warfarin and Dyspnea

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder, and increases in prevalence with increasing age and the number of cardiovascular comorbidities. AF is characterized by a rapid and irregular heartbeat that can be asymptomatic or lead to symptoms such as palpitations, dyspnoea and dizziness. The condition can also be associated with serious complications, including an increased risk of stroke. Important recent developments in the clinical epidemiology and management of AF have informed our approach to this arrhythmia. This Primer provides a comprehensive overview of AF, including its epidemiology, mechanisms and pathophysiology, diagnosis, screening, prevention and management. Management strategies, including stroke prevention, rate control and rhythm control, are considered. We also address quality of life issues and provide an outlook on future developments and ongoing clinical trials in managing this common arrhythmia.

Topics: Ablation Techniques; Anticoagulants; Aspirin; Atrial Fibrillation; Dizziness; Dyspnea; Electric Countershock; Flecainide; Heart Failure; Heart Rate; Humans; Hypertension; Myocardial Ischemia; Platelet Aggregation Inhibitors; Prevalence; Propafenone; Quality of Life; Risk Factors; Sodium Channel Blockers; Stroke; Thromboembolism; Warfarin

Topics: Anticoagulants; Diuretics; Drug Therapy, Combination; Dyspnea; Female; Humans; Hypertension, Pulmonary; Middle Aged; Phosphodiesterase 5 Inhibitors; Phosphodiesterase Inhibitors; Piperazines; Practice Guidelines as Topic; Purines; Sildenafil Citrate; Sulfones; Warfarin

Topics: Abdominal Pain; Aged; Anticoagulants; Diagnosis, Differential; Drug Interactions; Dyspnea; Female; Hematoma; Humans; Hypoprothrombinemias; International Normalized Ratio; Warfarin

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

We present a case of right sided chylothorax in the setting of cirrhosis believed to be secondary to extensive venous thromboembolism of the left upper extremity and exacerbated by chylous ascites. Our patient responded to conservative management with anticoagulation and a repeat thoracentesis revealed transformation of the fluid back to straw coloured transudate. We also include a brief discussion of the diagnosis and management of chylothorax.

Topics: Anticoagulants; Arm; Chylothorax; Diagnosis, Differential; Dyspnea; Humans; Male; Middle Aged; Paracentesis; Tomography, X-Ray Computed; Venous Thromboembolism; Warfarin

Topics: Adrenergic beta-Antagonists; Anticoagulants; Aspirin; Cardiomyopathy, Hypertrophic; Dyspnea; Echocardiography, Transesophageal; Female; Humans; Middle Aged; Mitral Valve Insufficiency; Platelet Aggregation Inhibitors; Reoperation; Systole; Treatment Outcome; Ventricular Outflow Obstruction; Warfarin

We describe a case with severe heart failure and moderate aortic stenosis. Due to previous atrial fibrillation and ischaemic heart disease, this patient was treated with both dabigatran and clopidogrel. Despite this, a large mural thrombus was found on echocardiography. The treatment was altered to warfarin, but the thrombus did not resolve during the next eight months.Guidelines for the use of anticoagulant treatment in left ventricular thrombus are needed. Previously, a few cases presenting resistance to novel oral anticoagulants have been published and cases with thrombus formation due to dabigatran have been described. Our patient showed resistance to both dabigatran and warfarin, and there was no thrombus resolution when changing the treatment to warfarin.

Topics: Aged, 80 and over; Anticoagulants; Antithrombins; Atrial Fibrillation; Clopidogrel; Dabigatran; Diagnosis, Differential; Drug Therapy, Combination; Dyspnea; Echocardiography; Fatal Outcome; Heart Diseases; Heart Failure; Humans; Male; Thrombosis; Ticlopidine; Warfarin

Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary arterial hypertension (PAH) in which the pulmonary thrombus fails to resolve, resulting in occlusion and remodelling of pulmonary arteries.

