warfarin and Heart-Diseases

Atrial fibrillation (AF) is one of the most common heart rate disorders, but most relevant studies are mainly focused on Europe and The United States, while information about AF in the Chinese population is scarce. The purpose of this study was to provide a review of the literature on atrial fibrillation in China.. A literature search (Medline 2001-2021) identified studies reporting the prevalence or incidence of AF, risk factors for AF, comorbidities of AF, and use of antithrombotic therapy in China. This report focuses on descriptive analytical data.. Studies reported a wide variation in the prevalence of AF, with a range of community-based and hospital-based AF rates (from 0.49% to 8.8% and 4.4% to 35.7%). Aspirin and warfarin use was found to be particularly low in community-based studies in China, and warfarin and amiodarone use was higher in hospital-based studies than in other countries. Stroke is the most common complication of atrial fibrillation.. More high-quality studies are needed to improve our understanding of the burden of atrial fibrillation in China. Efforts should be made to improve community delivery and monitoring of antithrombotic therapy after AF. Due to China's large population, the number of patients with untreated AF and the risk of accompanying complications can be high, so the impact on healthcare resources can be significant.

Topics: Atrial Fibrillation; China; Electrocardiography; Fibrinolytic Agents; Heart Diseases; Humans; Warfarin

Loeffler endocarditis is a relatively rare and potentially life-threatening heart disease. This study aimed to identify the characteristic features of Loeffler endocarditis with intracardiac thrombus on a background of hypereosinophilic syndrome (HES).. We described a 57-year-old woman with Loeffler endocarditis and intracardiac thrombus initially presenting with neurological symptoms, who had an embolic stroke in the setting of HES. After cardiac magnetic resonance (CMR), corticosteroids and warfarin were administered to control eosinophilia and thrombi, respectively. During a 10-month follow-up, the patient performed relatively well, with no adverse events. We also systematically searched PubMed and Embase for cases of Loeffler endocarditis with intracardiac thrombus published until July 2021. A total of 32 studies were eligible and included in our analysis. Further, 36.4% of recruited patients developed thromboembolic complications, and the mortality rate was relatively high (27.3%). CMR was a powerful noninvasive modality in providing diagnostic and follow-up information in these patients. Steroids were administered in 81.8% of patients, achieving a rapid decrease in the eosinophil count. Also, 69.7% of patients were treated with anticoagulant therapy, and the thrombus was completely resolved in 42.4% of patients. Heart failure and patients not treated with anticoagulation were associated with poor outcomes.. Cardiac involvement in HES, especially Loeffler endocarditis with intracardiac thrombus, carries a pessimistic prognosis and significant mortality. Early steroids and anticoagulation therapy may be beneficial once a working diagnosis is established. Further studies are needed to provide evidence-based evidence for managing this uncommon manifestation of HES.

Topics: Adolescent; Adrenal Cortex Hormones; Adult; Aged; Anticoagulants; Child; Child, Preschool; Embolic Stroke; Female; Heart Diseases; Humans; Hypereosinophilic Syndrome; Male; Middle Aged; Thrombosis; Treatment Outcome; Warfarin; Young Adult

Topics: Anticoagulants; Antithrombins; Dabigatran; Embolism; Factor Xa Inhibitors; Heart Diseases; Heart Ventricles; Hemorrhage; Humans; Odds Ratio; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Thiazoles; Thrombosis; Warfarin

Atrial fibrillation is the most common cardiac arrhythmia and is associated with an increased risk of stroke and thromboembolic complications. A rhythm control strategy with both electrical and pharmacological cardioversion is recommended for patients with symptomatic atrial fibrillation. Anticoagulant therapy for 3-4 weeks prior to cardioversion is recommended in order to avoid thromboembolic events deriving from restoring sinus rhythm. Transesophageal echocardiography has a pivotal role in this setting, excluding the presence of left atrial appendage thrombus before cardioversion. The aim of this review is to discuss the epidemiology and risk factors for left atrial appendage thrombosis, the role of echocardiography in the decision making before cardioversion, and the efficacy of different anticoagulant regimens on the detection and treatment of left atrial appendage thrombosis.

Topics: Anticoagulants; Atrial Appendage; Atrial Fibrillation; Echocardiography; Echocardiography, Transesophageal; Electric Countershock; Heart Diseases; Humans; Risk Factors; Thrombosis; Warfarin

Non-vitamin K antagonist oral anticoagulants (NOACs) include dabigatran, which inhibits thrombin, and apixaban, betrixaban, edoxaban and rivaroxaban, which inhibit factor Xa. In large clinical trials comparing the NOACs with the vitamin K antagonist (VKA) warfarin, dabigatran, apixaban, rivaroxaban and edoxaban were at least as effective for stroke prevention in atrial fibrillation and for treatment of venous thromboembolism, but were associated with less intracranial bleeding. In addition, the NOACs are more convenient to administer than VKAs because they can be given in fixed doses without routine coagulation monitoring. Consequently, the NOACs are now replacing VKAs for these indications, and their use is increasing. Although, as a class, the NOACs have a favourable benefit-risk profile compared with VKAs, choosing among them is complicated because they have not been compared in head-to-head trials. Therefore, selection depends on the results of the individual trials, renal function, the potential for drug-drug interactions and preference for once- or twice-daily dosing. In addition, several 'special situations' were not adequately studied in the dedicated clinical trials. For these situations, knowledge of the unique pharmacological features of the various NOACs and judicious cross-trial comparison can help inform prescription choices. The purpose of this position article is therefore to help clinicians choose the right anticoagulant for the right patient at the right dose by reviewing a variety of special situations not widely studied in clinical trials.

Topics: Administration, Oral; Antibodies, Monoclonal, Humanized; Anticoagulants; Arginine; Atrial Fibrillation; Benzamides; Biomarkers; Blood Coagulation; Clinical Trials as Topic; Dabigatran; Drug Administration Schedule; Factor Xa; Heart Diseases; Humans; Piperazines; Pyrazoles; Pyridines; Pyridones; Recombinant Proteins; Risk; Rivaroxaban; Stroke; Thiazoles; Thrombin; Venous Thromboembolism; Vitamin K; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Heart Diseases; Humans; Practice Guidelines as Topic; Stroke; Sweden; Warfarin

A potential interaction involving therapeutic doses of ascorbic acid and warfarin is described.. A 65-year-old Caucasian man with chronic cardiac and pulmonary disorders was admitted to the emergency room for chest pain, shortness of breath, nausea, and diaphoresis. Imaging scans showed acute pulmonary embolism and deep venous thrombosis of the lower extremities. Anticoagulation therapy (enoxaparin 60 mg twice daily) was initiated on the day of admission; warfarin sodium (5 mg daily) was initiated on the next day. After admission to the hospital, the patient continued to use several home medications and vitamins, including ascorbic acid, which he reported taking for three months to facilitate the absorption of oral supplemental iron. For more than a week, his International Normalized Ratio (INR) values remained below target as the dosage of warfarin was gradually increased to 20 mg daily. After potential contributors to warfarin resistance (e.g., impaired liver or renal function, clotting factor abnormalities) were ruled out, ascorbic acid use was discontinued on hospital day 8. The patient's INR rapidly increased to a high of 15.4 on hospital day 10, requiring intervention with phytonadione therapy and the suspension of warfarin use. On day 12, with an INR of 2.7, the patient was restarted on warfarin therapy; he was discharged three days later with stable INR values.. A patient who was unable to achieve anticoagulation during concurrent treatment with warfarin and ascorbic acid experienced a rapid increase in INR to above-target values after the discontinuation of ascorbic acid use, suggesting that the vitamin might have had an inhibitory effect on warfarin.

Topics: Aged; Ascorbic Acid; Drug Interactions; Drug Resistance; Heart Diseases; Humans; International Normalized Ratio; Male; Warfarin

The lack of national recommendations and generally accepted strategy of anticoagulant therapy for patients with prosthetic heart valves are principal causes precluding the solution of this problem. The factors responsible for poor efficiency of current therapeutic modalities are heterogeneous response to warfarin, genetic diversity, and frequent thrombosis of prosthetic valves. Neither pharmacogenetic testing for elusive susceptibility to warfarin nor use of portable equipment for detecting threshold coagulation levels can resolve these current problems without improving compliance to medical recommendations and awareness of anticoagulant therapy by both doctors and patients.

