: Anticoagulants; Aspirin; Coronary Thrombosis; Dose-Response Relationship, Drug; Drug Therapy, Combination; Female; Humans; Male; Myocardial Ischemia; Risk Factors; Treatment Outcome; Warfarin

Topics: Administration, Oral; Anticoagulants; Aspirin; Coronary Thrombosis; Dose-Response Relationship, Drug; Humans; Italy; Male; Myocardial Ischemia; Risk Factors; Treatment Outcome; Warfarin

Topics: Administration, Oral; Aspirin; Coronary Thrombosis; Dose-Response Relationship, Drug; Drug Therapy, Combination; Humans; Male; Myocardial Ischemia; Risk Factors; Treatment Outcome; Warfarin

Topics: Anticoagulants; Coronary Thrombosis; Dose-Response Relationship, Drug; Humans; Male; Thrombosis; Treatment Outcome; Warfarin

Topics: Anticoagulants; Aspirin; Coronary Thrombosis; Humans; Life Style; Male; Myocardial Ischemia; Risk Factors; Smoking Cessation; Treatment Outcome; Warfarin

Obstructive changes often occur in aortocoronary saphenous-vein bypass grafts because of atherosclerosis and thrombosis. We studied whether aggressive lowering of low-density lipoprotein (LDL) cholesterol levels or low-dose anticoagulation would delay the progression of atherosclerosis in grafts.. We studied 1351 patients who had undergone bypass surgery 1 to 11 years before base line and who had an LDL cholesterol level between 130 and 175 mg per deciliter and at least one patent vein graft as seen on angiography. We used a two-by-two factorial design to assign patients to aggressive or moderate treatment to lower LDL cholesterol levels (with lovastatin and, if needed, cholestyramine) and to treatment with warfarin or placebo. Angiography was repeated an average of 4.3 years after base line. The primary angiographic outcome was the mean percentage per patient of grafts with a decrease of 0.6 mm or more in lumen diameter.. As measured annually during the study period, the mean LDL cholesterol level of patients aggressive treatment ranged from 93 to 97 mg per deciliter; with moderate treatment, the range was from 132 to 136 mg per deciliter (P<0.001). The mean international normalized ratio was 1.4 in the warfarin group and 1.1 in the placebo group (P<0.001). The mean percentage of grafts with progression of atherosclerosis was 27 percent for patients whose LDL cholesterol level was lowered with aggressive treatment, and 39 percent for those who received moderate treatment (P<0.001). There was no significant difference in angiographic outcome between the warfarin and placebo groups. The rate of revascularization over four years was 29 percent lower in the group whose LDL cholesterol level was lowered aggressively than in the group receiving moderate treatment (6.5 percent vs. 9.2 percent, P= 0.03).. Aggressive lowering of LDL cholesterol levels to below 100 mg per deciliter reduced the progression of atherosclerosis in grafts. Low-dose warfarin did not reduce the progression of atherosclerosis.

Topics: Adult; Aged; Anticholesteremic Agents; Anticoagulants; Cholesterol, LDL; Cholestyramine Resin; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease; Coronary Thrombosis; Drug Therapy, Combination; Female; Graft Occlusion, Vascular; Humans; Hypercholesterolemia; Life Tables; Lovastatin; Male; Middle Aged; Saphenous Vein; Treatment Outcome; Warfarin

We evaluated the effect of antithrombotic regimens on subacute thrombosis and short-term clinical courses after successful implantation of the Cordis coronary stent, which is a flexible, balloon expandable, radiopaque tantalum stent. Two hundred seventy-five consecutive patients with 290 lesions were treated with 356 Cordis stent implantations. According to poststent antithrombotic regimen, patients were divided into 3 groups; 165 patients with 175 lesions received aspirin 200 mg/day, ticlopidine 500 mg/day, and warfarin for 1 month (group 1), 66 patients with 69 lesions received aspirin and ticlopidine (group 2), and 44 patients with 46 lesions received aspirin alone (group 3) after successful Cordis stenting. The overall procedural success rates were 97.7% in group 1, 98.6% in group 2, and 100% in group 3. More than 65% of the patients were eligible for elective stenting. The overall rate of stent thrombosis was 1.8%: 1.2% in patients assigned to the treatment with aspirin, ticlopidine, and warfarin; 0% in patients with aspirin and ticlopidine; and 6.8% in patients assigned to the treatment with aspirin alone. In conclusion, the Cordis coronary stent is an effective endovascular stent in various clinical indications including unstable angina and acute myocardial infarction. Antiplatelet therapy using aspirin and ticlopidine after successful Cordis coronary stenting is a promising alternative to anticoagulation therapy to overcome the drawbacks of stenting. However, poststent antithrombotic therapy with aspirin alone is associated with a significant rate of stent thrombosis.

Topics: Anticoagulants; Aspirin; Coronary Angiography; Coronary Disease; Coronary Thrombosis; Evaluation Studies as Topic; Fibrinolytic Agents; Humans; Middle Aged; Platelet Aggregation Inhibitors; Stents; Ticlopidine; Time Factors; Warfarin

Treatment of calcified (in contrast to simple) lesions with PTCA has been associated with a lower success rate and more procedural complications. Rotablation can improve acute results, but the high restenosis rate remains a problem. The purpose of this study was to evaluate the clinical and angiographic outcome of patients with complex and calcified lesions treated with a combination of rotablation and stenting.. Seventy-five consecutive patients with 106 lesions had rotablation prior to coronary stenting. Intravascular ultrasound-guided stenting was used without subsequent anticoagulation in 93% of patients. Procedural success was achieved in 93.4% of lesions. Acute stent thrombosis occurred in two lesions (1.9%), and subacute stent thrombosis in one lesion (0.9%). Angiographic follow-up was performed in 82.5% of lesions at 4.6 +/- 1.9 months with an angiographic restenosis rate of 22.5%. Clinical follow-up was performed in all patients at 6.4 +/- 3 months; target lesion revascularization was needed in 18% of lesions; Q-wave myocardial infarction occurred in 1.3%, coronary bypass surgery in 4.0%, and death in 1.3%.. Optimal coronary stenting after rotablation in calcified and complex lesions can be performed with a high success rate, an acceptable rate of procedural complications, and a low rate of stent thrombosis. This approach was associated with a low incidence of angiographic restenosis compared with results usually obtained with other interventional strategies in calcified and complex lesion subsets.

Topics: Aged; Aspirin; Atherectomy, Coronary; Calcinosis; Coronary Angiography; Coronary Disease; Coronary Thrombosis; Female; Fibrinolytic Agents; Follow-Up Studies; Heparin; Humans; Male; Middle Aged; Recurrence; Retrospective Studies; Stents; Ticlopidine; Ultrasonography; Warfarin

In the APRICOT study (Antithrombotics in the Prevention of Reocclusion In Coronary Thrombolysis), we sought to determine whether angiographic characteristics of the culprit lesion could predict reocclusion after successful thrombolysis and to analyze the influence of three antithrombotic treatment regimens.. After successful thrombolysis, reocclusion is a major problem. Prediction of reocclusion by angiographic data and choice of antithrombotic treatment would be important for clinical management.. After thrombolysis, patients were treated with intravenous heparin until initial angiography was performed within 48 h. Patients with a patent infarct-related artery were eligible. Three hundred patients were randomly selected for treatment with coumadin, aspirin (300 mg once daily) or placebo. Patency on a second angiographic study after 3 months was the primary end point of the study.. Reocclusion rate was 25% with aspirin, 30% with coumadin and 32% with placebo (p = NS). Lesions with > 90% stenosis reoccluded more frequently (42%) than did those with < 90% stenosis (23%) (p < 0.01). Reocclusion rate of smooth lesions was higher (34%) than that of complex lesions (23%) (p < 0.05). In lesions with < 90% stenosis, the reocclusion rate was lower with aspirin (17%) than with coumadin (25%) or placebo (30%) (p < 0.01). In complex lesions, the reocclusion rate was lower with aspirin (14%) than with coumadin (32%) or placebo (25%) (p < 0.02). Multivariate analysis showed only stenosis severity > 90% to be an independent predictor of reocclusion (odds ratio 2.31, 95% confidence interval 1.28 to 4.18, p = 0.006).. Angiographic features of the culprit lesion after successful coronary thrombolysis significantly predict the risk of reocclusion: high grade (> 90%) stenoses reoccluded more frequently. Aspirin was effective only in complex and less severe lesions (< 90% stenosis). These findings should prompt investigation of the effects of an aggressive approach to patients with severe residual stenosis.

Topics: Aspirin; Coronary Angiography; Coronary Thrombosis; Female; Humans; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Predictive Value of Tests; Recurrence; Risk Factors; Thrombolytic Therapy; Warfarin

Because atrial thrombi are poorly detected by conventional noninvasive techniques such as transthoracic echocardiography, patients with prolonged atrial fibrillation usually receive several weeks of oral anticoagulation therapy before cardioversion is attempted. We wondered whether transesophageal echocardiography, an accurate method of detecting atrial thrombi, would allow early cardioversion to be performed safely if no thrombi were identified.. A total of 669 consecutive patients admitted with the diagnosis of atrial fibrillation were screened. Patients were excluded if they were receiving long-term anticoagulation, if the duration of atrial fibrillation was two days or less, if they were not candidates for cardioversion, or if transesophageal echocardiography was contraindicated. Of 119 qualifying patients, 94 agreed to participate; the average duration of atrial fibrillation was 4.5 weeks. Participating patients underwent transthoracic echocardiography and transesophageal echocardiography followed by cardioversion if no thrombi were seen. Short-term anticoagulation with heparin was used in 80 patients before cardioversion, and 60 patients received warfarin for one month after cardioversion.. Fourteen atrial thrombi were identified in 12 patients (13 percent), and 12 of the 14 thrombi were visualized only on transesophageal echocardiography. Cardioversion was deferred in all 12 patients. Two of these 12 patients died suddenly; 4 of the 10 surviving patients underwent uneventful cardioversion after prolonged oral anticoagulation. Seventy-eight of the 82 patients without thrombi underwent successful cardioversion to sinus rhythm (47 by means of antiarrhythmic drugs and 31 by electrical cardioversion), all without long-term oral anticoagulation. None of these patients (95 percent confidence interval, 0 to 4.6 percent) had an embolic event.. In patients with atrial fibrillation of unknown or prolonged duration who are not receiving long-term anticoagulation, atrial thrombi are detected by transesophageal echocardiography in only a small minority (13 percent in our study). Our preliminary data suggest that if transesophageal echocardiography excludes the presence of thrombi, early cardioversion can be performed safely without the need for prolonged oral anticoagulation before the procedure.