Topics: Adult; Angiography; Anticoagulants; Chronic Disease; Dyspnea; Electrocardiography; Humans; Hypertension, Pulmonary; Male; Pulmonary Artery; Pulmonary Embolism; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Adult; Antibodies, Anticardiolipin; Antibodies, Antiphospholipid; Anticoagulants; Antiphospholipid Syndrome; Diagnosis, Differential; Dyspnea; Echocardiography; Endocarditis, Non-Infective; Female; Heparin; Humans; Livedo Reticularis; Mitral Valve Insufficiency; Radiography, Thoracic; Symptom Assessment; Treatment Outcome; Warfarin

: An 84-year-old man presented urgently to the cardiology clinic with rapid onset exertional dyspnoea while walking on the flat. Five months previously, he underwent implantation of a balloon-expandable 26 mm transcatheter heart valve (SAPIEN 3, Edwards Lifesciences) for severe aortic stenosis. On clinical examination, the jugular venous pressure was elevated and a mid-late ejection systolic murmur was audible in the aortic region. ECG demonstrated sinus rhythm with a left ventricular (LV) strain pattern. Transthoracic echocardiography and cardiac CT were performed (figure 1). heartjnl;103/21/1703/F1F1F1Figure 1(A) Transthoracic continuous wave Doppler through the transcatheter AV. ECG-gated cardiac CT oblique reconstruction of the LV outflow tract and aortic root in mid-diastole (B) with axial reconstruction of the transcatheter AV in end-systole (inset). AT, acceleration time; AV, aortic valve; LV, left ventricular.. Which aetiology best explains this presentation?Pannus formationTranscatheter bioprosthetic valve endocarditisPatient-prosthesis mismatchTranscatheter bioprosthetic valve leaflet thrombosisStructural valve degeneration.

Topics: Administration, Oral; Aged, 80 and over; Anticoagulants; Aortic Valve Stenosis; Bioprosthesis; Dyspnea; Echocardiography, Doppler; Heart Valve Prosthesis; Humans; Male; Prosthesis Design; Severity of Illness Index; Thrombosis; Tomography, X-Ray Computed; Transcatheter Aortic Valve Replacement; Treatment Outcome; Warfarin

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

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

The case of a patient whose International Normalized Ratio (INR) became elevated due to a probable interaction between ceftaroline and warfarin is reported.. A 65-year-old African-American man developed an INR of >18.0 after completing 12 days of ceftaroline therapy for the treatment of cellulitis while taking warfarin therapy. The patient was on warfarin due to his history of deep vein thrombosis of a lower extremity and pulmonary embolism, and his INR was consistently therapeutic for approximately 2 years before ceftaroline therapy. The patient reported no known drug allergies, had no history of adverse drug reactions, and had no recent changes in medications or diet. Phytonadione was administered, and the patient's INR began to decrease, returning to a therapeutic range of 2.30 after approximately 48 hours, at which time warfarin was restarted. After six days of hospitalization, the patient was discharged on his previous regimen of warfarin 7.5 mg orally once daily, with a therapeutic INR of 2.11. His cellulitis had resolved, so no further antibiotic therapy was warranted. To determine the likelihood of the drug interaction between warfarin and ceftaroline in this patient, the Drug Interaction Probability Scale of Horn and colleagues was applied and yielded a score of 6, indicating a probable likelihood of an interaction. Rechallenge was not attempted, as the patient's cellulitis had resolved and there were no evident signs or symptoms of infection.. A 65-year-old man experienced an increase in INR values after the addition of ceftaroline to his medication regimen.