Topics: Anticoagulants; Heart Diseases; Heart Valve Prosthesis; Humans; Prescriptions; Warfarin

A 59-year-old white woman with previous history of arterial hypertension consulted because of palpitations. Atrial fibrillation of uncertain duration was diagnosed. She was not receiving anticoagulants. A trans-esophageal echocardiogram was performed, and a large left atrial appendage thrombus was detected. A strategy of rate control and anti-vitamin K treatment was started. On the subsequent days, we could not reach therapeutic INRs. Therefore, it was decided to stop warfarin and initiate dabigatran. We describe the evolution of the patient, the thrombus resolution, and a successful electrical cardioversion. In our comments, we summarize the natural history of left atrial thrombus, both with and without anticoagulant therapy. We also discuss the differences between warfarin and dabigatran.

Topics: Antithrombins; Atrial Appendage; Benzimidazoles; beta-Alanine; Dabigatran; Female; Heart Diseases; Humans; Middle Aged; Thrombosis; Warfarin

An increasing number of patients with an indication for long-term oral anticoagulation (OAC) have undergone percutaneous coronary intervention with stent implantation (PCI-s). However, the optimal antithrombotic treatment for these patients is currently unknown. The purpose of this study was to characterize the benefits and risks of triple antithrombotic therapy (combined aspirin, clopidogrel, and OAC) after stent implantation in patients under long-term OAC treatment compared with dual antiplatelet therapy (combined aspirin and clopidogrel).. The study consisted of clinical controlled trials with ≥ 3 months of follow-up that compared triple antithrombotic therapy with dual antiplatelet therapy after stent implantation in patients undergoing long-term OAC treatment.. Nine clinical trials included 1,996 participants. The meta-analysis was feasible because the grouping criterion was similar. The meta-analysis of the prevention of a major adverse cardiovascular event shows triple antithrombotic therapy to be more efficacious than dual antiplatelet therapy (OR, 0.60; 95% CI, 0.42-0.86; P = .005). There was a significant reduction in all-cause mortality with triple antithrombotic therapy compared with dual antiplatelet therapy. The meta-analysis of major bleeding in the first 6 months during follow-up shows significantly more events with triple antithrombotic therapy (OR, 2.12; 95% CI, 1.05-4.29; P = .04).. Based on our analysis, triple antithrombotic therapy is substantially more efficacious in reducing the occurrence of cardiovascular events and mortality in PCI-s patients with an indication for long-term OAC, compared with dual antiplatelet therapy. Although triple therapy predisposes patients to an increased risk of bleeding, especially major bleeding, it is the better choice for patients with a low bleeding risk.

Topics: Administration, Oral; Anticoagulants; Aspirin; Clopidogrel; Drug Therapy, Combination; Heart Diseases; Humans; Platelet Aggregation Inhibitors; Stents; Stroke; Thromboembolism; Ticlopidine; Warfarin

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

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

The decline in stroke incidence and mortality in the U.S. over the past 20 years is reaching a plateau, and the number of strokes may actually start to increase as the population ages. However, recent clinical trials have demonstrated that there are numerous opportunities to improve stroke prevention strategies and also opportunities to effectively intervene in and treat acute strokes. For patients with diabetes and for those with prior strokes or transient ischemic attacks, it has become evident that aggressive low-density lipoprotein lowering with statin medications will decrease the risk for total and fatal strokes. Optimal anticoagulation and antiplatelet therapy for primary and secondary stroke prevention in atrial fibrillation is being carefully defined. With numerous novel factor Xa and direct thrombin inhibitor drugs completing phase III clinical trials, it is likely that additional oral anticoagulant drugs will be clinically available for stroke prevention soon. Additionally, a major clinical trial is nearing completion that may resolve the role of carotid stenting and carotid endarterectomy in primary and secondary stroke prevention. There are recent notable advances in the acute treatment of stroke. It is likely that the time window for thrombolysis for appropriate patients with strokes will be increased from 3 to 4.5 h, permitting the inclusion of more patients in this treatment approach. There is ongoing investigation of intra-arterial thrombolysis and of acute intra-arterial thrombus extraction for treatment of selected patients with strokes. Unlike the progress in treatment of ischemic strokes, treatment of hemorrhagic stroke is progressing more slowly.

Topics: Anticoagulants; Atrial Fibrillation; Brain Ischemia; Cholesterol, LDL; Diabetic Angiopathies; Endarterectomy, Carotid; Foramen Ovale, Patent; Heart Diseases; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypertension; International Normalized Ratio; Intracranial Hemorrhages; Stents; Stroke; Thrombectomy; Thrombolytic Therapy; Thrombosis; United States; Warfarin

Topics: Anticoagulants; Aspirin; Drug Synergism; Heart Diseases; Hemorrhage; Humans; Platelet Aggregation Inhibitors; Time Factors; Warfarin

Topics: Anticoagulants; Diagnostic Imaging; Heart Diseases; Heparin; Humans; Prognosis; Thrombectomy; Thrombosis; Warfarin

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Female; Heart Diseases; Humans; Thrombosis; Warfarin

A 53-year-old man with a history of repair of atrial septal defect 3-months ago by primary suture was admitted to an emergency department with sudden onset chest pain and dyspnea. Transthoracic echocardiography revealed a large and mobile thrombus attached to the right side of the interatrial septum. The chest X ray and perfusion lung scan established the diagnosis of the multiple pulmonary emboli. Doppler examination of the venous system for a possible source of thrombus was unremarkable. The postoperative early appearance of thrombus and multiple pulmonary emboli defects at lung scan supported that thrombus was originated from the primary suture site. Thrombolytic treatment achieved complete resolution of the thrombus both in the pulmonary artery and at the repaired septal defect site. The patient was placed on warfarin and thrombus was not detected by transesophageal echocardiography at the 9-month follow-up.

Topics: Anticoagulants; Echocardiography; Fibrinolytic Agents; Heart Diseases; Heart Septal Defects, Atrial; Humans; Male; Middle Aged; Pulmonary Embolism; Streptokinase; Sutures; Thrombolytic Therapy; Thrombosis; Warfarin

Although pharmacologic prophylaxis against venous thromboembolism has become the standard of care following total hip and knee replacement, prophylaxis among patients undergoing surgery for hip fracture and other lower extremity trauma remains underutilized. Available experience consistently supports the view that low-molecular-weight heparins are more effective than unfractionated heparin for prevention of proximal deep vein thrombosis (DVT) with no additional hemorrhagic risk and more effective than oral anticoagulants for prevention of in-hospital (mostly distal) venous thrombosis at the price of a higher surgical site bleeding and wound hematoma. The choice between low-molecular-weight heparin and warfarin should be tailored to the individual patients based on the clinical assessment of postoperative thrombosis and bleeding risk as well as the prophylaxis-specific cost and convenience. Whether thromboprophylaxis should be continued for a few additional weeks after hospital discharge is controversial. The overall incidence of postoperative DVT in patients with cancer is about twice as high as that of patients free of malignancy. Accordingly, they require prophylactic measures comparable with those usually recommended for major orthopedic surgery. In this setting, dermatan sulfate shows promise. In contrast to surgical patients, prevention of venous thromboembolism is less well studied in hospitalized medical patients. In a recent controlled randomized trial, enoxaparin in high prophylactic doses was an effective and safe measure of thromboprophylaxis in ordinary bedridden patients.