Topics: Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Coronary Thrombosis; Echocardiography; Electric Countershock; Female; Heart Atria; Heparin; Humans; Male; Middle Aged; Warfarin

Successful coronary thrombolysis involves a risk for reocclusion that cannot be prevented by invasive strategies. Therefore, we studied the effects of three antithrombotic regimens on the angiographic and clinical courses after successful thrombolysis.. Patients treated with intravenous thrombolytic therapy followed by intravenous heparin were eligible when a patent infarct-related artery was demonstrated at angiography < 48 hours. Three hundred patients were randomized to either 325 mg aspirin daily or placebo with discontinuation of heparin or to Coumadin with continuation of heparin until oral anticoagulation was established (international normalized ratio, 2.8-4.0). After 3 months, in which conservative treatment was intended, vessel patency and ventricular function were reassessed in 248 patients. Reocclusion rates were not significantly different: 25% (23 of 93) with aspirin, 30% (24 of 81) with Coumadin, and 32% (24 of 74) with placebo. Reinfarction was seen in 3% of patients on aspirin, in 8% on Coumadin, and in 11% on placebo (aspirin versus placebo, p < 0.025; other comparison, p = NS). Revascularization rate was 6% with aspirin, 13% with Coumadin, and 16% with placebo (aspirin versus placebo, p < 0.05; other comparisons, p = NS). Mortality was 2% and did not differ between groups. An event-free clinical course was seen in 93% with aspirin, in 82% with Coumadin, and in 76% with placebo (aspirin versus placebo, p < 0.001; aspirin versus Coumadin, p < 0.05). An event-free course without reocclusion was observed in 73% with aspirin, in 63% with Coumadin, and in 59% with placebo (p = NS). An increase of left ventricular ejection fraction was only found in the aspirin group (4.6%, p < 0.001).. At 3 months after successful thrombolysis, reocclusion occurred in about 30% of patients, regardless of the use of antithrombotics. Compared with placebo, aspirin significantly reduces reinfarction rate and revascularization rate, improves event-free survival, and better preserves left ventricular function. The efficacy of Coumadin on these end points appears less than that of aspirin. The still-high reocclusion rate emphasizes the need for better antithrombotic therapy in these patients.

Topics: Aged; Aspirin; Coronary Angiography; Coronary Thrombosis; Female; Fibrinolytic Agents; Humans; Male; Middle Aged; Myocardial Infarction; Prospective Studies; Recurrence; Warfarin

The importance of the thrombotic component of coronary heart disease is increasingly recognised, and in particular the role of the coagulation system in this process. The Northwick Park Heart study was the first major prospective study to identify both fibrinogen and factor VIIc as risk factors, as powerful as total cholesterol in predicting ischaemic events. Since then, a number of epidemiological studies have confirmed the importance of fibrinogen, not just in CHD but in stroke as well. A variety of environmental factors are known to influence levels of factor VII and fibrinogen and therefore support their role in the development of coronary thrombosis. Both are known to increase with age and body weight and are relatively elevated in diabetes. Fibrinogen is strongly related to smoking habit and a substantial proportion of the IHD risk associated with smoking is mediated through this relationship. There is a dose response effect between number of cigarettes smoked and level of fibrinogen and an inverse relationship with time since cessation of the habit. Factor VII is known to correlate with total cholesterol level, and there is a relationship between dietary variability of fat intake and factor VII, which is likely to play an important role in the risk of CHD. The case for using either anticoagulation or anti platelet agents in secondary prevention of myocardial infarction is now clear, but there are still uncertainties in primary prevention which relate to the ideal dose intensity of either aspirin or anti-coagulation and the type of patient most likely to benefit. The ongoing Thrombosis Prevention Trial identifies middle-aged males at high risk of a myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Aspirin; Blood Coagulation; Coronary Thrombosis; Dietary Fats; Drug Therapy, Combination; Factor VII; Fibrinogen; Humans; Intracranial Embolism and Thrombosis; Male; Middle Aged; Risk Factors; Smoking; Warfarin

Recent studies have evidenced an association between the time of heparin discontinuance and coronary artery reocclusion. Some investigators have concluded that inadequate heparinization was responsible, and further heparin infusion or an increase in dose would have been indicated. However, several investigators (Rao: Thrombosis Research 24:181-186, 1981; Marciniak and Gockerman: Lancet September 17:581-584, 1977; Fisken et al.: Lancet December 10: 1231, 1977; Conard et al.: Thrombosis Research 22:507-511, 1981; Kakkar et al.: Lancet January 12:103-104; Green: Lancet February 16:374, 375; Harborne and Nicolaides: Thrombosis Research 43:657-662, 1986; Bonen et al.: Thrombosis Research 27:123-124, 1982; Blomback et al.: Acta Physiologica Scandinavica 58:306-318, 1963; Holm et al.: Scandinavian Journal of Haematology 35:564-569, 1985; Andersson et al.: Thrombosis Research 34:333-340, 1984) have demonstrated that antithrombin III levels are reduced in patients on intravenous heparin. Both reduced antithrombin III levels and reduced rate of antithrombin inhibition of thrombin at the time of heparin discontinuance may increase the risk of coronary rethrombosis. If this theory is correct, increasing heparin infusion may exacerbate this risk. We propose an investigation that will provide evidence for or against the decreased antithrombin III theory, and in doing so, test an experimental therapy designed to prevent coronary reocclusion upon heparin discontinuance. In a randomized, placebo-controlled double-blinded study, we will determine whether simultaneous administration of warfarin with heparin initiation provides more time to increase antithrombin III levels and prevent coronary reocclusion upon heparin discontinuance, compared to heparin without warfarin therapy.

Topics: Antithrombin III; Coronary Disease; Coronary Thrombosis; Double-Blind Method; Heparin; Humans; Randomized Controlled Trials as Topic; Recurrence; Substance Withdrawal Syndrome; Time Factors; Warfarin

The most severe complication associated with giant coronary aneurysm in children with Kawasaki disease is ischemic cardiomyopathy (ICM) caused by thrombosis. Addition of tissue plasminogen activator, Alteplase, in the treatment regimen can be an efficient thrombolytic therapy, and therefore can have a significantly positive impact on patients' quality of life in long term.. Total four male KD patients with central thromboses in coronary aneurysm were treated in Pediatric Cardiology Department of Shengjing Hospital, China Medical University, from January 2020 to August 2021. These patients received thrombolytic treatments including Alteplase once + Heparin for 1 week followed by continuous oral Warfarin + Aspirin + Clopidogrel.. 4 young male KD patients had coronary aneurysm (CAA) complicated with total 7 occurrences of central thrombosis. These patients were given alteplase and heparin/oral Warfarin + Aspirin + Clopidogrel treatment. 9 days to 2 months later, thromboses were significantly dissolved. The treatment successfully diminished the thrombosis complication.. 1. Pediatric KD patients complicated with coronary aneurysm thrombosis are prone to recurrence of thrombosis. 2.  In KD patients complicated with coronary aneurysm thrombosis, treatments described in Method can be used for treating either small thromboses formed less than 1 month with strong echo and convex lumen or large thromboses with mixed strong and weak echo. With these treatments, coronary artery blood flow can be improved or completely recovered. 3. Clinical experiences at our center in treating these KD patients suggest that Alteplase can be considered in thrombolytic treatment beyond the limitation of less than 12 h of thrombosis occurrence.

Topics: Aspirin; Child; Clopidogrel; Coronary Aneurysm; Coronary Thrombosis; Fibrinolytic Agents; Heparin; Humans; Male; Mucocutaneous Lymph Node Syndrome; Quality of Life; Tissue Plasminogen Activator; Warfarin

Complete P wave disappearance (CPWD) in patients without atrial fibrillation is an uncommon clinical phenomenon. We aimed to study the relationship between CPWD and thromboembolism.. Between July 2007 and December 2018, consecutive patients with CPWD on surface ECG and 24-hour Holter recording were recruited into the study from 4 centers in China. All recruited patients underwent transesophageal echocardiography or cardiac computed tomography to screen for atrial thrombus. Atrial electrical activity and scar were assessed by electrophysiological study (EPS) and 3-dimensional electroanatomic mapping. Cardiac structure and function were assessed by multimodality cardiac imaging.. Twenty-three consecutive patients (8 male; mean age 48.5±14.7 years) with CPWD were included. Only 3 patients demonstrated complete atrial electrical silence with atrial noncapture. Thirteen patients who had invasive atrial endocardial mapping demonstrated extensive scar. Pulse-wave mitral inflow Doppler demonstrated absent and dampened A waves in 18 and 5 patients, respectively. Pulse-wave tricuspid inflow Doppler showed absent and dampened A waves in 19 and 4 patients, respectively. Upon recruitment, 8 patients had previous stroke and 3 patients had atrial thrombus. Warfarin was prescribed to all patients. During median follow-up of 42.0 months, 2 patients developed massive ischemic stroke due to warfarin discontinuation.. Our study suggested that CPWD reflects extensive atrial electrical silence and significantly impaired atrial mechanical function. It was strongly associated with thromboembolism and the clinical triad of CPWD-atrial paralysis-stroke was proposed. Anticoagulation should be recommended in such patients.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; China; Coronary Thrombosis; Echocardiography, Transesophageal; Electrocardiography; Electrocardiography, Ambulatory; Female; Follow-Up Studies; Humans; Infant, Newborn; Male; Middle Aged; Mitral Valve; Risk; Stroke; Thromboembolism; Tomography, X-Ray Computed; Tricuspid Valve; Warfarin

Warfarin treatment has been associated with lower risks of prostate cancer, without a specified biological mechanism. Our study tested the hypothesis that reluctance to perform prostate biopsies in men who are anticoagulated results in lower rates of diagnosed prostate cancer, leading to an apparent protective effect. Rates of prostate biopsies have decreased from 2000 to 2015, allowing calendar time to be used as the intervention. In a national population-based sample of elderly men, our study compared trends in prostate cancer incidence between 17,815 men treated with chronic oral anticoagulation for prosthetic heart valve thromboprophylaxis and a general population comparison group of 356,300 men. Cancer events were based on administrative claims. Among men enrolled in 2000-2001 and followed through 2015, prostate cancer incidence was substantially lower in the anticoagulation group (adjusted incidence rate ratio [IRR] 0.70; 95% confidence interval [CI] 0.62-0.80). Incidence decreased over time in the general population group to approach that of the anticoagulation group among men enrolled in 2008-2010 (IRR 0.86; 95% CI 0.71-1.04). Rates of prostate biopsies also decreased over time in the general population group to match the rate in the anticoagulation group. These results indicate that the apparent protective effect of warfarin treatment on the risk of prostate cancer is likely the result of detection bias from lower rates of biopsies among men who are anticoagulated.

Topics: Aged; Anticoagulants; Bias; Biopsy; Coronary Thrombosis; Heart Valve Prosthesis; Humans; Male; Prostatic Neoplasms; Retrospective Studies; Venous Thromboembolism; Warfarin

Topics: Anticoagulants; Aspirin; Computed Tomography Angiography; Coronary Aneurysm; Coronary Angiography; Coronary Thrombosis; Echocardiography; Female; Humans; Imaging, Three-Dimensional; Mucocutaneous Lymph Node Syndrome; Platelet Aggregation Inhibitors; Tomography, X-Ray Computed; Vascular Calcification; Warfarin; Young Adult

Topics: Antigens, Human Platelet; Arginine; Aspirin; Autoantibodies; Combined Modality Therapy; Coronary Thrombosis; Drug Substitution; Drug Therapy, Combination; Eptifibatide; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Pipecolic Acids; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Platelet Transfusion; Purpura, Thrombocytopenic, Idiopathic; Shock, Cardiogenic; ST Elevation Myocardial Infarction; Stents; Sulfonamides; Thrombectomy; Thrombolytic Therapy; Thrombosis; Ticagrelor; Warfarin

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

Topics: Acute Disease; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aspirin; Blood Vessel Prosthesis Implantation; Coronary Angiography; Coronary Thrombosis; Heparin; Humans; Male; Middle Aged; Plastic Surgery Procedures; Platelet Aggregation Inhibitors; Postoperative Complications; Treatment Outcome; Warfarin

An 81-year-old woman presented with acute decompensated heart failure due to new-onset atrial fibrillation and a flail myxomatous mitral valve which necessitated surgical mitral valve repair. No atrial thrombi were noted on transoesophageal echocardiograms performed prior to surgery and intraoperatively. Immediately postoperatively, while treated with unfractionated heparin, the patient developed thrombocytopaenia with positive platelet factor 4 antibodies and an abnormal serotonin functional platelet assay, consistent with heparin-induced thrombocytopaenia. The anticoagulation therapy was changed to the direct thrombin inhibitor bivalirudin with an improvement in the platelet count. Despite bivalirudin therapy, a left atrial layering thrombus was revealed on transoesophageal echocardiogram performed in preparation for cardioversion of the symptomatic atrial fibrillation. Anticoagulation was changed to warfarin, and the patient was discharged without thromboembolic complications neither during her hospital stay nor the 3-year outpatient follow-up.