Topics: Aged; Anticoagulants; Ceftaroline; Cephalosporins; Drug Interactions; Drug Therapy, Combination; Dyspnea; Humans; International Normalized Ratio; Male; Warfarin

Topics: Aged; Anticoagulants; Computed Tomography Angiography; Diagnosis, Differential; Diagnostic Errors; Dyspnea; Fluorodeoxyglucose F18; Hemangiosarcoma; Humans; Male; Positron Emission Tomography Computed Tomography; Pulmonary Artery; Pulmonary Embolism; Radiopharmaceuticals; Vascular Neoplasms; Warfarin

Topics: Adult; Aneurysm, False; Aneurysm, Ruptured; Drug Overdose; Dyspnea; Echocardiography, Doppler, Color; Humans; Leg Ulcer; Lupus Coagulation Inhibitor; Lupus Erythematosus, Systemic; Male; Treatment Outcome; Venous Thrombosis; Ventricular Dysfunction, Left; Warfarin

Topics: Aged; Anticoagulants; Atrial Appendage; Cardiomyopathy, Hypertrophic; Chronic Disease; Dyspnea; Echocardiography, Transesophageal; Heart Diseases; Heart Failure; Humans; Male; Thrombosis; Tomography, X-Ray Computed; Warfarin

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

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

Topics: Anticoagulants; Coronary Artery Disease; Dyspnea; Echocardiography, Transesophageal; Embolism; Foramen Ovale, Patent; Humans; Intracranial Embolism; Magnetic Resonance Angiography; Male; Middle Aged; Multimodal Imaging; Pulmonary Embolism; Renal Artery Obstruction; Ultrasonography, Doppler; Venous Thrombosis; Warfarin

Mitral valve prolapse is not commonly on the list of differential diagnosis when a patient presents in the emergency department (ED) in severe distress, presenting with non-specific features such as abdominal pain, tachycardia and dyspnea. A healthy 55-year-old man without significant past medical history arrived in the ED with a unique presentation of a primary mitral valve prolapse with an atrial septal defect uncommon in cardiology literature. Early recognition of mitral valve prolapse in high-risk patients for severe mitral regurgitation or patients with underlying cardiovascular abnormalities such as an atrial septal defect is crucial to prevent morbid outcomes such as sudden cardiac death.

Topics: Abdominal Pain; Anticoagulants; Anxiety; Cardiotonic Agents; Continuous Positive Airway Pressure; Digoxin; Dopamine; Dyspnea; Electrocardiography; Emergencies; Heart Septal Defects, Atrial; Heart Valve Prosthesis Implantation; Humans; Male; Metoprolol; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Prolapse; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Bone Cements; Diagnosis, Differential; Dyspnea; Enoxaparin; Humans; Male; Pulmonary Artery; Pulmonary Embolism; Tomography, X-Ray Computed; Warfarin

Pulmonary thromboembolism after upper extremity operation is rare. We report a patient with thromboembolism after debridement open reduction and internal fixation for bilateral open distal radius fractures.. The Japanese patient was an 80-year-old previously healthy female who was able to walk on her own. She fell down and was taken to our hospital. She was diagnosed with bilateral open distal radius fractures and we performed debridement open reduction and internal fixation on the same day. Although she could not walk and was depressed, she was discharged on the ninth postoperative day. However, on the eleventh postoperative day, she returned to our emergency department with complaints of dyspnea and cold sweat. Her serum D-dimer level was 19.0 μg/dl, troponin T was positive, and urgent contrast computed tomography scan of her thorax revealed thrombosis in the bilateral main pulmonary artery. She was diagnosed with pulmonary thromboembolism and admitted to our hospital again. On the second admission, although she had breathing problems, she did not require a respirator. Oxygen was supplied as well as anticoagulants. On the seventh day after being diagnosed with embolism, thrombosis in the bilateral main pulmonary arteries had disappeared.. The patient did not have any "strong" risk factors as reported in the Japanese Orthopedic Association Clinical Practice Guideline on the Prevention of Venous Thromboembolism in Patients Undergoing Orthopedic Treatments. In general, upper extremity operation carries a low risk for pulmonary thromboembolism. For patients with decreased activity of daily living and depression, we should consider postponing discharge and performing rehabilitation until activity of daily living is improved.