Topics: Anesthesia, Conduction; Anticoagulants; Arthroplasty, Replacement, Hip; Comorbidity; Heart Diseases; Heparin, Low-Molecular-Weight; Hospitalization; Humans; Neoplasms; Postoperative Complications; Spinal Cord Injuries; Venous Thrombosis; Warfarin

Topics: Algorithms; Anticoagulants; Atrial Fibrillation; Cardiac Output, Low; Contraindications; Heart Diseases; Hemorrhage; Heparin; Humans; Myocardial Infarction; Rheumatic Heart Disease; Risk Factors; Thromboembolism; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Clinical Trials as Topic; Heart Diseases; Humans; Intracranial Embolism and Thrombosis; Recurrence; Warfarin

Cardiac causes of stroke account for approximately 20% of strokes occurring in the United States. Transthoracic echocardiography (TTE) remains the cornerstone of non-invasive cardiac imaging, but transesophageal echocardiography (TEE) is superior for identifying potential cardiac sources of emboli, including left atrial thrombi, valvular vegetations, thoracic aortic plaque, patent foramen ovale, and spontaneous left atrial echocardiographic contrast. The diagnostic yield of TEE for potential cardiac causes of thromboembolism exceeds 50%. The impact of TEE on the clinical management of this group, however, remains undefined for most TEE-specific diagnoses. Thus, routine use of TEE in these patients has been questioned. The diagnostic yield is highest if the clinical history/physical examination suggests a cardiac source. However, the clinical scenario often dictates patient management, and TEE data are used to "validate" the clinical impression. Data from large, prospective, randomized (aspirin/warfarin) studies, in which TEE data are obtained from patients with suspected cardiac thromboembolism, are needed. If specific TEE diagnoses can be identified in which defined therapies are beneficial, "source of embolism" will continue to be the most common indication for TEE referral. In this paradigm, TEE (without initial TTE) will probably become a more direct diagnostic pathway. However, if these studies demonstrate that all patients with suspected cardiac source benefit from one (or no) therapy, independent of TEE data, referrals for TEE will decline. Results of ongoing randomized trials to evaluate the efficacy of TEE in patients with cryptogenic stroke or transient ischemic attack are awaited.

Topics: Anticoagulants; Aorta, Thoracic; Aortic Diseases; Arteriosclerosis; Aspirin; Cerebrovascular Disorders; Echocardiography, Transesophageal; Heart Atria; Heart Diseases; Heart Septal Defects, Atrial; Heart Valve Diseases; Humans; Intracranial Embolism and Thrombosis; Ischemic Attack, Transient; Medical History Taking; Physical Examination; Platelet Aggregation Inhibitors; Prospective Studies; Randomized Controlled Trials as Topic; Referral and Consultation; Reproducibility of Results; Thrombosis; Treatment Outcome; Warfarin

Left atrial appendage obliteration was historically ineffective for the prevention of postoperative stroke in patients with rheumatic atrial fibrillation who underwent operative mitral valvotomy. It is, however, a routine part of modern "curative" operations for nonrheumatic atrial fibrillation, such as the maze and corridor procedures.. To assess the potential of left atrial appendage obliteration to prevent stroke in nonrheumatic atrial fibrillation patients, we reviewed previous reports that identified the etiology of atrial fibrillation and evaluated the presence and location of left atrial thrombus by transesophageal echocardiography, autopsy, or operation.. Twenty-three separate studies were reviewed, and 446 of 3,504 (13%) rheumatic atrial fibrillation patients, and 222 of 1,288 (17%) nonrheumatic atrial fibrillation patients had a documented left atrial thrombus. Anticoagulation status was variable and not controlled for. Thrombi were localized to, or were present in the left atrial appendage and extended into the left atrial cavity in 254 of 446 (57%) of patients with rheumatic atrial fibrillation. In contrast, 201 of 222 (91%) of nonrheumatic atrial fibrillation-related left atrial thrombi were isolated to, or originated in the left atrial appendage (p < 0.0001).. These data suggest that left atrial appendage obliteration is a strategy of potential value for stroke prophylaxis in nonrheumatic atrial fibrillation.

Topics: Aged; Atrial Fibrillation; Cerebrovascular Disorders; Contraindications; Heart Atria; Heart Diseases; Humans; Mitral Valve Stenosis; Postoperative Complications; Thrombosis; 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

Stroke is ideally suited for prevention. It has a high prevalence, burden of illness, and economic cost, and safe and effective prevention measures. The estimated $30 billion that is being spent for stroke each year in the United States should not come as a surprise given the approximately 3 million stroke survivors and 400,000 to 500,000 new or recurrent stroke cases annually. Stroke remains the third leading cause of death among adults and has been targeted for cost containment by managed care health systems and other insurers. The US Public Health Service in conjunction with the National Health Promotion and Disease Prevention Objectives has set a goal to reduce stroke deaths to 20 per 100,000 by the year 2000. This goal could be attained as the estimate of "preventable" strokes could be as high as 80%. In this article, I will review the status of stroke risk factors, prevention approaches to reduce stroke, clinical trial data from primary and secondary stroke prevention studies, and future directions in stroke prevention.

Topics: Alcohol Drinking; Aspirin; Carotid Stenosis; Cerebrovascular Disorders; Clinical Trials as Topic; Diabetes Complications; Exercise; Female; Heart Diseases; Humans; Hypertension; Ischemic Attack, Transient; Male; Platelet Aggregation Inhibitors; Risk Factors; Smoking; Warfarin

Topics: Aspirin; Atrial Fibrillation; Embolism; Heart Diseases; Humans; Thrombolytic Therapy; Warfarin

Cardiac disorders associated with cerebral embolism including cardiac surgery, myocardial infarction, endocarditis and non-valvular atrial fibrillation (NVAF) are reviewed along with methods to detect cardioembolic sources. Warfarin and aspirin are effective in the primary prevention of stroke in NVAF but the relative efficacy remains to be determined.

Topics: Cerebrovascular Disorders; Heart Diseases; Humans; Intracranial Embolism and Thrombosis; Postoperative Complications; Risk Factors; Warfarin

Although several large trials have failed to demonstrate unequivocally that anticoagulation decreases mortality following myocardial infarction (MI), anticoagulation has been advocated to prevent embolic cerebrovascular accidents (CVAs). Since CVAs occur during hospitalization in only 1.5% to 3% of MIs, it is not justifiable to anticoagulate all patients after MI because the risk of anticoagulation exceeds the potential benefit. However, a group of patients who are at high risk of developing left ventricular thrombi (LVT) and CVA following MI can be identified. Thirty percent to 40% of patients with transmural anterior MI develop LVT, and early anticoagulation with heparin sodium prevents LVT formation and CVAs in this group. A two-dimensional echocardiogram before hospital discharge allows the identification of patients at risk for later embolization and helps determine the need for anticoagulation with warfarin sodium following hospitalization.

Topics: Cardiovascular Diseases; Echocardiography; Heart Diseases; Heparin; Humans; Length of Stay; Myocardial Infarction; Risk; Thrombosis; Warfarin

Topics: Adolescent; Adult; Aged; Anti-Bacterial Agents; Aspirin; Child; Child, Preschool; Female; Heart Diseases; Humans; Infant; Infant, Newborn; Japan; Lymphatic Diseases; Male; Middle Aged; Mucocutaneous Lymph Node Syndrome; Prednisone; United States; Warfarin

Topics: Anticoagulants; Arteriosclerosis; Blood Coagulation; Blood Coagulation Tests; Blood Platelets; Coronary Disease; Drug Interactions; Fibrinolysis; Heart Diseases; Heart Valve Prosthesis; Hemolysis; Hemostasis; Heparin; Humans; Myocardial Infarction; Platelet Aggregation; Pulmonary Embolism; Stress, Physiological; Thrombophlebitis; Warfarin

ENSURE-AF (NCT02072434) was the largest prospective randomized clinical trial of anticoagulation for cardioversion in atrial fibrillation (AF), which also provides the largest prospective dataset for transoesophageal echocardiography (TOE) prior to cardioversion. This ancillary analysis investigated determinants of TOE-detected left atrium thrombi (LAT) in patients scheduled for electrical cardioversion (ECV).. The ENSURE-AF multicentre PROBE evaluation trial compared edoxaban 60 mg once daily (QD) with enoxaparin/warfarin in 2199 subjects undergoing ECV of non-valvular AF. Patients were stratified by the use of TOE, anticoagulant experience, and selected edoxaban dose. Electrical cardioversion was cancelled or deferred when TOEdetected LAT. In total, 1183 subjects were stratified to the TOE arm and LAT was reported in 91 (8.2%). In univariate analysis, age ≥75 years (26.4% vs. 16.9%, P = 0.0308), lower weight (86.5 ± 15.0 vs. 90.7 ± 18.0 kg, P = 0.0309), lower creatinine clearance (80.1 ± 30.6 vs. 93.2 ± 33.9 mL/min, P = 0.0007), heart failure (59.3% vs. 43.0%, P = 0.0029), and diuretic treatment (53.9% vs. 40.1%, P = 0.0141) were more prevalent in the LAT group. Non-significant trends were seen for higher mean CHA2DS2-VASc score (3.0 ± 1.41 vs. 2.7 ± 1.48, P = 0.0571) and more prevalent anticoagulation use prior to enrolment (60.4% vs. 50.3%, P = 0.0795) in the LAT group. In logistic regression analysis, age (P = 0.0202) and heart failure (P = 0.0064) were independently associated with LAT.. Elective ECV is commonly cancelled or deferred due to TOE-detected LAT in patients with non-valvular AF. Age ≥75 years and heart failure were associated with the presence of LAT.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Dose-Response Relationship, Drug; Drug Therapy, Combination; Echocardiography, Transesophageal; Electric Countershock; Factor Xa Inhibitors; Female; Heart Atria; Heart Diseases; Humans; Male; Prospective Studies; Pyridines; Thiazoles; Thrombosis; Treatment Outcome; Warfarin