Topics: Aged, 80 and over; Anticoagulants; Antithrombins; Coronary Thrombosis; Echocardiography, Transesophageal; Female; Heparin; Hirudins; Humans; Peptide Fragments; Recombinant Proteins; Thrombocytopenia; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Coronary Thrombosis; Echocardiography, Transesophageal; Enoxaparin; Female; Heart Atria; Humans; Middle Aged; Warfarin

Coronary sinus thrombosis is a rare phenomenon. When identified, it most often is a complication of infective endocarditis or procedural intervention. We present an unusual and unreported case of spontaneous coronary sinus thrombosis as embolic sequela of an intra-abdominal infectious process.. We report a case of a 61-year-old white woman with a history of end-stage renal disease on hemodialysis, paroxysmal atrial fibrillation not on long-term systemic anticoagulation, and history of recurrent diverticulitis that presented with acute onset abdominal pain and nausea. Computed tomography of her abdomen and pelvis with intravenous contrast was negative for acute intra-abdominal pathology, but incidentally identified an oval-shaped filling defect at the ostium of the coronary sinus suspicious for thrombus or mass which was confirmed on subsequent transesophageal echocardiogram. In light of her concomitant transaminitis but otherwise negative workup, the mass was believed to be thromboembolic in nature, originating within the hepatic venous system as a manifestation of recurrent diverticulitis with associated pylephlebitis and ultimately lodging into the coronary sinus. With the newly detected thrombus and history of paroxysmal atrial fibrillation, she was started on warfarin for therapeutic systemic anticoagulation that resolved her clot by 3-month follow up.. Although coronary sinus thrombosis is rare, a high index of suspicion and close scrutiny of the venous system in patients with intra-abdominal infectious processes would prevent delay in management of this potentially serious complication. The discussion of this case highlights the anatomy of the cardiac venous system, the pathophysiology of thrombus formation, and the utility of transesophageal echocardiography in confirming a diagnosis and assessing treatment efficacy.

Topics: Abdominal Pain; Anticoagulants; Coronary Thrombosis; Diagnosis, Differential; Echocardiography, Transesophageal; Female; Humans; Incidental Findings; Middle Aged; Portal Vein; Thrombophlebitis; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Coronary Thrombosis; Female; Femoral Vein; Gastrointestinal Hemorrhage; Hemostatics; Humans; Male; Middle Aged; Stroke; Thrombosis; Venous Thrombosis; Warfarin

To explore effective and convenient rescue therapy options for coronary artery aneurysms (CAA) with thrombosis in Kawasaki disease (KD). A total of 210 patients with KD between the years 2003 and 2013 were retrospectively reviewed in our institute. 144 of these 210 KD developed CAA, and 10 patients with CAA had associated thrombosis. Thrombosis was confirmed by two-dimensional echocardiograms (2-DE). Laboratory values for CAA were analyzed with and without the thrombus group. The characteristics of CAA were monitored by ultrasound. All patients with thrombus received intravenous (IV) antithrombotic therapy, including urokinase, heparin, and oral warfarin. The effectiveness of antithrombotic treatment was evaluated by measuring the ability to dissolve the thrombus. All thrombi in these patients were preceded by a giant CAA and a history of KD. There are no differences in the blood analyses of both CAA with and without thrombus. Moreover, typical KD symptoms and acute myocardial infarction were not found in CAA with thrombosis. The progression of coronary thrombosis in these patients was arrested by antithrombotic and anti-platelet treatment including low-dose urokinase and heparin. Neither clinical features nor laboratory data could reliably predict CAA associated thrombosis. Therapy with IV anti-thrombus and anti-platelet treatment with low-dose warfarin can effectively dissolve thrombi in KD patients.

Topics: Child; Child, Preschool; Coronary Thrombosis; Dose-Response Relationship, Drug; Echocardiography; Female; Fibrinolytic Agents; Heparin; Humans; Male; Mucocutaneous Lymph Node Syndrome; Treatment Outcome; Urokinase-Type Plasminogen Activator; Warfarin

Topics: Anticoagulants; Coronary Aneurysm; Coronary Thrombosis; Female; Humans; Male; Myocardial Infarction; Warfarin

To evaluate the role of systemic anticoagulation using warfarin in patients with post-myocardial infarction left ventricular (LV) aneurysm formation with or without definite LV thrombus formation.. This study included 648 patients with post-myocardial infarction LV aneurysm formation diagnosed retrospectively by 2-dimensional echocardiography from December 1, 1994, to February 29, 2012. Of these 648 patients, 106 patients received warfarin and 542 patients did not. We studied a composite of death, nonfatal myocardial infarction, cerebrovascular accident, and systemic embolization as the primary outcome and a composite of cerebrovascular accident and systemic embolization as the secondary outcome by using propensity score-adjusted multiple Cox proportional hazards regression analysis.. In patients with LV aneurysm, LV thrombus was observed in 89 patients (13.7%) and it was associated with a higher incidence of adverse secondary events (hazard ratio [HR], 3.63; 95% CI, 1.12-11.8; P=.03) in unadjusted analysis. However, in adjusted analysis, anticoagulation did not predict either a better or a worse outcome for primary outcomes (HR, 1.05; 95% CI, 0.67-1.64; P=.84) or for secondary outcomes (HR, 1.52; 95% CI, 0.670-3.46; P=.31). The benefit of anticoagulation was also not established in patients with LV thrombus (HR, 1.38; 95% CI, 0.32-5.97; P=.66).. In patients with ischemic LV aneurysms, oral anticoagulation therapy with warfarin may not be effective enough to reduce cardiac and cerebrovascular events including systemic embolism. Further studies are needed to confirm this finding.

Topics: Aged; Anticoagulants; Coronary Aneurysm; Coronary Thrombosis; Female; Heart Ventricles; Humans; Male; Middle Aged; Myocardial Infarction; Retrospective Studies; Stroke; Treatment Outcome; Warfarin

Topics: Anticoagulants; Contrast Media; Coronary Thrombosis; Echocardiography; Heparin; Humans; Pulmonary Embolism; Takotsubo Cardiomyopathy; Warfarin

A 72-year-old man with non-valvular atrial fibrillation and metastatic liver and lung cancer after surgery for colon cancer developed thrombosis in the right atrium one month after decreasing the dose of warfarin due to the introduction of double anti-platelet therapy for coronary stent implantation. Restoring the warfarin dose with ordinary control for two months did not result in any changes in the size of the thrombus; however, the subsequent substitution of rivaroxaban (oral treatment with a direct Factor Xa inhibitor) for warfarin ultimately resolved the thrombosis.

Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Coronary Thrombosis; Factor Xa Inhibitors; Heart Atria; Humans; Male; Morpholines; Rivaroxaban; Thiophenes; Treatment Outcome; Vitamin K; Warfarin

Anticoagulant responses to warfarin vary among patients, based on genetic factors, diet, concomitant medications, and disease state. We evaluated the effectiveness and safety of a 10mg warfarin initiation nomogram in an Asian population. Retrospective cross-sectional audit studies were conducted from March 2009 to March 2010. The use of a 10mg-loading dose to initiate warfarin treatment resulted in 33(84.6%) patients attaining a therapeutic INR within four days (mean time, 2.6 days). There was no significant correlation between age, gender, race, and serum albumin for the time to reach a therapeutic INR. A significant correlation was noted for patient's baseline INR and time to reach a therapeutic INR (P<0.05). No significant differences were observed in time to reach a therapeutic INR in patients treated with specific class of concomitant drugs or patients with specific disease states. The overall incidence of over-anticoagulation was 35.9%; however, no bleeding episodes were encountered. In conclusion, the use of a 10mg warfarin nomogram was effective in rapidly achieving a therapeutic INR. However, the nomogram's safety is debatable owing to the high over-anticoagulation rate warfarin-administered patients. Caution is recommended in the initiation of warfarin treatment using the 10mg nomogram.

Topics: Adult; Aged; Anticoagulants; Asian People; Atrial Fibrillation; Coronary Thrombosis; Cross-Sectional Studies; Humans; Malaysia; Male; Middle Aged; Nomograms; Pulmonary Embolism; Retrospective Studies; Stroke; Venous Thrombosis; Warfarin

There are limited data on the optimal antithrombotic therapy for patients with atrial fibrillation (AF) who undergoing coronary stenting. We reviewed 203 patients (62.6 % men, mean age 68.3 ± 10.1 years) between 2003 and 2012, and recorded clinical and demographic characteristics of the patients. Clinical follow-up included major adverse cardiac and cerebrovascular events (MACCE) (cardiac death, myocardial infarction, target lesion revascularization, and stroke), stent thrombosis, and bleeding. The most commonly associated comorbidities were hypertension (70.4 %), diabetes mellitus (35.5 %), and congestive heart failure (26.6 %). Sixty-three percent of patients had stroke risk higher than CHADS2 score 2. At discharge, dual-antiplatelet therapy (aspirin, clopidogrel) was used in 166 patients (81.8 %; Group I), whereas 37 patients (18.2 %) were discharged with triple therapy (aspirin, clopidogrel, warfarin; Group II). The mean follow-up period was 42.0 ± 29.0 months. The mean international normalized ratio (INR) in group II was 1.83 ± 0.41. The total MACCE was 16.3 %, with stroke in 3.4 %. Compared with the group II, the incidence of MACCE (2.7 % vs 19.3 %, P = 0.012) and cardiac death (0 % vs 11.4 %, P = 0.028) were higher in the group I. Major and any bleeding, however, did not differ between the two groups. In multivariate analysis, no warfarin therapy (odds ratio 7.8, 95 % confidence interval 1.02-59.35; P = 0.048) was an independent predictor of MACCE. By Kaplan-Meier survival analysis, warfarin therapy was associated with a lower risk of MACCE (P = 0.024). In patients with AF undergoing coronary artery stenting, MACCE were reduced by warfarin therapy without increased bleeding, which might be related to tighter control with a lower INR value.

Topics: Aged; Anticoagulants; Asian People; Aspirin; Atrial Fibrillation; Blood Coagulation; Clopidogrel; Coronary Artery Disease; Coronary Thrombosis; Disease-Free Survival; Drug Monitoring; Drug Therapy, Combination; Female; Hemorrhage; Humans; International Normalized Ratio; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Odds Ratio; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Proportional Hazards Models; Republic of Korea; Retrospective Studies; Risk Factors; Stents; Stroke; Ticlopidine; Time Factors; Treatment Outcome; Warfarin

A free-floating thrombus in the left atrium is very rare in mitral stenosis. Such a thrombus can lead to sudden circulatory arrest and syncope or can cause severe cerebral or peripheral thromboembolic events. Clinical diagnosis is difficult, but left atrial thrombus should be suspected if patients with mitral stenosis and atrial fibrillation have intermittent or changing murmurs, emboli, or syncope. We describe the case of a patient with mild mitral stenosis under warfarin therapy, and a left atrial pedunculated thrombus discovered during the investigation for syncope attacks.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Coronary Thrombosis; Diagnosis, Differential; Echocardiography, Transesophageal; Female; Heart Atria; Humans; Mitral Valve Stenosis; Syncope; Warfarin

Coronary embolism is an uncommon cause of myocardial infarction. The usual source of a coronary embolus is an intracardiac thrombus or vegetation. Embolisation to the left main coronary artery is an extremely rare event and is usually fatal. We present a case of a 38-year-old woman with embolisation to the left main coronary artery which further embolised distally to the left anterior descending artery leading to a non-ST elevation myocardial infarction. The non-occlusive nature of the left main coronary artery embolus might have led to a favourable prognosis in our patient.