Topics: Accidental Falls; Aged, 80 and over; Anticoagulants; Bed Rest; Bone Plates; Combined Modality Therapy; Debridement; Depression; Dyspnea; Female; Fracture Fixation, Internal; Fractures, Open; Heparin; Humans; Multiple Trauma; Oxygen Inhalation Therapy; Patient Readmission; Postoperative Complications; Pulmonary Embolism; Radius Fractures; Warfarin

Topics: Adult; Anticoagulants; Chronic Disease; Dyspnea; Edema; Endarterectomy; Female; Heparin; Humans; Hypertension, Pulmonary; Lower Extremity; Pulmonary Embolism; Recurrence; Respiratory Insufficiency; Thromboembolism; Warfarin

Topics: Anticoagulants; Contraindications; Dalteparin; Dyspnea; Female; Fibrinolytic Agents; Humans; Middle Aged; Popliteal Vein; Prognosis; Pulmonary Embolism; Stockings, Compression; Venous Thrombosis; Warfarin

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

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

Topics: Aged; Alcohol Withdrawal Delirium; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aortic Valve Insufficiency; Atrial Fibrillation; Delayed Diagnosis; Diagnostic Errors; Dyspnea; Edema; Epilepsy, Tonic-Clonic; Fatal Outcome; Heart Failure; Heart Valve Prosthesis; Humans; Hypertension; Male; Postoperative Complications; Psychomotor Agitation; Tomography, X-Ray Computed; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Blood Coagulation Disorders; Diagnosis, Differential; Dyspnea; Factor V; Female; Humans; Warfarin

Topics: Aged; Anticoagulants; Atrial Fibrillation; Biopsy, Fine-Needle; Diagnosis, Differential; Dyspnea; Female; Fluorodeoxyglucose F18; Humans; Hypertension; Lung Neoplasms; Multimodal Imaging; Positron-Emission Tomography; Pulmonary Artery; Pulmonary Embolism; Radiography, Thoracic; Sarcoma; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography; Vascular Neoplasms; Warfarin

Atrial fibrillation (AF) is the most common clinically encountered arrhythmia in adults. Because it is associated with an increased risk of atrial thrombus formation and embolism, medical and/or electrical cardioversion is the preferred treatment method in the majority of clinics. Thrombus formation in the setting of AF most commonly occurs in the left atrial appendage (LAA), left atrium (LA), right atrial appendage (RAA), and right atrium in decreasing frequency. In routine transesophageal echocardiographic evaluation for AF, examination is generally limited to LA and LAA. Although relatively rare when compared with the left side, RAA thrombus has also the potential of embolism and should be screened. A case of RAA thrombus in which the LA and LAA were spared is described. The authors aimed to underline the importance of this rare but potentially dangerous complication of AF.

Topics: Aged; Atrial Appendage; Atrial Fibrillation; Contraindications; Dyspnea; Echocardiography, Transesophageal; Electric Countershock; Embolism; Female; Humans; Mitral Valve Insufficiency; Pulmonary Embolism; Thrombosis; Warfarin

We report a case of Hughes-Stovin syndrome (HSS) associated with hyperhomocysteinemia. A 24-year-old man who has no clinical features suggestive of Behcet's disease was admitted for hemoptysis and dyspnea. Radiological and laboratory evaluation revealed multifocal pulmonary artery aneurysms involving bilateral segmental pulmonary artery, thrombi in right atrium and ventricle, and hyperhomocysteinemia. Accordingly, HSS associated with hyperhomocysteinemia was diagnosed, and the clinical and radiological improvement was achieved after treatment with prednisolone, warfarin, and folic acid.

Topics: Anti-Inflammatory Agents; Anticoagulants; Dyspnea; Folic Acid; Hematinics; Hemoptysis; Humans; Hyperhomocysteinemia; Male; Prednisolone; Syndrome; Treatment Outcome; Warfarin; Young Adult

We describe the case of an 83-year-old man with a family history of pulmonary hypertension (PH) who presented with severe pulmonary arterial hypertension (PAH) and later tested positive for a novel bone morphogenetic protein receptor 2 (BMPR2) gene mutation. To our knowledge, this may be the oldest reported patient with PAH in whom a BMPR2 mutation was initially identified.