Dabigatran is a direct thrombin inhibitor shown to be an effective alternative to warfarin in patients with non-valvular atrial fibrillation (AF). We evaluated the use of dabigatran in patients with bioprosthetic mitral and/or aortic valve replacement and AF.. We selected 34 and randomized 27 patients in a 1:1 ratio to receive dabigatran or warfarin. The primary endpoint was the presence of a new intracardiac thrombus at 90 days, by transesophageal echocardiogram (TEE). Secondary endpoints included the development of dense spontaneous echo contrast (SEC) and incidence of stroke (ischemic or hemorrhagic), myocardium infarction, valve thrombosis and peripheral embolic events.. The trial was terminated prematurely because of low enrollment. There were 27 patients in total: 15 patients placed in the dabigatran group and 12 in the warfarin group. After 90 days, one patient (8.3 %) in the warfarin group and none in the dabigatran group had developed a new intracardiac thrombus. In the dabigatran group, two patients (13.3 %) developed dense SEC versus one patient (8.3 %) in the warfarin group. In the warfarin group, one patient (8.3 %) presented ischemic stroke, and none did in the dabigatran group. We observed no cases of hemorrhagic stroke, valve thrombosis, embolic events or myocardial infarction in either group throughout the study. However, one patient (6.7 %) in the dabigatran group had a fully recovered transient ischemic attack and one patient in the warfarin group died of heart failure.. The use of dabigatran appears to be similar to warfarin in preventing the formation of intracardiac thrombus.. Clinicaltrials.gov NCT01868243.

Topics: Adolescent; Adult; Antithrombins; Atrial Fibrillation; Bioprosthesis; Cardiac Valve Annuloplasty; Dabigatran; Female; Heart Diseases; Humans; Male; Middle Aged; Pilot Projects; Thrombosis; Treatment Outcome; Warfarin; Young Adult

Left ventricular (LV) thrombus is one of the most common complications in patients with anterior acute myocardial infarction (AMI) and LV dysfunction. Although anticoagulation is frequently prescribed, data regarding the appropriate drug, duration, risks, and effect on echocardiographic indices of thrombus are lacking. Moreover, given the difficulty in obtaining adequate anticoagulation with warfarin, it is possible that short-term treatment with a more predictable agent would be effective. We randomized 60 patients at high risk of developing LV mural thrombus (anterior acute myocardial infarction with Q waves and ejection fraction≤40%) to receive either enoxaparin 1 mg/kg (maximum 100 mg) subcutaneously every 12 hours for 30 days or traditional anticoagulation (intravenous heparin followed by oral warfarin for 3 months). Clinical evaluations and transthoracic echocardiograms were obtained at baseline, in-hospital, and at 3.5 months. There were no differences between the groups regarding baseline demographics, acute echocardiographic findings, and in-hospital outcomes. The length of hospital stay tended to be shorter for the enoxaparin group (4.6 vs 5.6; p=0.066) and the corresponding hospital costs ($25,837 vs $34,666; p=0.18). At 3 months, bleeding and thromboembolic events were rare and similar between enoxaparin and warfarin groups. Although more patients had probable mural thrombus in the enoxaparin group compared with warfarin at 3.5 months (15% vs 4%; p=0.35), this was not significantly different. In conclusion, the use of enoxaparin tends to shorten hospitalization and lower cost of care. However, at 3.5 months, there appears to be numerically higher (but statistically insignificant) rates of LV thrombus in the enoxaparin group.

Topics: Adult; Aged; Aged, 80 and over; Anterior Wall Myocardial Infarction; Anticoagulants; Enoxaparin; Female; Heart Diseases; Heparin; Hospital Costs; Humans; Length of Stay; Male; Middle Aged; Percutaneous Coronary Intervention; Stroke Volume; Thrombosis; Treatment Outcome; Warfarin

Increasing numbers of children require warfarin thromboprophylaxis. Home INR testing by the patient (PST) has revolutionized warfarin management. However, the family/patient must contact the health team for guidance for warfarin dosing. Patient self management(PSM) prepares a patient performing PST to take an active role in warfarin dosing. Adult studies demonstrate that PSM is safe and effective with improved adherence and treatment satisfaction quality of life (QOL).. To estimate the safety and efficacy in children performing PSM or PST, to evaluate warfarin dose decision making in PSM, and warfarin related QOL.. Warfarinized children performing PST for >3m were randomized to PST or PSM. The PSM group underwent warfarin management education and assumed independent warfarin management. INRs were collected for a year prior to and for 1 year of study to determine TTR and warfarin decision making. QOL was assessed through inventory completion and interviews.. 28 children were randomized and followed for 12 months. TTR was (83.9% pre/ post), and 77.7% pre to 83.0% post for PST and PSM (p=0.312). Appropriate warfarin decision making was 90% with no major bleeding episodes and no thromboembolic events. PSM was preferred by families.. PSM for children may be a safe and effective management strategy for warfarinized children. Clinical studies with larger sample size are required.

Topics: Adolescent; Adult; Anticoagulants; Child; Heart Diseases; Humans; Infant; Infant, Newborn; International Normalized Ratio; Pilot Projects; Quality of Life; Self Administration; Warfarin; Young Adult

To prospectively compare the efficacy and procedural safety of the radial versus femoral route for cardiac catheterization during uninterrupted warfarin therapy.. The optimal treatment strategy for cardiac catheterization in patients receiving long-term oral anticoagulation has not been defined. Increasing evidence suggests the feasibility and safety of catheterization without warfarin interruption. However, the relative safety and efficacy of the radial and femoral access in fully anticoagulated patients are unknown.. Fifty-six consecutive patients on chronic warfarin treatment with international normalized ratio (INR) between 1.8 and 3.5 were randomized to undergo coronary angiography, alone, or followed by percutaneous coronary intervention (PCI), via the femoral (n = 29) or radial route (n = 27). Procedural success, in-hospital major adverse cardiac and cerebrovascular events, access-site, and bleeding complications were recorded.. The two groups were well balanced with similar clinical characteristics at baseline. There were no significant differences in preprocedural antiplatelet therapy or in INR levels between the radial and femoral group (2.62 ± 0.7 vs. 2.48 ± 0.6, respectively, P = 0.63). Procedural success was achieved in all femoral patients, whereas one patient in the radial group (3.7%) required crossover to femoral access. Eight patients from the femoral and 10 patients from the radial group successfully underwent PCI. Access-site complications occurred only in patients who underwent PCI: three (37.5%) in the femoral versus none in the radial group (P = 0.034).. The radial access is as efficacious and safe as the femoral route for coronary angiography in fully anticoagulated patients, but is likely to result in fewer access-site complications in patients who also undergo PCI.