Topics: Adult; Anticoagulants; Coronary Thrombosis; Coronary Vessels; Drug-Eluting Stents; Embolism; Female; Humans; Intra-Aortic Balloon Pumping; Myocardial Infarction; Radiography; Thrombectomy; Ultrasonography; Warfarin

A 46-year-old man presented to our hospital with ST elevation myocardial infarction (STEMI). Previous records revealed a history of recurrent non-STEMI, stroke and transient ischaemic attacks. He was thoroughly investigated with coronary angiography, a cerebral CT angiography, thrombophilia panel and autoimmune screening tests, all of which proved negative. His current episode of STEMI resulted while on dual antiplatelet therapy; the patient was investigated for P2Y12 receptor resistance, which was also negative. A diagnosis of idiopathic recurrent arterial thrombosis was established and the patient was discharged home on aspirin and warfarin. Routine follow-up has revealed no recurrence of symptoms.

Topics: Anticoagulants; Aspirin; Brain Ischemia; Coronary Thrombosis; Diagnosis, Differential; Electrocardiography; Humans; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Recurrence; Warfarin

Patients with coronary artery aneurysms caused by Kawasaki disease are at increased risk of coronary thrombosis and ischemia. To prevent coronary thrombosis, long term thromboprophylaxis using anti-platelet drugs, such as aspirin, dipyridamole, ticlopidine, clopidogrel, and abciximab, with or without warfarin is recommended by official guidelines. In fact, aspirin or aspirin with warfarin are the most frequently administered regimen in these patients with coronary aneurysms. However, still there has been paucity of data and no randomized controlled study to determine the efficacy of these drugs. This short article describes the currently accepted practice of thromboprophylaxis in patients with coronary aneurysms caused by Kawasaki disease.

Topics: Aspirin; Coronary Aneurysm; Coronary Thrombosis; Humans; Mucocutaneous Lymph Node Syndrome; Platelet Aggregation Inhibitors; Warfarin

The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have 'failed' thrombectomy, characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 55-year-old man who was admitted to our institution with chest pain non-ST-elevation myocardial infarction due to a huge nonocclusive thrombus in an aneurysmatic segment of the left anterior descending coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with unfractioned heparin infusion and warfarin. Repeat coronary angiography at 7 days revealed complete thrombus resolution with thrombolysis in myocardial infarction grade 3 anterograde flow.This case demonstrates the potential for appropriate anticoagulation therapy as a treatment option for the management of patients following failed thrombectomy in PPCI.

Topics: Anticoagulants; Coronary Aneurysm; Coronary Angiography; Coronary Circulation; Coronary Thrombosis; Drug Therapy, Combination; Heparin; Humans; Infusions, Intravenous; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Suction; Thrombectomy; Treatment Failure; Warfarin

The safety of drug-eluting stents (DES) in patients on long-term warfarin treatment has been questioned due to high risk of bleeding complications during prolonged triple (aspirin, clopidogrel, and warfarin) antithrombotic therapy.. We analysed the long-term outcome of 415 consecutive warfarin-treated patients who underwent DES (n = 191) or bare-metal (n = 224) stenting in six hospitals.. The mean duration of triple therapy was longer (4.2 ± 3.1 versus 2.1 ± 1.8 months; P < 0.001) in the DES group. The incidence of major adverse cardiovascular and cerebrovascular events was comparable in the DES and bare-metal groups (39.8% versus 42.4%; P = 0.59) during a median follow-up of 3.5 years. Similarly, major bleeding events occurred equally often in both study groups (14.7% versus 12.9%). Six patients in the DES group and seven patients in the bare-metal group suffered stent thrombosis (3.1% versus 3.1%). In the propensity score analyses of 101 matched pairs, the outcome was similar in the two groups.. Selective use of DES with a short triple therapy seems to be safe in patients with warfarin therapy. The prognosis of this fragile patient population is quite poor, and major bleeding events are common irrespective of stent type.

Topics: Adult; Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Contraindications; Coronary Thrombosis; Drug Therapy, Combination; Drug-Eluting Stents; Female; Follow-Up Studies; Hemorrhage; Humans; Incidence; Kaplan-Meier Estimate; Male; Middle Aged; Platelet Aggregation Inhibitors; Propensity Score; Stents; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Coronary Thrombosis; Dabigatran; Humans; Male; Recurrence; Stroke; Ultrasonography; Warfarin

Topics: Aged; Anticoagulants; Atrial Fibrillation; Coronary Thrombosis; Echocardiography; Heparin; Humans; Male; Mitral Valve Stenosis; Pacemaker, Artificial; Rheumatic Heart Disease; Warfarin

Patients with nephrotic syndrome are at risk of developing thrombosis in both veins and arteries. Various manifestations in different organs have been reported. Thrombi in heart seen, associated with multiorgan thrombosis have been reported on autopsy earlier, but only once in a living patient with nephrotic syndrome. Here, we report a 13 years old boy with steroid-resistant nephrotic syndrome, who developed an asymptomatic but potentially hazardous large intracardiac thrombus. The child developed nephrotic syndrome at the age of 9 years and had multiple recurrences. At the age of 13 years, he developed myocardial infarction (MI) due to embolism from a large intracardiac thrombus. Later on, he was treated with heparin and warfarin anticoagulation.

Topics: Acute Coronary Syndrome; Adolescent; Adrenal Cortex Hormones; Anterior Wall Myocardial Infarction; Anticoagulants; Coronary Angiography; Coronary Thrombosis; Disease Progression; Echocardiography, Doppler; Electrocardiography; Follow-Up Studies; Heparin; Humans; Male; Nephrotic Syndrome; Rare Diseases; Recurrence; Risk Assessment; Severity of Illness Index; Treatment Outcome; Warfarin

Topics: Adult; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Aortic Dissection; Coronary Angiography; Coronary Thrombosis; Female; Humans; Ventricular Dysfunction, Left; Warfarin

The antithrombotic management of atrial fibrillation (AF) is currently based on clinical scores (CHADS(2) or CHA(2)DS(2)VASc). The prevalence of left atrium (LA) thrombi in effectively anticoagulated AF patients has been reported as being up to 7.7 %. We tried to correlate LA/LA appendage (LAA) thrombus detection with possible clinical predictors in warfarin-treated patients.. We performed trans-esophageal echocardiography on 430 patients (mean age, 60.3 ± 9.8 years) receiving oral anticoagulant (OAC) therapy and undergoing pulmonary vein isolation. In 10/430 (2.3 %), an LA thrombus was found despite therapeutic OAC (mean INR 2.6 ± 0.6; range, 2.0-3.8) over the previous 4 weeks.. Two study groups were identified: 1. T-positive group = with LAA thrombus (10 patients) 2. T-negative group = without LAA thrombus (420 patients) The T-positive patients had a higher CHADS(2) score (1.5 ± 0.7 versus 0.7 ± 0.8; p = 0.004), a lower LVEF (54.7 ± 9.5 % versus 60.2 ± 7.4; p = 0.02), and a larger LA size (LA diameter, 56 ± 12.2 mm versus 46 ± 6.5 mm; p  < 0.001and normalized LA volume: 140.2 ± 66 ml/m² vs. 67 ± 39 ml/m²; p < 0.05). On multivariate analysis, a larger LA diameter and normalized LA volume (OR, 1.14; 95 % C.I., 1.04-1.26; p = 0.006 and OR, 1.02; 95 % C.I., 1.01-1.03; p = 0.001, respectively) and a higher CHA(2)DS(2)VASc score (OR, 2.4; 95 % C.I., 1.4-4.2; p = 0.001) predicted left atrium appendage (LAA) thrombus. In another 42/430 (9.8 %) patients, an LA spontaneous echo-contrast (SEC) was detected. Thus, cumulatively, 52/430 (12.1 %) patients had either LAA thrombi (10 patients) or SEC (42 patients). LA diameter continued to predict the presence of either thrombi or SEC (OR, 1.14; 95 % C.I., 1.07-1.2; p < 0.05).. We found a 2.3 % prevalence of LA thrombus (12.1 % when SEC was also considered). The thrombus was present despite on-target warfarin prevention. In addition to a higher CHA(2)DS(2)VASc score, a larger LA size was a strong predictor of clot detection.

Topics: Anticoagulants; Atrial Appendage; Atrial Fibrillation; Catheter Ablation; Coronary Thrombosis; Echocardiography, Transesophageal; Female; Heart Atria; Humans; Logistic Models; Male; Middle Aged; Pulmonary Veins; Risk Assessment; Statistics, Nonparametric; Warfarin

Chronic heart failure (HF) with either reduced or preserved left ventricular (LV) ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to heart failure can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thromboembolism and/or venous thromboembolism. This executive summary of a joint consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence, summarises 'best practice', and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is clearly recommended, and the CHA2DS2-VASc and HAS-BLED scores should be used to determine the likely risk-benefit ratio (thromboembolism prevention versus risk of bleeding) of oral anticoagulation. In HF patients with reduced LV ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Whilst there is the potential for a reduction in ischaemic stroke, there is currently no compelling reason to routinely use warfarin for these patients. Risk factors associated with increased risk of thromboembolic events should be identified and decisions regarding use of anticoagulation individualised. Patient values and preferences are important determinants when balancing the risk of thromboembolism against bleeding risk. Novel oral anticoagulants that offer a different risk-benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials.

Topics: Anticoagulants; Aspirin; Case-Control Studies; Coronary Thrombosis; Europe; Fibrinolytic Agents; Heart Failure; Hemorrhage; Humans; Randomized Controlled Trials as Topic; Risk Factors; Societies, Medical; Stroke; Thromboembolism; Ventricular Dysfunction, Left; Warfarin

The aim of this study was to define the independent determinants of left atrial appendage (LAA) thrombus among various echocardiographic parameters measured by Velocity Vector Imaging (VVI) in patients with nonvalvular atrial fibrillation (AF) receiving warfarin, particularly in patients with a low CHADS2 score.. LAA emptying fraction (EF) and LAA peak longitudinal strain were measured by VVI using transesophageal echocardiography in 260 consecutive patients with nonvalvular persistent AF receiving warfarin. The patients were divided into two groups according to the presence (n=43) or absence (n=217) of LAA thrombus. Moreover, the patients within each group were further divided into subgroups according to a CHADS2 score ≤1.. Multivariate logistic regression analysis showed that LAAEF was an independent determinant of LAA thrombus in the subgroup of 140 with a low CHADS2 score. Receiver operating characteristics curve analysis showed that an LAAEF of 21% was the optimal cutoff value for predicting LAA thrombus.. LAA thrombus formation depended on LAA contractility. AF patients with reduced LAA contractile fraction (LAAEF ≤21%) require strong anticoagulant therapy to avoid thromboembolic events regardless of a low CHADS2 score (≤1).

Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Coronary Thrombosis; Female; Humans; Male; Middle Aged; ROC Curve; Severity of Illness Index; Stroke Volume; Ultrasonography; Ventricular Function, Left; Warfarin

Chronic thromboembolic pulmonary hypertension (CTEPH) is a chronic progressive disease of pulmonary circulation characterised by indistinct ethiopathogenesis. We present a case of a 50 year-old male with thrombophilia of unknown origin leading to the formation of multiple thrombi within venous circulation followed by episodes of acute pulmonary embolism resulting ultimately in acute heart failure in the course of developing CTEPH. Unfortunately, despite the wide range of haemostasis laboratory tests we were not able to define the type of coagulation abnormality. Owing to the efficient cooperation between cardiologists and cardiosurgeons it was possible to save patient's life.