Topics: Aged, 80 and over; Amlodipine; Bone Morphogenetic Protein Receptors, Type II; Bosentan; Digoxin; Dyspnea; Humans; Hypertension, Pulmonary; Male; Pulmonary Artery; Sulfonamides; Warfarin

Topics: Aged; Anticoagulants; Brassica; Diet; Dyspnea; Female; Food-Drug Interactions; Hemorrhage; Humans; International Normalized Ratio; Pulmonary Embolism; Recurrence; Vitamin K Deficiency; Warfarin

Selective right pulmonary arteriography and 3-dimensional computed tomography revealed multiple severe stenoses of the peripheral pulmonary artery associated with poststenotic aneurysms in a 65-year-old woman. She was referred to the hospital for evaluation of dry cough, gradually increasing dyspnea and multiple nodular shadows on a chest radiograph. Echocardiography and cardiac catheterization showed severe pulmonary hypertension, though other structural heart diseases or well-characterized congenital syndromes were ruled out. She was diagnosed as isolated peripheral pulmonary artery branch stenosis. Recent advances in CT technology enable a less-invasive assessment of pulmonary artery, and can be useful in the management of pulmonary arterial hypertension.

Topics: Aged; Aneurysm; Arterial Occlusive Diseases; Cardiac Catheterization; Constriction, Pathologic; Cough; Dyspnea; Epoprostenol; Female; Humans; Hypertension, Pulmonary; Imaging, Three-Dimensional; Oxygen Inhalation Therapy; Piperazines; Pulmonary Artery; Purines; Sildenafil Citrate; Sulfones; Tomography, X-Ray Computed; Ultrasonography; Vasodilator Agents; Warfarin

Topics: Aspirin; Atrial Fibrillation; Cardiomegaly; Dyspnea; Echocardiography; Embolization, Therapeutic; Heart Failure; Heparin; Humans; Male; Middle Aged; Stroke Volume; Warfarin

Topics: Adult; Anticoagulants; Aspirin; Clopidogrel; Diagnosis, Differential; Dyspnea; Echocardiography, Transesophageal; Female; Heart Atria; Heart Diseases; Heparin; Humans; Platelet Aggregation Inhibitors; Radiography; Thrombosis; Ticlopidine; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Dyspnea; Echocardiography; Electrocardiography; Embolism; Enoxaparin; Female; Humans; Radiography, Thoracic; Warfarin

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

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

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

Topics: Aged; Aged, 80 and over; Angina Pectoris; Anticoagulants; Diagnosis, Differential; Dyspnea; Echocardiography; Edema; Female; Humans; Pulmonary Embolism; Venous Thrombosis; Warfarin

Heart failure and stroke are major causes of morbidity and mortality in older people. Angiotensin converting enzyme inhibitors improve symptoms and survival in left ventricular systolic dysfunction. Anticoagulants are effective in stroke prevention in atrial fibrillation with aspirin being a less effective alternative.. To determine the prevalence of left ventricular systolic dysfunction, health services utilisation and prescribing of diuretics and angiotensin converting enzyme inhibitors in left ventricular systolic dysfunction, and the prevalence of atrial fibrillation and anti-platelet/thrombotic therapy in atrial fibrillation in older people in the community.. 500 subjects were drawn by two-stage random sampling from 5,002 subjects aged 70 years and over living at home. Subjects were screened for atrial fibrillation and left ventricular systolic dysfunction using electrocardiography and echocardiography.. The population prevalence amongst older people of left ventricular systolic dysfunction was 9.8% and of atrial fibrillation 7.8%. More than two-thirds of those with left ventricular systolic dysfunction were not on angiotensin converting enzyme inhibitors. Of those in atrial fibrillation, 35% were taking aspirin, 24% were taking warfarin and 41% were on neither aspirin nor warfarin. Nearly 90% of older people in the community have had contact with their general practitioner over the past year, and over half of those with left ventricular systolic dysfunction have had contact with hospital-based services over the past 2 years.. Left ventricular systolic dysfunction is under-treated in older people in the community. Despite the high level of contact with hospital and community-based services, the majority of those with systolic left ventricular dysfunction are not on angiotensin converting enzyme inhibitors and a significant proportion of those in atrial fibrillation are not on any treatment for stroke prevention.