Topics: Administration, Oral; Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Blood Coagulation; Cardiac Catheterization; Cerebrovascular Disorders; Chi-Square Distribution; Coronary Angiography; Female; Femoral Artery; Greece; Heart Diseases; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Pilot Projects; Platelet Aggregation Inhibitors; Prospective Studies; Radial Artery; Risk Assessment; Risk Factors; Treatment Outcome; Warfarin

Warfarin prevents thromboembolism in patients with prosthetic heart valvular replacement. Cytochrome P4502C9 (CYP2C9) is polymorphic in human and is principally responsible for the metabolism of warfarin. However, known CYP2C9 polymorphisms cannot entirely account for the low dose requirement of warfarin in Chinese-Taiwanese receiving mitral valve replacement. We screened a new polymorphism of CYP2C9 and investigated its role in warfarin sensitivity.. We examined warfarin dose requirements in 239 Chinese-Taiwanese patients who had attended a cardiac surgery clinic in National Taiwan University Hospital. DNA samples were obtained from 106 Chinese-Taiwanese (37 patients and 69 unrelated healthy controls), and healthy control subjects of Caucasians (n=28) and African-Americans (n=28). Four out of those 37 patients were poor metabolizers of warfarin, and their DNA were subjected to sequencing analysis. Moreover, CYP2C9 genotyping analyses were performed using PCR-RFLP analysis. The chi2 test and Fisher's exact test were used to compare the differences of the allelic frequency and genotype. The association between warfarin dose requirement and genetic polymorphism of CYP2C9 was also analysed.. The mean daily warfarin dose was 3.11+/-1.62 mg for the maintenance of the international normalized ratio of 2 to 3 in 239 patients. A single nucleotide substitution from G to C was found in this study. This SNP, G-65/C, is in intron 3, 65 base pairs upstream of exon 4. The allelic frequencies of C-65 in healthy controls were 0.125, 0.058 and approximately 0 with respect to African-American, Chinese-Taiwanese and Caucasian, implying inter-ethnic variations of the C-65 allele. In addition, patients who were carrier of either the heterozygous or homozygous C-65 variant received half of the usual warfarin dose.. The novel intronic G-65/C mutation appears to be inter-racially different in allelic frequency, and that the anticoagulation was affected in response to warfarin sensitivity in Chinese-Taiwanese patients receiving mitral valve replacement.

Topics: Adult; Aged; Aryl Hydrocarbon Hydroxylases; Asian People; Base Sequence; Cytochrome P-450 CYP2C9; Female; Genotype; Heart Diseases; Humans; Male; Middle Aged; Pharmacogenetics; Polymorphism, Genetic; Taiwan; Warfarin

The objective of this study was to investigate the stereoselective influence of bucolome on the pharmacokinetics and pharmacodynamics of warfarin in Japanese inpatients with heart disease. Thirty patients were administered a fixed-maintenance dose of warfarin alone once a day for at least 7 days. The other 25 patients were concomitantly administered warfarin and a 300 mg dose of bucolome once a day, and blood samples were collected on days 1, 4, 7, 14, or 21 after administration of bucolome. Serum concentration of warfarin enantiomers was measured by a chiral reversed-phase HPLC-ultraviolet detection method. The PT-INR was used as a measure of the pharmacodynamic effect of warfarin. Coadministration of bucolome and warfarin had no effect on serum (R)-warfarin concentration and significantly increased serum (S)-warfarin concentration compared with warfarin alone. The PT-INR of warfarin alone was significantly lower with bucolome cotreatment. These results indicate that the augmented anticoagulant effect of warfarin by bucolome is due to inhibition of (S)-warfarin metabolism in vivo. When bucolome is added to a stabilized regimen of warfarin therapy, the dose of warfarin should be reduced by about 30% to 60%, and caution should be exercised during the first 7 days after coadministration of bucolome.

Topics: Administration, Oral; Adolescent; Adult; Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Barbiturates; Dose-Response Relationship, Drug; Drug Interactions; Female; Heart Diseases; Humans; Japan; Male; Metabolic Clearance Rate; Middle Aged; Stereoisomerism; Time Factors; Warfarin

The conventional treatment strategy for patients with atrial fibrillation who are to undergo electrical cardioversion is to prescribe warfarin for anticoagulation for three weeks before cardioversion. It has been proposed that if transesophageal echocardiography reveals no atrial thrombus, cardioversion may be performed safely after only a short period of anticoagulant therapy.. In a multicenter, randomized, prospective clinical trial, we enrolled 1222 patients with atrial fibrillation of more than two days' duration and assigned them to either treatment guided by the findings on transesophageal echocardiography or conventional treatment. The composite primary end point was cerebrovascular accident, transient ischemic attack, and peripheral embolism within eight weeks. Secondary end points were functional status, successful restoration and maintenance of sinus rhythm, hemorrhage, and death.. There was no significant difference between the two treatment groups in the rate of embolic events (five embolic events among 619 patients in the transesophageal-echocardiography group [0.8 percent]) vs. three among 603 patients in the conventional-treatment group [0.5 percent], P=0.50). However, the rate of hemorrhagic events was significantly lower in the transesophageal-echocardiography group (18 events [2.9 percent] vs. 33 events [5.5 percent], P=0.03). Patients in the transesophageal-echocardiography group also had a shorter time to cardioversion (mean [+/-SD], 3.0+/-5.6 vs. 30.6+/-10.6 days, P<0.001) and a greater rate of successful restoration of sinus rhythm (440 patients [71.1 percent] vs. 393 patients [65.2 percent], P=0.03). At eight weeks, there were no significant differences between the two groups in the rates of death or maintenance of sinus rhythm or in functional status.. The use of transesophageal echocardiography to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Echocardiography, Transesophageal; Electric Countershock; Embolism; Female; Heart Atria; Heart Diseases; Hemorrhage; Heparin; Humans; Ischemic Attack, Transient; Male; Middle Aged; Mortality; Prospective Studies; Stroke; Thromboembolism; Thrombosis; Warfarin

The concurrent use of amiodarone and warfarin inhibits metabolism of S-warfarinby cytochrome P450 (CYP) 2C9, thereby increasing the anticoagulant effect of warfarin. Amiodarone primarily inhibits CYP1A2 and CYP3A4, and desethylamiodarone primarily inhibits CYP2C9. We investigate whether a relationship exists between the plasma concentration of desethylamiodarone and anticoagulation when amiodarone is administered to patients receiving warfarin therapy.. The correlation between the plasma concentration of either amiodarone or desethylamiodarone, and prolongation of prothrombin time-international normalized ratio/dose of warfarin (Delta INR/Dose) on day 7 of amiodarone administration was studied in 25 patients (22-74 years old) with structural heart disease and refractory arrhythmias receiving stable warfarin therapy.. No correlation was found between the plasma concentration of amiodarone and Delta INR/Dose, but a correlation was found between the plasma concentration of desethylamiodarone and Delta INR/Dose.. It was suggested that inhibition of CYP2C9 by desethylamiodarone, the active metabolite of amiodarone, plays an important role in the interaction of warfarin and amiodarone.

Topics: Adult; Aged; Amiodarone; Anticoagulants; Drug Interactions; Drug Therapy, Combination; Female; Heart Diseases; Humans; International Normalized Ratio; Male; Middle Aged; Warfarin

Transesophageal echocardiography (TEE) visualizes potential sources of embolism in patients with atrial fibrillation, but the clinical significance of TEE findings has not been prospectively established.. To define TEE predictors of stroke in patients with atrial fibrillation and to examine response to antithrombotic therapy.. Prospective correlation of TEE findings at study entry with subsequent ischemic stroke during 1.1-year mean follow-up of participants in a randomized trial.. 18 echocardiography laboratories.. 382 patients with atrial fibrillation at high risk for thromboembolism.. Adjusted-dose warfarin (international normalized ratio, 2 to 3) or low-intensity warfarin (international normalized ratio, 1.2 to 1.5) plus aspirin (325 mg/d).. Size of left atrium and left atrial appendage, flow velocity, spontaneous echocardiographic contrast, thrombus, and plaque on the aortic arch.. 23 ischemic strokes occurred. In patients with dense spontaneous echocardiographic contrast (20%), the rate of stroke was 18.2% per year with combination therapy (2.9 times the rate in patients without this finding; P = 0.06) and 4.5% per year with adjusted-dose warfarin (P = 0.09 for rate reduction). Appendage thrombus, detected in 10% of patients, was associated with dense spontaneous echocardiographic contrast (P < 0.001), was seen more frequently after 2 weeks of combination therapy (15%) than after 2 weeks of adjusted-dose warfarin (4%) (P = 0.004), and tripled the overall rate of stroke (P = 0.04). Patients with complex aortic plaque (35%) had a fourfold increased rate of stroke compared with plaque-free patients (P = 0.005); adjusted-dose warfarin decreased risk by 75% (P = 0.02). Dense spontaneous echocardiographic contrast and complex aortic plaque were independent of each other as predictors of thromboembolism.. In high-risk patients with atrial fibrillation, subsequent rates of thromboembolism are correlated with dense spontaneous echocardiographic contrast, thrombus of the atrial appendage, and aortic plaque. Adjusted-dose warfarin reduces the rate of stroke among patients with dense contrast and complex plaque. In patients with atrial fibrillation, the pathogenesis of stroke is multifactorial, and warfarin seems effective for the diverse mechanisms.