Topics: Acenocoumarol; Anticoagulants; Cardiac Surgical Procedures; Coronary Thrombosis; Echocardiography, Doppler; Humans; Hypertension, Pulmonary; Intestine, Small; Male; Middle Aged; Myocardial Infarction; Necrosis; Pulmonary Embolism; Stroke; Time Factors; Treatment Outcome; Warfarin

Curable cause of stroke is the left atrial appendage (LAA) thrombi of atrial fibrillation (AF) patients. Some AF patients have the LAA thrombi. It is very important to cure AF patients by warfarin. Transoesophageal echocardiography (TOE) is the usual clinical tool to detect the LAA thrombi. Recently, a 64-slice multi-detector CT (64-MDCT) scan enables us to display the LAA thrombi more easily than TOE. I reported a case that a 64-MDCT scan had been used successfully in displaying the change of the LAA thrombi reduced by warfarin therapy. The size of the LAA thrombi was reduced from 25.2 mm × 19.3 mm (figure 1) to 22.1 mm × 14.8 mm (figure 2) after the 3-month warfarin therapy. It was useful to estimate the LAA thrombi by a 64-MDCT scan to estimate LAA thrombi itself and the change of LAA thrombi to evaluate the effectiveness of warfarin therapy.

Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Coronary Thrombosis; Female; Humans; International Normalized Ratio; Prothrombin Time; Tomography, X-Ray Computed; Warfarin

The optimal combination of anticoagulant and antiplatelet therapy following percutaneous coronary intervention with stenting (PCI-S) among patients requiring oral anticoagulation (OAC) is unknown.. We sought to compare the efficacy of a modified dual-antiplatelet regimen (daily aspirin and every other day clopidogrel) to conventional treatment (daily aspirin and daily clopidogrel) following percutaneous coronary intervention (PCI) with drug-eluting stents (DES) among patients who are also discharged on warfarin.. We performed a single-center, retrospective analysis of consecutive patients (n = 454) who underwent PCI-S with DES and were discharged on warfarin and either a conventional (n = 170) or modified (n = 284) antiplatelet regimen between March 2003 and May 2007. In-hospital and 1-year events were compared between the two groups.. There were no differences in 1-year rates of death, myocardial infarction, stent thrombosis or target lesion revascularization between patients receiving a conventional compared to a modified antiplatelet regimen. In-hospital bleeding rates were also similar between the two groups.. An antiplatelet regimen of aspirin with every-other-day clopidogrel may be as efficacious as daily aspirin and clopidogrel among patients receiving warfarin following PCI-S with DES.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Clopidogrel; Combined Modality Therapy; Coronary Artery Disease; Coronary Restenosis; Coronary Thrombosis; Drug Therapy, Combination; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Retrospective Studies; Ticlopidine; Treatment Outcome; Warfarin

Mechanical prosthetic valve thrombosis is a rare but life threatening complication after valve replacement. Although the traditional treatment of prosthetic valve thrombosis is surgery, recently thrombolytic therapy has been accepted as an alternative treatment. We describe for the first time prosthetic valve obstructive thrombus that was resolved by administering tirofiban (glycoprotein IIb/IIIa receptor antagonist) in a patient using warfarin with an international normalized ratio of 3.4. In our view, although this issue need to be clarified in further studies, tirofiban seems to be an alternative therapy especially in patients who have high risk of bleeding or surgical complication.

Topics: Adult; Anticoagulants; Coronary Thrombosis; Echocardiography, Transesophageal; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Tirofiban; Tyrosine; Warfarin

Sheath- and catheter-associated thrombi have become increasingly identified with the use of intracardiac echocardiography during left-sided ablation procedures. Despite adequate anticoagulation, these thrombi are found in ∼10% of cases. Management of these thrombi includes withdrawal of the sheath and catheter when the thrombi are felt to be firmly attached. In our case, we show another management technique, aspiration.

Topics: Atrial Fibrillation; Catheter Ablation; Coronary Thrombosis; Enoxaparin; Female; Heart Atria; Humans; Middle Aged; Suction; Thrombectomy; Treatment Outcome; Warfarin

A cardiac thrombus provides a substrate for thromboembolic events. Delayed enhancement cardiac magnetic resonance imaging detects a thrombus based on avascular tissue properties, and has been shown to provide improved detection of a left ventricular thrombus, compared with anatomic imaging using echocardiography. We present a case of a young man with cerebrovascular stroke in whom delayed enhancement cardiac magnetic resonance provided incremental diagnostic utility for identification of a thrombus within both the left-sided and right-sided cardiac chambers.

Topics: Adult; Anticoagulants; Coronary Thrombosis; Diagnosis, Differential; Follow-Up Studies; Heart Failure; Humans; Magnetic Resonance Imaging, Cine; Male; Stroke; Warfarin; Young Adult

Topics: Acute Disease; Anticoagulants; Contrast Media; Coronary Angiography; Coronary Thrombosis; Fibrinolytic Agents; Humans; Male; Middle Aged; Recombinant Proteins; Thrombolytic Therapy; Tissue Plasminogen Activator; Tomography, X-Ray Computed; Warfarin

This report describes the rapid buildup of an intraluminal thrombus and secondary myocardial ischemia after a brief therapeutic withdrawal of warfarin in a case of Kawasaki-related chronic giant coronary aneurysm. The importance of tight antithrombotic control in such cases is underscored.

Topics: Anticoagulants; Coronary Aneurysm; Coronary Thrombosis; Humans; Mucocutaneous Lymph Node Syndrome; Myocardial Ischemia; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Coronary Thrombosis; Female; Fibrinolytic Agents; Heart Valve Prosthesis; Humans; Middle Aged; Mitral Valve; Reoperation; Thrombolytic Therapy; Tissue Plasminogen Activator; Treatment Refusal; Warfarin

To determine the prognosis of patients with giant coronary aneurysms (GA) caused by Kawasaki disease (KD) treated with combined oral warfarin and aspirin.. A multicenter follow-up study of 83 patients (65 males, 18 females) with GA who had been treated for > or =3 months with warfarin. Most patients were placed on the combination therapy as soon as the GA was detected and remained on it for 6.0 +/-5.3 years, giving a total of 482 patient-years. Target international normalized ratio of prothrombin time ranged from 1.5 to > or =2.5. During this observational period, 5 patients suffered from 8 episodes of acute myocardial infarction and 1 died. Coronary thrombus formation enforced 6 courses of intracoronary thrombolysis in 3 patients (1-4 times). Consequently, freedom of cardiac events was 92.5% at 1 year and 91% at 10 years and the linearized cardiac event rate was 2.9% patient-year. Hemorrhagic complications occurred on 8 occasions (1 subdural hematoma) in 5 patients, giving 1.7% patient-year.. The combination of warfarin and aspirin has an acceptably high cardiac-event-free survival in patients with GA caused by KD, though it has a certain risk of hemorrhagic complications.

Topics: Administration, Oral; Adolescent; Anticoagulants; Aspirin; Child; Child, Preschool; Coronary Aneurysm; Coronary Thrombosis; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Infant; Male; Mucocutaneous Lymph Node Syndrome; Prognosis; Retrospective Studies; Risk Factors; Treatment Outcome; Warfarin

Free-floating left atrial ball thrombus is rare. We describe a case of a 48-year-old man who had free-floating left atrial ball thrombus that was not accompanied by mitral stenosis and that was treated aggressively with anticoagulants. Echocardiography revealed dramatic disappearance of the thrombus.

Topics: Anticoagulants; Coronary Thrombosis; Echocardiography; Heart Atria; Heparin; Humans; Male; Middle Aged; Mitral Valve Stenosis; Treatment Outcome; Urokinase-Type Plasminogen Activator; Warfarin

Topics: Acute Coronary Syndrome; Anticoagulants; Coronary Angiography; Coronary Thrombosis; Humans; Male; Platelet Aggregation Inhibitors; Risk Factors; Smoking; Stents; Warfarin; Young Adult

Topics: Aged; Anticoagulants; Cardiomyopathy, Dilated; Coronary Thrombosis; Echocardiography; Electrocardiography; Female; Heart Ventricles; Humans; Warfarin

In the present study, the authors investigated the management of mechanical valve thrombosis (MVT). From January 1981 through March 2006, 2,908 mechanical valve replacements were performed in 2,298 patients at our institution. Twenty (0.87%) patients presented with MVT, 14 (70.0%) were women, and the mean age of the patients was 42.0+/-14.0 (27-66) yr. Thrombosis involved mitral in 14 (70.0%), aortic in 2 (10.0%), tricuspid/aortic in 1 (5%), and tricuspid in 3 (15%). The interval from first operation to valve thrombosis was 121.8+/-75.4 (0.9-284.7) months. The most frequent clinical presentation was heart failure (13/20, 65%), and predisposing causes of MVT were: poor compliance with warfarin (7), pregnancy (5), drug interaction (2), and unknown (6). All 20 patients underwent valve replacement: mitral (14, 70.0%), tricuspid (3, 15.0%), aortic (2, 10%) and tricuspid/aortic (1, 5%). One early death occurred due to left ventricular failure, but no late mortality occurred during 63.3+/-49.9 (0.5-165.1) months of follow-up. MVT was treated successfully, and pregnancy and inadequate anticoagulation were found to influence the occurrence of this rare complication.

Topics: Adult; Aged; Anticoagulants; Coronary Thrombosis; Drug Interactions; Female; Follow-Up Studies; Heart Valve Prosthesis; Heparin; Humans; International Normalized Ratio; Male; Middle Aged; Patient Compliance; Postoperative Complications; Pregnancy; Pregnancy Complications; Recurrence; Reoperation; Retrospective Studies; Risk Factors; Thrombolytic Therapy; Warfarin

Topics: Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Coronary Thrombosis; Cough; Cytochrome P-450 CYP2C9; Genotype; Heart Failure; Humans; International Normalized Ratio; Losartan; Male; Middle Aged; Pharmacogenetics; Polypharmacy; Ramipril; Warfarin

Antiphospholipid syndrome is a well-defined entity that is characterized by spontaneous abortion, thrombocytopenia, and recurrent arterial and venous thromboses. A partially calcified right atrial thrombus mimicking myxoma with recurrent pulmonary embolism has not been previously reported in a patient who also had systemic lupus erythematosus and secondary antiphospholipid syndrome. Herein, we describe the case of a 37-year-old woman with systemic lupus erythematosus and secondary antiphospholipid syndrome who was admitted to the hospital with progressive exertional dyspnea. Ventilation-perfusion scanning showed multiple parenchymal defects in the lungs that portended pulmonary embolism. In addition, the scanning revealed normal regional ventilation. Transthoracic and transesophageal echocardiography showed a right atrial mass that was highly suggestive of myxoma, and the patient subsequently underwent surgery. A histologic examination showed an organized, partially calcified thrombus. Intracardiac thrombus has been rarely reported as a complication of antiphospholipid syndrome. In our patient, the preoperative investigations could not differentiate the partially calcified right atrial thrombus from a myxoma, and the diagnosis was made postoperatively.