Topics: Adrenergic beta-Antagonists; Aged; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Atrial Fibrillation; Community Health Services; Comorbidity; Cross-Sectional Studies; Drug Utilization; Dyspnea; Echocardiography; Electrocardiography; Family Practice; Female; Humans; Male; Mass Screening; Ventricular Dysfunction, Left; Wales; Warfarin

Topics: Abdominal Muscles; Activated Protein C Resistance; Anticoagulants; Dyspnea; Ecchymosis; Factor V; Hemothorax; Humans; Male; Middle Aged; Point Mutation; Venous Thrombosis; Warfarin

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

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

The occurrence of thromboembolic phenomena during long-duration airplane flights is called "economy-class syndrome". Recently it has become more popular for Japanese to go abroad by airplane, and an increase in the prevalence of pulmonary thromboembolism should be expected. However, there are few reports of the economy-class syndrome in Japan. A 52-year-old woman was admitted to our hospital because of chest discomfort and dyspnea that developed during an airplane flight. We suspected pulmonary thromboembolism, on the basis of a chest X-ray film and on electrocardiogram. A ventilation-perfusion lung scan disclosed mismatching between ventilation and perfusion in the right upper lung field. Pulmonary thromboembolism was confirmed by pulmonary arteriography. The patient was treated with heparin and urokinase. A phlebogram of the legs showed no significant findings. There was no history of thromboembolic disease or of consumption of oral contraceptives. We conclude that the pulmonary thromboembolism might have been caused by stasis of blood in the lower limb veins during the airplane flight. We emphasize the importance of including pulmonary thromboembolism in the differential diagnosis of patients with chest discomfort and dyspnea that develop during airplane flights. No noninvasive test can lead to a definitive diagnosis of pulmonary thromboembolism. Early pulmonary angiography should be recommended when pulmonary thromboembolism is suspected.

Topics: Dehydration; Dyspnea; Female; Heparin; Humans; Middle Aged; Pulmonary Embolism; Syndrome; Thrombolytic Therapy; Travel; Urokinase-Type Plasminogen Activator; Warfarin

Use of the Internet for patient-specific consultation across international boundaries has been demonstrated. This report describes the efforts of Baylor College of Medicine and NASA to conduct a telemedicine consultation with Moscow, Russia. Consultation between Russian and American physicians was performed over the Internet with a combination of real-time and store-and-forward techniques. The clinical focus involved a 65-year old Russian scientist who had undergone mitral valve replacement in the United States 5 years earlier. Development of new activity-related chest pain, dyspnea, and intermittent atrial fibrillation led to a consultation with his American cardiologist and cardiac surgeon. Real-time video was supplemented with telephone voice communication to overcome bandwidth limitations. Prior to the video link, the patient's recent history and clinical data were made available via the Internet using file transfer protocol (FTP). The patient's medications, new electrocardiographic findings, and activity status were reviewed. Specific clinical recommendations were made as a result of this telemedicine consultation. This case illustrates the technical factors, clinical implications, and confidentiality issues related to using the Internet for telemedicine consultations and demonstrates that the Internet may provide an alternative means for long-term clinical follow-up of patients.