Topics: Aged; Anticoagulants; Aortic Diseases; Arteriosclerosis; Aspirin; Atrial Fibrillation; Drug Therapy, Combination; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Humans; Male; Platelet Aggregation Inhibitors; Prospective Studies; Risk Factors; Thromboembolism; Warfarin

To determine whether genetic polymorphism of cytochrome P450 (CYP) 2C9 affects the in vivo metabolism of warfarin enantiomers.. Eighty-six Japanese patients heart disease who were given warfarin participated in the study. Plasma unbound concentrations of warfarin enantiomers and urinary (S)-7-hydroxywarfarin concentrations were measured by means of a chiral HPLC and ultrafiltration technique to calculate the unbound oral clearance (CLpo,u) for the enantiomers and the formation clearance (CLm) for (S)-warfarin 7-hydroxylation. Genotyping for CYP2C9 (the wild type [wt], Arg144/Cys, and I1e359/Leu) and for CYP2C19 (wt, ml, and m2) was performed with a polymerase chain reaction method.. Three patients were heterozygous for the CYP2C9 Leu359 mutation but none were homozygous for the mutation (the allele frequency of 0.017). None had a CYP2C9 Cys144 allele. The medians for (S)-warfarin CLpo,u and its 7-hydroxylation CLm obtained from heterozygotes of CYP2C9 Leu359 were significantly less than those obtained from homozygotes of the wt allele, as follows: 234 ml/min (range, 156 to 269 ml/min) versus 632 ml/min (range, 180 to 2070 ml/min) (p < 0.001) and 0.20 ml/min (range, 0.05 to 0.77 ml/min) versus 0.80 ml/min (range, 0.05 to 14.9 ml/min) (p < 0.05), respectively. In contrast, no difference was observed in (R)-warfarin CLpo,u between the groups. The allele frequencies for CYP2C19 m1 and CYP2C19 m2 were 0.26 and 0.14, respectively, indicating 15% of patients were genotypically poor metabolizers of CYP2C19. No difference in CLpo,u for warfarin enantiomers was observed between the assumed CYP2C19 phenotypes.. Heterozygotes for CYP2C9 I1e359/Leu allele have reduced in vivo metabolism of (S)-warfarin but not (R)-warfarin. Because (S)-warfarin has a greater anticoagulant potency than its (R)-congener, the genetic polymorphism of CYP2C9 may partly account for the large interpatient variability in therapeutic dosages of warfarin.

Topics: Adult; Aged; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Cytochrome P-450 CYP2C19; Cytochrome P-450 CYP2C9; Cytochrome P-450 Enzyme System; Female; Genotype; Heart Diseases; Humans; Japan; Male; Metabolic Clearance Rate; Middle Aged; Mixed Function Oxygenases; Polymerase Chain Reaction; Polymorphism, Genetic; Stereoisomerism; Steroid 16-alpha-Hydroxylase; Steroid Hydroxylases; Warfarin

A prospective study was designed to investigate potential changes of left atrial (LA) spontaneous echo contrast with time and the effects of antithrombotic therapy on its presence in 77 patients with chronic nonrheumatic atrial fibrillation (AF), using serial transesophageal echocardiography (TEE). During a mean follow-up period of 20 +/- 15 months (range 6 to 77), a total of 197 TEE studies were performed in these patients. Baseline TEE revealed that LA spontaneous echo contrast was absent in 43 patients (group 1) and present in 34 (group 2). LA thrombus was found in 8 of group 2 but in none of the group 1 patients. During the follow-up period, only 2 of the group 1 patients were receiving antithrombotic agents; the patients in group 2 without LA thrombus were treated with either warfarin or aspirin, whereas those with LA thrombus were treated with warfarin. On the latest TEE study, LA spontaneous echo contrast was observed in 19 of the group 1 patients (44%) and was persistently found in all of the group 2 patients. During the study period, no patient was found to develop new LA thrombus formation and only 4 episodes of transient ischemic attack were recorded in 4 patients (embolic event rate = 3.1% per year). Of these, 2 were observed in group 1 and the remaining 2 were from group 2 and under aspirin therapy (event rate = 2.2% and 4.7% per year, respectively). In the subgroup of patients with LA thrombus receiving warfarin therapy, follow-up TEE revealed complete resolution of the thrombi in 6 and partial resolution in the remaining 2 in spite of the persistence of LA spontaneous echo contrast; none of these patients developed clinical thromboembolic events during the study period. Thus, future occurrence of LA spontaneous echo contrast could be observed by serial TEE at a substantial rate in patients with nonrheumatic AF who have no LA spontaneous echo contrast; follow-up TEE should be recommended for these patients to detect early the potential occurrence of LA spontaneous echo contrast if preventive antithrombotic therapy is not considered. Although warfarin therapy is associated with resolution of LA thrombus, neither warfarin nor aspirin is effective for suppressing the presence of LA spontaneous echo contrast in nonrheumatic AF.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Chronic Disease; Disease Progression; Echocardiography, Transesophageal; Female; Heart Atria; Heart Diseases; Humans; Male; Middle Aged; Prospective Studies; Thrombosis; Warfarin

The use of warfarin anticoagulation for several weeks before cardioversion results in a 90% reduction in the incidence of cardioversion-related thromboembolism. The mechanism of this benefit, however, is unknown; it has been widely attributed to organization and adherence of atrial thrombi, a finding observed among pathological studies of patients with rheumatic valvular disease.. Serial transesophageal echocardiography was performed in 14 patients with nonrheumatic atrial fibrillation after identification of atrial thrombi on initial transesophageal study. All patients received warfarin anticoagulation and were followed clinically for signs of thromboembolism. Eighteen atrial thrombi were identified on initial transesophageal study, including 14 thrombi confined to the left atrial appendage, 2 in the body of the left atrium, 1 in the right atrial appendage, and 1 in the body of the right atrium. Thrombus size varied from 5 to 20 mm, and 6 were considered mobile. After a median of 4 weeks of warfarin, 16 of 18 atrial thrombi (89%; 95% CI, 73% to 100%) had completely resolved on transesophageal echocardiographic study. In addition, no new thrombi were identified on follow-up study, and no patient had a clinical thromboembolic event between studies.. These data strongly support the hypothesis that among patients with nonrheumatic atrial fibrillation, the mechanism of clinical benefit with 3 to 4 weeks of warfarin before cardioversion is related to thrombus resolution and prevention of new thrombus formation rather than thrombus organization.

Topics: Aged; Atrial Fibrillation; Echocardiography, Transesophageal; Electric Countershock; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Humans; Male; Premedication; Thromboembolism; Thrombosis; Time Factors; Warfarin

Transesophageal echocardiography was used to assess cardiac abnormalities associated with embolization in patients who had completed the Department of Veterans Affairs Cooperative Study of Stroke Prevention in Nonrheumatic Atrial Fibrillation at the Minneapolis and West Haven Department of Veterans Affairs Medical Centers without an embolic event. Patients were men, 71 +/- 7 years old, with atrial fibrillation of 6.2 +/- 4.3 years' duration who had received warfarin (n = 32) or placebo (n = 23) for 2 years. Thrombi were found in 5 of 55 patients (warfarin 4 and placebo 1; p = 0.39); spontaneous echo contrast was seen in 4 of 5 patients. Other abnormalities identified included spontaneous echo contrast (47%), patent foramen ovale (54%), atrial septal aneurysm (7.3%), and left ventricular thrombus (3.6%). During 34 months of posttreatment follow-up, 5 patients had a stroke (1 fatal), and 10 died. Potential sources of emboli did not predict subsequent outcome. Thus warfarin therapy did not preclude the presence of thrombi. Stroke reduction likely involves the prevention of emboli from sources in addition to the atrial appendage.