Topics: Adult; Antibodies, Monoclonal; Antibodies, Monoclonal, Murine-Derived; Anticoagulants; Antineoplastic Agents; Antiphospholipid Syndrome; Coronary Thrombosis; Diagnosis, Differential; Female; Heart Atria; Humans; Immunologic Factors; Lupus Erythematosus, Systemic; Myxoma; Perfusion; Pulmonary Embolism; Risk Factors; Rituximab; Ultrasonography; Warfarin

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Clopidogrel; Coronary Restenosis; Coronary Thrombosis; Drug-Eluting Stents; Humans; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Stroke; Ticlopidine; Warfarin

We review the case of a 46-year-old man who underwent elective percutaneous coronary intervention and stenting of the left anterior descending artery and right coronary artery with two sirolimus- and paclitaxel-eluting stents. Four days after angioplasty, he was readmitted with cardiogenic shock due to acute anterior and inferior myocardial infarction. Coronary angiography revealed subacute thrombosis of both stents, and balloon dilation was performed successfully thereafter. The follow-up investigations revealed that the patient was a carrier of factor V Leiden. We hereby discuss the importance of factor V Leiden as the most common cause of hypercoagulable state and its probable role in acute and subacute coronary stent thrombosis in drug-eluting stents.

Topics: Angioplasty, Balloon; Anticoagulants; Aspirin; Clopidogrel; Coronary Angiography; Coronary Thrombosis; Drug-Eluting Stents; Factor V; Humans; Male; Middle Aged; Mutation; Paclitaxel; Platelet Aggregation Inhibitors; Sirolimus; Ticlopidine; Warfarin

Topics: Aged; Anticoagulants; Carotid Stenosis; Coronary Angiography; Coronary Artery Bypass; Coronary Thrombosis; Diagnosis, Differential; Echocardiography; Endarterectomy, Carotid; Humans; Male; Myocardial Infarction; Ventricular Dysfunction, Left; Warfarin

Topics: Aspirin; Atrial Fibrillation; Clopidogrel; Coronary Thrombosis; Drug Therapy, Combination; Fibrinolytic Agents; Humans; Risk Factors; Ticlopidine; Venous Thrombosis; Warfarin

A 53-year-old man presented to hospital 2 hours after the abrupt onset of left upper abdominal pain. He was treated with analgesics and discharged after 4 hours of observation, but presented to another hospital 2 hours later with severe left abdominal pain. His past medical history included ischemic dilated cardiomyopathy due to recurrent myocardial infarction.. Physical examination, electrocardiography, laboratory investigations, contrast-enhanced computed tomography, and transesophageal echocardiography.. Renal artery thromboembolism resulting from dilated cardiomyopathy, severely reduced cardiac function and an intracardiac thrombus.. Anticoagulation with unfractionated heparin followed by enoxaparin and warfarin.

Topics: Abdominal Pain; Acute Disease; Anticoagulants; Cardiomyopathy, Dilated; Coronary Thrombosis; Diagnosis, Differential; Echocardiography, Transesophageal; Enoxaparin; Humans; Infarction; Kidney Diseases; Male; Middle Aged; Renal Artery; Tomography, X-Ray Computed; Warfarin

Topics: Aged; Anticoagulants; Cardiomegaly; Coronary Thrombosis; Female; Heart Atria; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Thromboembolism; Ultrasonography; Warfarin

Here is a case where the right coronary artery is filled with thrombus and has been successfully treated with warfarin.

Topics: Angina Pectoris; Anticoagulants; Aspirin; Clopidogrel; Coronary Thrombosis; Drug Therapy, Combination; Enoxaparin; Female; Humans; Infusion Pumps; Middle Aged; Platelet Aggregation Inhibitors; Risk Factors; Ticlopidine; Tirofiban; Treatment Failure; Treatment Outcome; Tyrosine; Warfarin

Coronary embolism as a cause of myocardial infarction is an uncommon but important entity both in terms of aetiology and treatment. Previous cases of coronary emboli in association with prosthetic mechanical valves have been reported previously but the mechanism of pharmacology and lack of patient awareness of medication importance is quite unique in this case. A 65-year-old male presented to the emergency room with an anterior ST elevation myocardial infarction after 14 h of symptoms. Past medical history included aortic valve replacement with a mechanical tilting-disc valve 18 months earlier for symptomatic severe calcific aortic stenosis. Pre-operative coronary angiography revealed normal coronary arteries. On this occasion, coronary angiography revealed an occluded LAD with an embolic occlusion at the midpoint of the vessel. Successful PTCA and stenting of the lesion were performed. Amazingly, the patient had decided 1 year earlier to stop taking his warfarin medication. He had begun taking a new "herbal remedy" which was helping with his joint pains but the combination with warfarin was causing excessive bleeding each day after facial shaving. He therefore decided to abruptly stop taking his warfarin without any medical advice. Embolic myocardial infarction is underdiagnosed and it is important to diagnose the source of embolism and treat the cause. Patient education is vital in our battle to prevent this entity in high-risk patients as in our case.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aortic Valve Stenosis; Coronary Thrombosis; Heart Valve Prosthesis Implantation; Humans; Male; Myocardial Infarction; Stents; Warfarin

Atrial fibrillation is the most common rhythm disturbance and can also occur in absence of true cardiac disease. However, also in these cases, it can generate left atrial appendage thrombi with systemic embolic potential. A regular and well conducted anticoagulant therapy with dicoumarol derivatives, as indicated in these patients, is not always successful. We report the case of a patient with lone atrial fibrillation and a left atrial appendage thrombus resistant to anticoagulant therapy with warfarin, which disappeared after catheter ablation of atrial fibrillation by electrical disconnection of the pulmonary veins, restoration of sinus rhythm and dual-chamber pacemaker implantation.

Topics: Anticoagulants; Atrial Appendage; Atrial Fibrillation; Cardiac Pacing, Artificial; Catheter Ablation; Combined Modality Therapy; Coronary Thrombosis; Drug Resistance; Echocardiography; Female; Humans; Middle Aged; Warfarin

Kawasaki disease (KD) has potentially serious cardiac complications including coronary artery aneurysms. Children who develop giant aneurysms (GA) are at increased risk of thrombosis and ischemia, and although longterm oral anticoagulation with warfarin is recommended, its efficacy has not been studied. We examined the longterm outcome of patients with GA secondary to KD, to determine if anticoagulation with warfarin aids in the prevention of myocardial ischemia.. We studied patients with KD followed between May 1990 and April 2000.. Thirty-nine GA occurred in 2.2% of patients with KD (22/997 patients), and 33 non-GA were also identified in these patients. Patients were divided into 2 groups, those taking warfarin and no warfarin. Most patients in both groups were also taking antiplatelet agents. The demographics of the 2 groups were statistically similar, except the median duration of followup was significantly longer for patients in the no-warfarin group (6.9 vs 13.3 yrs; p = 0.008). Four early ischemic events (< 1 year after KD diagnosis) occurred (3 myocardial infarctions and one stroke). Screening for late ischemic events by stress nuclear medicine myocardial perfusion imaging revealed only one patient, in the no-warfarin group, with reversible perfusion defects. No patient had clinical signs or symptoms of late myocardial ischemia. Echocardiographic regression of aneurysms was observed in both groups. In the warfarin vs no-warfarin group, the diameters of the GA regressed a median 22% vs 32% (p = 0.27), and non-GA regressed a median of 30% vs 25% (p = 0.61). Compliance with anticoagulation was good, and no major bleeding complication of anticoagulation occurred.. Regression of GA occurred in most of our patients, and minimal late ischemia was observed. Further studies are required to evaluate the use of oral anticoagulation in patients with GA secondary to KD.

Topics: Adolescent; Aneurysm; Anticoagulants; Child; Child, Preschool; Coronary Thrombosis; Coronary Vessels; Female; Humans; Infant; Male; Mucocutaneous Lymph Node Syndrome; Myocardial Ischemia; Retrospective Studies; Treatment Outcome; Warfarin

A 68-year-old man taking aspirin and warfarin for ectatic right coronary artery complained of chest pain and was admitted to our hospital with acute myocardial infarction. He had discontinued taking warfarin due to nail bleeding for a month. Coronary angiography revealed total occlusion at segment 3 of the ectatic right coronary artery with massive thrombus. Because of unsuccessful reperfusion by an aspiration device, a 5F straight catheter was inserted into the ectatic right coronary artery to aspirate the massive thrombus, and Thrombolysis in Myocardial Infarction grade 3 flow reperfusion was obtained. Intravascular ultrasonography showed "moyamoya" vessels in the ectatic right coronary artery, suggesting an abnormal coronary flow pattern, but there was no evidence of unstable plaque. Warfarization should be considered to treat ectatic coronary artery.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Coronary Angiography; Coronary Thrombosis; Coronary Vessels; Dilatation, Pathologic; Heparin; Humans; Male; Myocardial Infarction; Thrombectomy; Warfarin

Thromboembolic events are serious complications of atrial fibrillation (AF). We histologically investigated intraatrial thrombogenesis in a 52-year-old woman with mitral stenosis and chronic AF who had recurrent attacks of cerebral infarction despite continuous warfarin therapy. She underwent cardiac surgery for mitral valve replacement and maze procedure including left atrial thrombectomy. Macroscopic thrombi were found on the endocardium and their surfaces appeared rough and dark red in most areas. Histological examination showed that a single thrombus mass was composed of several tissue layers or blocks on the endocardium. Immunohistochemistry revealed stratum-like accumulations of small platelet aggregate/fibrin clot complexes in the superficial, fresh thrombus layers and multiple neovessel formation in the basal organized tissue layers. This case study suggests that intraatrial thrombi may develop in a stepwise fashion on the endocardium involving platelet aggregate/fibrin clot complex formation.

Topics: Adult; Atrial Fibrillation; Coronary Thrombosis; Drug Resistance; Female; Humans; Immunohistochemistry; Middle Aged; Mitral Valve Stenosis; Platelet Aggregation; Thrombectomy; Warfarin

Topics: Adult; Anticoagulants; Coronary Thrombosis; Female; Heart Valve Prosthesis; Humans; International Normalized Ratio; Mitral Valve; Myocardial Infarction; Warfarin

We report a case of acute thrombosis formation in the left atrium 3 days after the discontinuation of warfarin therapy prior to mitral valve replacement in a patient with mitral stenosis and atrial fibrillation. A 58-year-old Asian female patient was scheduled for mitral valve replacement for mitral stenosis. She had received warfarin therapy every day for 2 years. Warfarin therapy was discontinued 3 days before surgery. Using transesophageal echocardiography (TEE), we confirmed that there was no thromboembolism at the left atrium 10 days before surgery. No replacement anticoagulant therapy, such as heparin, was given after the discontinuation of warfarin. After the induction of anesthesia, a TEE probe was inserted through the esophagus to monitor left ventricular function. We found two thrombi (35 mm and 40 mm in diameter) in the left atrium. This case shows that discontinuation of warfarin therapy within a few days before operation carries a risk of thromboembolism formation.

Topics: Acute Disease; Anticoagulants; Coronary Thrombosis; Echocardiography, Transesophageal; Female; Heart Atria; Humans; Middle Aged; Mitral Valve; Warfarin

We sought to determine the frequency and timing of complications at our institution when surgery was performed within two months of coronary stent placement.. The optimal delay following coronary stent placement prior to non-cardiac surgery is unknown.. We analyzed the Mayo Clinic Percutaneous Coronary Intervention and Surgical databases between 1990 and 2000 and identified 207 patients who underwent surgery in the two months following successful coronary stent placement.. Eight patients (4.0%) died or suffered a myocardial infarction or stent thrombosis. All 8 patients were among the 168 patients (4.8%, 95% confidence interval [CI] 2.1 to 9.2) undergoing surgery six weeks after stent placement; the frequency of these events ranged from 3.8% to 7.1% per week during each of the six weeks. No events occurred in the 39 patients undergoing surgery seven to nine weeks after stent placement (0%, 95% CI 0.0 to 9.0).. These data suggest that, whenever possible, non-cardiac surgery should be delayed six weeks after stent placement, by which time stents are generally endothelialized, and a course of antiplatelet therapy to prevent stent thrombosis has been completed.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Blood Transfusion; Coronary Angiography; Coronary Disease; Coronary Thrombosis; Female; Humans; Male; Middle Aged; Minnesota; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Pyridines; Retrospective Studies; Stents; Surgical Procedures, Operative; Time Factors; Treatment Outcome; Warfarin

Patients with mechanical heart valves are treated with oral anticoagulant therapy in order to minimize the risk of thromboembolism. During invasive procedures it is recommended to temporarily discontinue the oral anticoagulant therapy and substitute with injections of low-molecular-weight heparin. We describe a case where a patient discontinued the oral anticoagulant therapy and had no substitution with low-molecular-weight heparin. The patient had an embolism to the coronary arteries causing progressive heart failure, and the patient was subsequently heart transplanted.