Topics: Aged; Angina Pectoris; Anticoagulants; Atrial Fibrillation; Computer Systems; Confidentiality; Database Management Systems; Dyspnea; Electrocardiography, Ambulatory; Follow-Up Studies; Heart Valve Prosthesis Implantation; Humans; Internet; Longitudinal Studies; Male; Mitral Valve; Postoperative Complications; Remote Consultation; Telephone; Warfarin

In a retrospective study, we tested the hypothesis that anticoagulant therapy with warfarin sodium (Coumadin) has a beneficial influence on the long-term prognosis in patients with primary pulmonary hypertension (PPH) and aminorex-induced plexogenic pulmonary hypertension. The study included a total of 173 patients from two European cities. One hundred four of these patients took the anorectic drug aminorex (Menocil), which was available in some European countries almost 30 years ago; 69 patients had pulmonary hypertension of unexplained etiology, ie, PPH. Fifty-six of the 104 aminorex-treated patients and 24 patients in the PPH group received warfarin after diagnosis was established. For analysis, patients were divided into four groups according to their history of aminorex intake and anticoagulant therapy. Survival time, changes in hemodynamics (pulmonary arterial pressure), and improvement in quality of life (scored by the New York Heart Association [NYHA] classification) were compared and analyzed. We found that aminorex-treated patients had a better long-term prognosis than those with PPH (7.5 vs 3.9 years; p < or = 0.001). The best mean survival time of 8.3 years was found in anticoagulated aminorex-treated patients, compared to 6.1 years in nonanticoagulated aminorex-treated patients. Moreover, aminorex-treated patients who received anticoagulant therapy soon after the onset of symptoms showed significantly better prognosis (10.9 years) than those who commenced treatment 2 years thereafter (5.9 years) (p < or = 0.05). In patients with PPH, systolic pulmonary pressure was shown to influence survival time significantly (p < or = 0.0005); however, this correlation was not found in aminorex-treated patients. An improvement of symptoms like dyspnea on exertion was seen in 44.8% of the anticoagulated aminorex-treated patients, while deterioration was evident in 72.2% of the nonanticoagulated aminorex-treated patients. In conclusion, our study has shown that anticoagulant therapy had a positive influence on long-term survival and a significant improvement in quality of life in patients with PPH, in particular in patients with a history of anorectic drug intake.

Topics: Adolescent; Adult; Aged; Aminorex; Analysis of Variance; Anorexia; Anticoagulants; Appetite Depressants; Blood Pressure; Dyspnea; Female; Hemodynamics; Humans; Hypertension, Pulmonary; Longitudinal Studies; Male; Middle Aged; Physical Exertion; Prognosis; Proportional Hazards Models; Pulmonary Artery; Quality of Life; Retrospective Studies; Survival Rate; Systole; Time Factors; Warfarin

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

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

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

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

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

Subacute massive thromboembolic occlusion of the left main pulmonary artery in a 52-year-old woman is described. This disease remains a rare entity with a much less dramatic presentation than acute massive pulmonary embolus. The presenting symptom was unexplained dyspnea. Physical signs and laboratory tests were nonspecific. The perfusion scan is the best screening test for this disorder. Antemortem diagnosis is established by pulmonary angiography. A literature review undertaken to ascertain the incidence of this entity as well as to recommend treatment of choice, be it medical or surgical therapy, was unrewarding. We decided to use thrombolytic therapy and found a marked improvement in the patient's symptoms and perfusion scan after 24 hours. Although thrombolytic therapy is commonly indicated for acute massive pulmonary embolism, we believe this mode of therapy should also be the initial treatment for subacute massive pulmonary thromboembolism.

Topics: Anticoagulants; Dyspnea; Female; Fibrinolytic Agents; Humans; Middle Aged; Pulmonary Embolism; Streptokinase; Warfarin

Topics: Dyspnea; Hemoptysis; Humans; Leg; Male; Middle Aged; Pain, Postoperative; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Thorax; Thrombophlebitis; Warfarin

Topics: Angiography; Catheterization; Dyspnea; Hemoptysis; Heparin; Humans; Leg; Pain; Phlebography; Pulmonary Artery; Pulmonary Embolism; Radionuclide Imaging; Serum Albumin, Radio-Iodinated; Syncope; Technetium; Warfarin

Topics: Adult; Anticoagulants; Dyspnea; Female; Hemorrhage; Heparin; Humans; Male; Middle Aged; Muscular Diseases; Peripheral Nervous System Diseases; Pregnancy; Warfarin; Wounds and Injuries