Topics: Aged; Atrial Fibrillation; Blood Flow Velocity; Chi-Square Distribution; Chronic Disease; Echocardiography, Transesophageal; Follow-Up Studies; Heart Aneurysm; Heart Atria; Heart Diseases; Heart Septal Defects, Atrial; Heart Septum; Heart Ventricles; Humans; Male; Middle Aged; Prevalence; Rheumatic Heart Disease; Thrombosis; Warfarin

The hemostatic condition under low-intensity anticoagulation in cardiac disorders is not fully elucidated. The aim of this study was to ascertain whether hemostatic molecular markers are a useful assessment for anticoagulation to detect the hypercoagulable state. A hematologic study was performed in 75 outpatients, without thromboembolic episodes, treated with low-intensity anticoagulation (average international normalized ratio [INR] 1.72) because of potential cardiac sources of arterial emboli, and in 40 age-matched control subjects. The average level of thrombin-antithrombin III complex (TAT) was significantly lower in patients than in control subjects (p = 0.005), and the mean value of D-dimer was not statistically different between patients and control subjects. Although TAT correlated moderately with D-dimer (r = 0.45, p = 0.0001), INR did not correlate with TAT or D-dimer. Elevated TAT > 3.0 ng/ml and/or D-dimer S 150 ng/ml were observed in 15 patients (20.0%), whereas the remaining 60 patients (80.0%) had no obvious increase in the level of TAT or D-dimer at overall INR. Antithrombin III activity did not correlate significantly with INR, but protein C activity and free protein S antigen showed a significant negative relation to INR (r = 0.82, r = 0.62, respectively, p = 0.0001). Low-intensity anticoagulation was sufficient to reduce coagulation and subsequent fibrinolytic activation in cardiac disorders, but may not be sufficient in some patients with elevated TAT or D-dimer concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Antithrombin III; Blood Coagulation Disorders; Blood Coagulation Tests; Embolism; Female; Fibrin Fibrinogen Degradation Products; Heart Diseases; Humans; Male; Middle Aged; Peptide Hydrolases; Warfarin

To assess the efficacy of immediate anticoagulation therapy on intracardiac thrombus formation in acute cardioembolic stroke, serial two-dimensional echocardiographic examinations were performed in 25 patients with acute cardioembolic stroke. Anticoagulation therapy was commenced within two days of onset in 7 patients (group A) but not in 18 patients (group B). Appearance or enlargement of intracardiac thrombi were not detected in group A but were noted in 7 patients (39%) of group B. Recurrence of systemic embolism was demonstrated in 3 patients (17%) of group B. There were no serious hemorrhagic complications in either group. Immediate anticoagulation could, therefore, be effective in preventing intracardiac thrombus formation and the consequent recurrence of systemic embolization in acute cardioembolic stroke. Because the study was preliminary and not randomized, further randomized study is desirable to establish the efficacy of immediate anticoagulation therapy.

Topics: Cerebrovascular Disorders; Echocardiography; Female; Heart Diseases; Heparin; Humans; Male; Middle Aged; Recurrence; Thrombosis; Time Factors; Warfarin

Thirty patients with a first episode of an anterior acute myocardial infarction (AMI) without a history of cardiac disease were prospectively randomized into a prophylactic heparin-treated group (group I) and a control nonanticoagulated group (group II) within 12 hours of the onset of chest pain to determine the effectiveness of anticoagulation for preventing left ventricular (LV) thrombi. Serial two-dimensional echocardiograms were performed during the hospital stay and patients were followed clinically for systemic emboli for 1 month after discharge from the hospital. Thirty-one percent of patients in group I (4/13) and 35% of patients in group II (6/17) developed LV thrombi on two-dimensional echocardiograms. There was no statistical difference in the incidence of LV thrombi between the two groups (p greater than 0.05). Infarct size as determined by creatine phosphokinase isoenzymes (2,386 +/- 1,568 vs 2,083 +/- 1,462 IU for groups I and II, respectively; p greater than 0.05), wall motion score (12.7 +/- 5 vs 10.7 +/- 5 for groups I and II, respectively; p greater than 0.05) and wall motion index (1.8 +/- 0.6 vs 1.8 +/- 0.56 for groups I and II, respectively; p greater than 0.05) were not statistically different between the two groups of patients. One patient in both groups had an embolic event. In conclusion, prophylactic anticoagulation in high-risk AMI patients for LV thrombus development does not prevent LV thrombus formation during the acute and subacute stages of an AMI. The results also suggest that anticoagulation may not prevent systemic embolization.

Topics: Adult; Aged; Anticoagulants; Clinical Trials as Topic; Female; Heart Diseases; Heparin; Humans; Male; Middle Aged; Myocardial Infarction; Prospective Studies; Random Allocation; Thrombosis; Warfarin

To examine whether early intervention with timolol influences the occurrence of left ventricular thrombi in acute anterior myocardial infarction, 40 patients with acute anterior myocardial infarction admitted to hospital within 6 hr of onset of symptoms were randomly assigned to receive intravenous followed by oral timolol maleate or placebo. Five (25%) of 20 patients in the placebo group and 14 (73.7%) of 19 patients with confirmed infarction in the timolol group developed a left ventricular apical thrombus as detected by two-dimensional echocardiography from 2 to 10 days after inclusion (p less than .005). Patients received anticoagulants only after a left ventricular thrombus had been diagnosed. Only one patient with thrombus suffered peripheral embolization (timolol group). The treatment groups were comparable with respect to location of regional left ventricular dysfunction, electrocardiographic changes, and infarct size estimated by creatine kinase release. However, computer-assisted regional wall motion analysis demonstrated significantly reduced apical wall motion in the timolol group compared with the placebo group (p less than .01). Also, the mean heart rate during the first 10 days after the acute infarction was reduced by 13% in the timolol group (p less than .001). The reduction in heart rate and left ventricular apical wall motion caused by timolol in patients with acute anterior myocardial infarction may increase the occurrence of left ventricular thrombi.

Topics: Creatine Kinase; Double-Blind Method; Drug Evaluation; Echocardiography; Heart Diseases; Heart Ventricles; Humans; Myocardial Infarction; Random Allocation; Systole; Thrombosis; Time Factors; Timolol; Warfarin

To determine the effect of early anticoagulation on the incidence of left ventricular thrombi complicating anterior acute myocardial infarction (AMI), 82 consecutive patients admitted within 12 hours of symptom onset and with electrocardiographic changes consistent with anterior AMI were randomly assigned to 1 of 2 treatment groups. Group 1 patients received high-dose intravenous heparin to maintain the whole blood clotting time between 15 and 20 minutes, and commenced warfarin therapy within 48 hours. Group 2 patients received low-dose subcutaneous heparin and warfarin therapy if the peak creatine kinase level was more than 1,000 U/liter. Eighteen group 2 patients received warfarin, but none had a therapeutic prothrombin ratio within 5 days. The presence and morphologic characteristics of thrombus were assessed by serial 2-dimensional echocardiography. Thirty patients were excluded because AMI was not confirmed or because of technically unsatisfactory echocardiograms, death, surgery or, in group 1 patients, inadequate anticoagulation. Thrombi were identified in 29 of 52 patients (56%): in 14 of 25 group 1 patients (56%) and 15 of 27 group 2 patients (56%). Twenty-three thrombi formed within 3 days. Thrombi were protruding rather than mural only in 3 group 2 patients. The groups did not differ in baseline characteristics or in incidence, time of appearance or morphologic characteristics of thrombus (p greater than 0.05, beta for more than 25% reduction in incidence with group 1 treatment less than 0.10). Systemic embolism occurred only in 1 group 2 patient with mural thrombus.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Female; Heart Diseases; Heart Ventricles; Heparin; Humans; Male; Middle Aged; Myocardial Infarction; Thrombosis; Warfarin

Topics: Clinical Trials as Topic; Echocardiography; Embolism; Heart Diseases; Heparin; Humans; Myocardial Infarction; Retrospective Studies; Thrombosis; Warfarin

Topics: Chloral Hydrate; Drug Synergism; Evaluation Studies as Topic; Heart Diseases; Humans; Placebos; Prothrombin Time; Time Factors; Warfarin

Direct oral anticoagulants use in pediatric cardiology is poorly defined.. We present the largest experience of apixaban use in children with heart disease, using weight- and level-based dosing.. Retrospective single-center analysis of cardiac patients ≤19 years treated with apixaban. Patients were evaluated for safety (clinically relevant non-major [CRNM] or major bleeding; thrombotic events) and effectiveness (thrombus improvement by imaging). Peak drug-specific anti-Xa chromogenic assay results ("apixaban levels") were analyzed.. Over 3 years (5/2018-9/2021), 219 children, median age 6.8 years (0.3-19), median weight 20.8 kg (4.8-160) received apixaban, totaling 50,916 patient days. Of them, 172 (79%) warranted thromboprophylaxis and 47 (21%) thrombosis treatment (with 10 arterial, 19 venous, 15 intracardiac, and 3 pulmonary). The median initial peak apixaban level was 165 ng/mL (23-474; n = 125) in the prophylaxis subgroup and 153 ng/mL (30-450; n = 33) in the treatment subgroup; dosage was adjusted in response to levels in 25% of the patients. There were 4 bleeding safety events (3 CRNM; 1 major, hemoptysis complicating empyema); the serious bleeding event rate was 2.9 per 100 patient-years of apixaban. Minor bleeding events (42) were noted in 18 patients, with an additional 2 having leukopenia, 1 transaminitis, and 3 rashes. An improvement in thrombosis was seen in 95% of the treated patients with available follow-up imaging (37/39 patients).. Apixaban use was feasible with a low rate of adverse events across a diverse pediatric cardiac population using commercially available tablets dosed to weight and adjusted based on peak apixaban levels.