Topics: Adult; Anticoagulants; Aortic Valve Insufficiency; Coronary Thrombosis; Heart Transplantation; Heart Valve Prosthesis; Humans; Male; Substance Withdrawal Syndrome; Thromboembolism; Warfarin

We report herein a patient in whom a very large and old thrombus in the left atrium was detected by transesophageal echocardiography. The patient started warfarin and aspirin. After 2 years of therapy, transesophageal echocardiography showed the complete resolution of thrombus in the absence of clinical evidence of embolism. This case indicates that large and presumably organized thrombi may be dissolved by an anticoagulant therapy, although the lytic activity of warfarin has never been demonstrated. Transesophageal echocardiography helps in the identification and follow-up of such conditions and contributes to understanding of warfarin action in left atrial thrombosis.

Topics: Anticoagulants; Aspirin; Chronic Disease; Coronary Thrombosis; Drug Therapy, Combination; Echocardiography, Transesophageal; Heart Atria; Humans; Male; Middle Aged; Warfarin

Topics: Anticoagulants; Coronary Thrombosis; Homocysteine; Humans; Protein C Deficiency; Warfarin

The optimal therapeutic range for laboratory evaluation of oral anticoagulant therapy is now defined by the prothrombin time international normalized ratio (PT-INR). However, the thrombo test (TT), an alternative method to measure intensity of anticoagulation, is also currently used throughout Japan. The relationship between PT-INR and TT (%) has yet to be clarified. This study investigated the relationship between PT-INR and TT (%).. The PT-INR and TT (%) were simultaneously measured of 505 consecutive samples from patients treated with warfarin in our hospital. Fourteen functions were used for regression analyses: a fractional function (Y = a/X + b), a square root function (Y = aX0.5 + b), a natural logarithmic function (Y = a.lnX + b), a power series function (Y = aXb), a quotient function (Y = abX), and polynomial functions [Y = anXn + an - 1Xn - 1 +......+ a1X1 + b, (1 < or = n < or = 9)]. The results were confirmed by the same methods in 383 samples and 296 samples from another two laboratories.. The power series function showed the most significant (p < 0.0001) and highest adjusted R2 (0.858) correlation, with a regression formula of TT (%) = e4.48 (PT-INR)-2.09 in our laboratory. Using the same analyses, the power series function also showed the most significant and highest adjusted R2 in samples from the other two laboratories.. This study showed that a power series function is the most appropriate for expressing the relationship between PT-INR and TT (%) among the 14 functions. The function between PT-INR and TT (%) is mainly derived from the relationship between TT (%) and TT (sec). Both internal validity and external validity confirmed the relationship between PT-INR and TT (%).

Topics: Aged; Anticoagulants; Atrial Fibrillation; Blood Coagulation Tests; Coronary Thrombosis; Female; Humans; International Normalized Ratio; Male; Middle Aged; Prothrombin Time; Reference Standards; Regression Analysis; Warfarin

Topics: Animals; Anticoagulants; Aspirin; Coronary Thrombosis; Dogs; Humans; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Stents; Ticlopidine; Warfarin

Right ventricular thrombus is a very rare manifestation of cardiovascular Behcet's disease. A 25-year-old man was admitted to hospital due to cough and fever of unknown origin. He experienced repetitive pulmonary embolism due to a right ventricular thrombus, which was surgically removed. A diagnosis of Behcet's disease was made based on his clinical course and the histological findings of the right ventricular wall and the skin lesion. He was quickly relieved of his symptoms after warfarinization and cyclosporine therapy.

Topics: Adult; Behcet Syndrome; Coronary Thrombosis; Cyclosporine; Diagnosis, Differential; Humans; Male; Paresis; Pulmonary Embolism; Ventricular Dysfunction, Right; Warfarin

We sought to determine the influence of plaque morphology and warfarin anticoagulation on the risk of recurrent emboli in patients with mobile aortic atheroma.. An epidemiologic link between aortic atheroma and systemic emboli has been described both in pathologic and transesophageal studies. Likewise, a few studies have found an increased incidence of recurrent emboli in these patients. The therapeutic implications of these findings has not been studied.. Thirty-one patients presenting with a systemic embolic event and found to have mobile aortic atheroma were studied. The height, width and area of both immobile and mobile portions of atheroma were quantitated. The dimensions of the mobile component was used to define three groups: small, intermediate and large mobile atheroma. The patients were followed up by means of telephone interview and clinical records, with emphasis on anticoagulant use and recurrent embolic or vascular events.. Patients not receiving warfarin had a higher incidence of vascular events (45% vs. 5%, p = 0.006). Stroke occurred in 27% of these patients and in none of those treated with warfarin. The annual incidence of stroke in patients not taking warfarin was 0.32. Myocardial infarction occurred in 18% of patients also in this group. Taken together, the risk of myocardial infarction or stroke was significantly increased in this group (p = 0.001). Forty-seven percent of patients with small, mobile atheroma did not receive warfarin. Recurrent stroke occurred in 38% of these patients, representing an annual incidence of 0.61. There were no strokes in patients with small, mobile atheroma treated with warfarin (p = 0.04). Likewise, none of the patients with intermediate or large mobile atheroma had a stroke during follow-up. Only three of these patients had not been taking warfarin.. Patients presenting with systemic emboli and found to have mobile aortic atheroma on transesophageal echocardiography have a high incidence of recurrent vascular events. Warfarin is efficacious in preventing stroke in this population. The dimension of the mobile component of atheroma should not be used to determine the need for anticoagulation.

Topics: Aged; Anticoagulants; Aortic Diseases; Arteriosclerosis; Cerebrovascular Disorders; Coronary Thrombosis; Echocardiography, Transesophageal; Female; Humans; Male; Middle Aged; Recurrence; Treatment Outcome; Warfarin

Topics: Administration, Oral; Anticoagulants; Aspirin; Coronary Thrombosis; Dose-Response Relationship, Drug; Drug Therapy, Combination; Humans; Male; Myocardial Ischemia; Risk Factors; Survival Rate; Warfarin

We report the case of a 74-year-old woman who underwent an elective procedure to replace her mitral valve with a 27-mm CarboMedics bileaflet valve (CarboMedics, Inc.; Austin, Tex) to correct mitral incompetence. Massive thrombosis of the prosthesis was clinically evident on the 6th postoperative day, despite administration of warfarin therapy according to our usual protocol. After an unsuccessful attempt at thrombolysis with recombinant tissue plasminogen activator, the mechanical prosthesis was replaced with a bioprosthesis. The cause of the thrombosis is unknown, but transient suboptimal anticoagulation is assumed to be responsible. Although very early massive valve thrombosis is a rare occurrence, it is a known risk of prosthetic valve implantation. Antiplatelet therapy, in addition to the usual warfarin anticoagulation, can help to prevent it. If thrombosis is diagnosed, it can be managed by thrombolysis or, when thrombolysis is unsuccessful, by reoperation. Transesophageal echocardiography is fundamental in the diagnosis and management of this sequela.

Topics: Aged; Anticoagulants; Bioprosthesis; Coronary Thrombosis; Female; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Postoperative Complications; Reoperation; Warfarin

Topics: Adolescent; Anticoagulants; Cardiomyopathy, Dilated; Coronary Thrombosis; Heart-Assist Devices; Heparin; Humans; Male; Muscular Dystrophies; Platelet Activation; Warfarin

To evaluate the safety and efficacy of transition in practice after coronary stenting to antiplatelet therapy alone compared with anticoagulation with warfarin.. Retrospective analysis of coronary stent management in a tertiary Canadian centre.. A total of 136 consecutive patients (146 lesions) were analyzed who underwent Palmaz-Schatz coronary stenting over a 15-month period and were treated with anticoagulation with warfarin (56 patients) or antiplatelet therapy alone with ticlopidine and acetylsalicylic acid (80 patients) during the transition in poststenting therapy in the authors' practice. Treatment was continued for 30 days in both groups. High pressure stent deployment was used in the majority of cases (greater than 90%), and use of intravascular ultrasound was infrequent (less than 12%).. At 30 days, there were no clinical manifestations of stent thrombosis, coronary artery bypass surgery or repeat angioplasty in either group. One death occurred in the antiplatelet group. Periprocedural non-Q wave myocardial infarction occurred in two patients in the antiplatelet group and in one patient in the warfarin group. There was a significantly higher incidence of vascular complications in the warfarin group than in the antiplatelet group (14.3% versus 2.5%, respectively, P = 0.04). The length of hospital stay was significantly shorter in the antiplatelet group than in the warfarin group (3.0 +/- 1.8 versus 6.7 +/- 2.6 days, respectively, P < 0.001).. Reduced anticoagulation with antiplatelet therapy alone after coronary stenting, despite infrequent use of intravascular ultrasound, is an effective and safe strategy with a low rate of vascular complications, a relatively short hospital stay and a low incidence of clinical manifestations of stent thrombosis.

Topics: Adult; Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Coronary Artery Bypass; Coronary Disease; Coronary Thrombosis; Female; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Radiography; Reoperation; Retrospective Studies; Stents; Ticlopidine; Treatment Outcome; Warfarin

Two hundred forty-three stents (203 Palmaz-Schatz, 40 Glanturco-Roubin) were electively Implanted in 188 lesions in 168 patients (mean age 58 +/- 10 years, 77% males) using angiographic but not ultrasound guidance. Patients were treated subsequently with aspirin and observed in hospital for up to 7 days. Those with acute myocardial infarction, radiolucent defects in coronary arteries suggestive of thrombus, and results that were not optimal after stent implantation were anticoagulated with warfarin and not Included in the study. Two had subacute stent thrombosis and two patients non-Q-wave myocardial infarction in-hospital. At follow-up (median 149 days) none had had subacute stent thrombosis, one suffered non-Q-wave myocardial infarction, none had died, and none had developed major complications at the vascular access site. Fourteen (8%) had undergone further revascularisation procedures. This initial experience suggests that aspirin is sufficient to prevent subacute stent thrombosis after elective high pressure assisted coronary stent implantation without intravascular ultrasound guidance if the angiographic appearance after stent deployment is optimal.

Topics: Adult; Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Combined Modality Therapy; Coronary Angiography; Coronary Disease; Coronary Thrombosis; Female; Fibrinolytic Agents; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Infarction; Premedication; Recurrence; Stents; Treatment Outcome; Ultrasonography, Interventional; Warfarin

Atrial fibrillation is an important risk factor for systemic embolism. A number of clinical studies demonstrated the beneficial effect of anticoagulant therapy for the prevention of embolism. But there has been no study on the fate of left atrial thrombus demonstrated by transesophageal echocardiography in the course of anticoagulation therapy.. Thirteen patients, demonstrated to have left atrial thrombus by transesophageal echocardiography were followed with anticoagulation therapy. Repeated transesophageal echocardiography was done 15 months after 1st study.. Among 9 patients with adequate anticoagulation effect (INR > 2.0), left atrial thrombus disappeared in 3 patients. The size of thrombus decreased from 2.2 +/- 0.8cm to 0.9 +/- 1.0cm (p < 0.05 by paired Student's t-test).. Left atrial thrombus could dissolve or decrease in size with adequate anticoagulation.

Topics: Coronary Thrombosis; Echocardiography, Transesophageal; Female; Follow-Up Studies; Humans; Male; Warfarin

Topics: Coronary Thrombosis; Heart Ventricles; Heparin; Humans; Myocardial Infarction; Warfarin

Three clinical cases have been selected to focus on the role of thrombosis in unstable and refractory angina. The histories are abbreviated for simplicity. For example, it can be assumed that non-coronary causes of chest discomfort have been excluded, and that exacerbating factors such as anaemia, hyperthyroidism, hypoxia, arrhythmia, valve disease, obvious coagulopathy, and emotional stress have also been excluded by history, examination, and appropriate testing. These patients all underwent coronary angiography for severe symptoms associated with marked electrocardiographic or haemodynamic changes (and therefore did not undergo radionuclide stress testing) or for symptoms refractory to a medical regimen of rest, reassurance, oxygen, nitrates, cardioselective beta blockers, aspirin 325 mg once or twice daily, heparin 1000 U/h, and sometimes, calcium antagonists and sedatives.

Topics: Aged; Angina, Unstable; Angioplasty, Balloon, Coronary; Coronary Angiography; Coronary Thrombosis; Female; Heparin; Humans; Male; Middle Aged; Recurrence; Warfarin

The presence of a left atrial thrombus is considered to be a relative contraindication to percutaneous transvenous mitral commissurotomy (PTMC) in patients with rheumatic mitral stenosis. However, resolution of left atrial thrombus after anticoagulant therapy with warfarin makes PTMC possible. From July 1989 to June 1991, a total of 70 patients with rheumatic mitral stenosis received PTMC at National Taiwan University Hospital. Of these, four patients underwent PTMC uneventfully after resolution of left atrial thrombi with anticoagulant therapy. The prothrombin time was kept at around 1.5 times that for the normal controls and transesophageal echocardiography (TEE) was used for follow-up. The time for resolution of left atrial thrombi was 1.5, 11, 12, and 2 months. In all four patients with chronic atrial fibrillation, TEE revealed the presence of left atrial thrombi; in only two of these cases was there a suspicion of left atrial thrombi on transthoracic echocardiography. It is concluded that: (1) left atrial thrombi may be resolved after anticoagulant therapy with warfarin, but the time required varies for different patients; and (2) TEE is better than conventional transthoracic echocardiography for detecting a left atrial thrombus and is recommended as the tool of choice for observing the response of a left atrial thrombus to anticoagulant therapy.

Topics: Adult; Anticoagulants; Coronary Thrombosis; Echocardiography; Female; Heart Atria; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Stenosis; Rheumatic Heart Disease; Warfarin

To clarify the relationship between clotting and lytic activities of intracardiac thrombi, and to elucidate whether this could be used to evaluate the embolic risk the ratio of indium-111 radioactivity accumulated on thrombi to that in the blood pool using dual-tracer technique %IE as a parameter of the clotting activity, and D-dimer, which is a fibrin specific degradation product, as a parameter of lytic activity were measured in 37 patients with intracardiac thrombi. Fifteen of the 37 patients had past histories of arterial embolization. The values of D-dimer correlated significantly with those of %IE (r = 0.758, p less than 0.01), e.g., the higher the values of D-dimer the higher the values of %IE. 37 patients were divided into 2 groups using the regression line for the D-dimer and %IE domains. Eleven patients above the regression line had thrombosis in excess of fibrinolysis but the remaining 26 patients under the regression line had fibrinolysis in excess of thrombosis. The incidence of past embolic episodes was 82% (9/11) in patients with thrombosis in excess of fibrinolysis but 23% (6/26) in patients with fibrinolysis in excess of thrombosis. These results demonstrated that intracardiac thrombi were under the dynamic process between the clotting and the lytic activities and moreover patients with intracardiac thrombi and thrombosis in excess of fibrinolysis had a substantial risk of arterial embolization.

Topics: Aged; Coronary Thrombosis; Female; Fibrin Fibrinogen Degradation Products; Fibrinolysis; Humans; Indium Radioisotopes; Male; Middle Aged; Technetium Tc 99m Aggregated Albumin; Thromboembolism; Ventriculography, First-Pass; Warfarin

A 37-yr-old white female was admitted to hospital with an evolving anterior myocardial infarction. Coronary arteriography revealed multiple aneurysms in the left anterior descending (and right) coronary arteries. In the left anterior descending artery, there was evidence of extensive thrombus formation. The patient was successfully treated with intracoronary urokinase, intravenous heparin, and oral warfarin. There was partial thrombolysis in 16 hr and complete thrombolysis noted 6 wk later. This case of multiple coronary aneurysms, secondary to presumed Kawasaki disease, is the first documentation of antemortem intra-aneurysmal coronary thrombosis treated successfully by thrombolytic and anticoagulant therapy.

Topics: Administration, Oral; Adult; Cardiac Catheterization; Coronary Aneurysm; Coronary Angiography; Coronary Thrombosis; Drug Therapy, Combination; Female; Heparin; Humans; Infusions, Intravenous; Mucocutaneous Lymph Node Syndrome; Myocardial Infarction; Thrombolytic Therapy; Urokinase-Type Plasminogen Activator; Warfarin

The purpose of this study was to determine the criteria of valve selection from the long-term results of Hancock, Carpentier-Edwards, St Jude Medical and Bjork-Shiley prostheses, taking into special account the frequency of reoperation. Reoperations on the Hancock bioprosthesis were performed on six patients for tissue leaflet disruption with an incidence of 2.2 per cent/patient-year. Reoperations on the Carpentier-Edwards bioprosthesis were performed on 24 patients for tissue leaflet disruption in 23 patients and prosthetic valve endocarditis (PVE) in one, with an incidence of 3.8 per cent/patient-year. Reoperations on the Bjork-Shiley prosthesis were performed in two patients for severe hemolysis, with an incidence of 0.32 per cent/patient-year. Reoperations on the St Jude Medical prosthesis were performed on 3 patients, for valve thrombosis in one patient, PVE in one, and hemolysis in one, with an incidence of 0.23 per cent/patient-year. The overall mortality rate was 20 per cent, or 7 patients, and the indications for reoperation affected this. Patients with primary tissue failure had a mortality rate of 10.3 per cent; those with a thrombosed valve, 0 per cent; those with hemolysis, 66.7 per cent; and those with valve infection, 100 per cent. A good chance of survival may be achieved in patients facing prosthetic valve complications by performing reoperation as soon as possible after early detection, since mortality is high following emergency reoperation and in patients with severe symptoms. Currently, we recommend mechanical prostheses for valve replacement except in patients over 70 years old and in younger patients with absolute contraindications to anticoagulative therapy.

Topics: Aged; Aortic Valve; Bioprosthesis; Coronary Thrombosis; Evaluation Studies as Topic; Heart Valve Diseases; Heart Valve Prosthesis; Hemolysis; Humans; Mitral Valve; Prosthesis Failure; Reoperation; Time Factors; Tricuspid Valve; Warfarin

Topics: Aged; Anticoagulants; Coronary Disease; Coronary Thrombosis; Female; Heart Atria; Humans; Intracranial Embolism and Thrombosis; Warfarin

The relationship between left ventricular thrombus and left ventricular dynamics in dilated cardiomyopathy (DCM) was studied by echocardiography and postmortem examination. The subjects were 57 patients with DCM, 40 were survival patients examined by echocardiography and 17 were autopsy patients. Systemic or pulmonary embolism occurred in 10 of 57 patients, 4 of 40 survival patients and 6 of 17 autopsy patients. Intracardiac thrombus was detected in 11 of 40 survival patients and was found in 8 of 17 autopsy patients. Left ventricular segmental wall motion abnormalities were observed in all 40 patients examined by two-dimensional echocardiography and apical dyskinesis or akinesis was observed more frequently in patients with left ventricular thrombus than in patients without left ventricular thrombus. Of 33 patients examined by pulsed Doppler echocardiography, Doppler ejection flow signals in the apical long axis view were recorded in 9% at the apex, in 17% at the middle portion and in 57% at the portion near the interventricular septal center. The signals at the portion near the interventricular septal center were recorded in only 2 patients with left ventricular thrombus but in 66% of patients without left ventricular thrombus. Systemic or pulmonary embolism and intracardiac thrombus occurred less frequently in patients treated with warfarin than in patients without warfarin. These results indicate that endomyocardial and blood flow disorders of the left ventricle play important roles in the occurrence of left ventricular thrombus and that anticoagulant therapy is useful for the prevention of systemic or pulmonary embolism and cardiac thrombus.

Topics: Adult; Cardiomyopathy, Dilated; Coronary Disease; Coronary Thrombosis; Female; Heart; Heart Ventricles; Humans; Male; Middle Aged; Stroke Volume; Warfarin

A 41-year-old man presenting with unstable angina was found to have diffuse coronary ectasia with a partially occluding thrombus in the proximal left anterior descending artery. Anticoagulation with heparin followed by warfarin resulted in relief of angina and resolution of thrombosis at follow-up angiography 3.5 months later. The patient remains well after three years. Nonatherosclerotic ectatic coronary arteries are prone to thrombosis possibly because of spasm, intimal damage, and blood current eddies. We believe that chronic warfarin therapy may be indicated in many patients with coronary ectasia.

Topics: Adult; Angina, Unstable; Angiography; Coronary Angiography; Coronary Disease; Coronary Thrombosis; Coronary Vessels; Heparin; Humans; Male; Vasodilation; Warfarin

Although left ventricular thrombi that form acutely after myocardial infarction frequently resolve spontaneously or with anticoagulant therapy, the fate of left ventricular thrombi in patients with remote myocardial infarction or with idiopathic cardiomyopathy remains unknown. To determine the natural history of such chronic left ventricular thrombi, we performed serial echocardiograms on 51 patients with remote myocardial infarction (greater than or equal to 3 months; mean, 31 +/- 41 months) and on nine patients with idiopathic dilated cardiomyopathy. Mean follow-up was 24 +/- 22 months during which 3.5 +/- 1.4 echocardiograms were obtained. Studies were interpreted by blinded observers, and an increase or decrease of more than 5 mm in maximal thrombus thickness was defined as significant. Among all 60 patients left ventricular thrombi were unchanged in 24 (40%), completely resolved in 24 (40%), decreased in size in four (7%), increased in size in five (8%), and decreased and then increased in size in three (5%). Results in patients with remote infarction and idiopathic cardiomyopathy were similar. Warfarin therapy, which was at the discretion of the primary physician, was associated with a higher prevalence of thrombus resolution compared with no therapy (59% vs. 29%, p = 0.02). Definite systemic emboli occurred in seven patients (12%), all at times while they were not anticoagulated. Among the 48 thrombi that were present on two or more echocardiograms, changes in thrombus shape (classified as protruding or flat) occurred in only 16%, and changes in thrombus movement (classified as mobile or immobile) occurred in only 10%.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Cardiomyopathies; Coronary Disease; Coronary Thrombosis; Echocardiography; Female; Humans; Male; Middle Aged; Myocardial Infarction; Prospective Studies; Remission, Spontaneous; Warfarin

Embolic complications due to prosthetic heart valves are common. The present report documents a left main coronary artery thrombus extending from a Starr Edward's aortic ball valve prosthesis 22 years after its placement. It resulted in unstable angina and a small myocardial infarction. This rare complication illustrates the importance of adequate anticoagulation.

Topics: Adult; Angina Pectoris; Angina, Unstable; Aortic Valve; Coronary Disease; Coronary Thrombosis; Female; Heart Valve Prosthesis; Humans; Myocardial Infarction; Warfarin