Topics: Anticoagulants; Child; Factor Xa Inhibitors; Heart Diseases; Hemorrhage; Humans; Pyridones; Retrospective Studies; Thrombosis; Venous Thromboembolism; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Child; Cost-Benefit Analysis; Heart Diseases; Humans; Pyrazoles; Pyridones; Stroke; Warfarin

Intracardiac thrombus (ICT) formation is a common complication of several cardiovascular diseases. Warfarin is recommended for treatment of ICT by guidelines based on observational studies occurring before the advent of nonvitamin K antagonist direct oral anticoagulants (DOACs). We aim to evaluate the current prescribing patterns at our institution and to compare the efficacy and safety profiles of warfarin versus DOACs for ICT. This is a retrospective review of adult patients treated with oral anticoagulation for ICT between May 2013 and December 2019. Our primary end point was complete thrombus resolution. Secondary outcomes included time to resolution of thrombus, treatment failure, and duration of therapy. Safety end points included stroke and systemic embolization (SSE) and bleeding events. A total of 123 patients were included (DOAC n = 61; warfarin n = 62). At baseline, more patients in the DOAC group had anemia [6 (10%) vs. 0 (0%), P = 0.013] and alcohol use disorder [6 (10%) vs. 0 (0%), P = 0.013]. Complete thrombus resolution occurred in 50 (82%) and 46 (74%) patients in the DOAC and warfarin groups, respectively (P = 0.298). There was a shorter time to thrombus resolution in the DOAC group versus the warfarin group {63 days [interquartile range (IQR) 40-138] vs. 123 days [IQR 86-244], P = 0.003}. There were no differences found in SSE or bleeding between the groups [DOAC 11 (19%) vs. warfarin 17 (28%), P = 0.213]. For patients with an ICT, treatment with a DOAC for at least 3 months may be a comparable alternative to warfarin in safety and efficacy.

Topics: Aged; Anticoagulants; Blood Coagulation; Drug Prescriptions; Drug Utilization; Factor Xa Inhibitors; Female; Heart Diseases; Hemorrhage; Humans; Male; Middle Aged; Practice Patterns, Physicians'; Retrospective Studies; Risk Assessment; Risk Factors; Thrombosis; Time Factors; Treatment Outcome; Warfarin

Bioprosthetic valve thrombosis (BPVT) is increasingly recognised as a major cause of prosthetic dysfunction in the first years postimplantation. How early abnormal gradients can be detected prior to diagnosis and how fast they normalise with anticoagulant therapy is unknown. We set forth to (1) evaluate patterns of increase in gradients prior to BPVT diagnosis and (2) characterise time-course of response to anticoagulation.. Patients treated with warfarin for BPVT (1999-2019) with clinically significant reduction of mean gradients (≥25%) were identified retrospectively. Recovery was defined as gradient decrease ≥50%, to postimplantation or to normal-range gradients per position, model and size. Time-to-BPVT (implantation-BPVT diagnosis), potential diagnostic delay (first abnormal gradient by position, model and size-BPVT diagnosis) and time-to-recovery (BPVT diagnosis-complete resolution) were recorded.. 77 patients were identified; 32 (42%) aortic (23 surgical-12 porcine, 11 pericardial; 9 transcatheter); 24 (31%) mitral; 21 (27%) tricuspid. Median time-to-BPVT was 24, 21 and 10 months, respectively. Potential diagnostic delay was median 21 months for aortic, 4 months for mitral, but 0 for tricuspid. Recovery was significantly faster in mitral than aortic (median 2.5 vs 4.8 months, p=0.038) and tricuspid (median 5.9 months, p=0.025) positions. Porcine aortic valves responded faster than pericardial aortic valves (median 2.9 vs 20.3 months, p=0.004).. Gradients start to increase months before the clinical BPVT diagnosis. Recovery is faster in mitral and surgical aortic porcine valves; a longer warfarin trial seems indicated in tricuspid and surgical aortic pericardial valves.

Topics: Aged; Aged, 80 and over; Animals; Anticoagulants; Bioprosthesis; Blood Coagulation; Delayed Diagnosis; Echocardiography; Heart Diseases; Heart Valve Prosthesis; Humans; Middle Aged; Prosthesis Design; Prosthesis Failure; Retrospective Studies; Swine; Thrombosis; Warfarin

The objective of this study is to estimate the prevalence of VKORC1, CYP2C9, and CYP4F2 genetic variants and their contribution to warfarin dose variability in Qataris. One hundred and fifty warfarin-treated Qatari patients on a stable dose and with a therapeutic INR for at least three consecutive clinic visits were recruited. Saliva samples were collected using Oragene DNA self-collection kit, followed by DNA purification and genotyping via TaqMan Real-Time-PCR assay. The population was stratified into derivation and validation cohorts for the dosing model. The minor allele frequency (MAF) of VKORC1 (-1639G>A) was A (0.47), while the MAF's for the CYP2C9*2 and *3 and CYP4F2*3 were T (0.12), C (0.04) and T (0.43), respectively. Carriers of at least one CYP2C9 decreased function allele (*2 or *3) required lower median (IQR) warfarin doses compared to noncarriers [24.5 (14.5) mg/week vs. 35 (21) mg/week, p < 0.001]. Similarly, carriers of each additional copy of (A) variant in VKORC1 (-1639G>A) led to reduction in warfarin dose requirement compared to noncarriers [21(7.5) vs. 31.5(18.7) vs. 43.7(15), p < 0.0001]. CYP4F2*3 polymorphism on the other hand was not associated with warfarin dose. Multivariate analysis on the derivation cohort (n = 104) showed that a dosing model consisting of hypertension (HTN), heart failure (HF), VKORC1 (-1639G>A), CYP2C9*2 & *3, and smoking could explain 39.2% of warfarin dose variability in Qataris (P < 0.001). In the validation cohort (n = 45), correlation between predicted and actual warfarin doses was moderate (Spearman's rho correlation coefficient = 0.711, p < 0.001). This study concluded that VKORC1 (-1639G>A), CYP2C9*2 & *3 are the most significant predictors of warfarin dose along with HTN, HF and smoking.

Topics: Aged; Anticoagulants; Cohort Studies; Cross-Sectional Studies; Cytochrome P-450 CYP2C9; Dose-Response Relationship, Drug; Female; Heart Diseases; Humans; Male; Middle Aged; Population Surveillance; Qatar; Smoking; Vitamin K Epoxide Reductases; Warfarin

ENSURE-AF (NCT02072434) assessed therapy with edoxaban vs enoxaparin-warfarin in patients with nonvalvular atrial fibrillation (AF) undergoing elective electrical cardioversion (ECV).. To evaluate clinical features and primary efficacy (composite of stroke, systemic embolic events, myocardial infarction and cardiovascular mortality during study period) and safety endpoints (composite of major and clinically relevant nonmajor bleeding during on-treatment period) in patients awaiting ECV of AF with a transesophageal echocardiography (TEE)-guided vs a non-TEE-guided strategy.. In this prospective, randomized, open-label, blinded endpoint study, 2199 patients were randomized to edoxaban 60 mg once-daily (30 mg for creatinine clearance 15-50 mL/min, weight ≤60 kg and/or concomitant use of P-glycoprotein inhibitor) or enoxaparin-warfarin. Primary efficacy endpoint and safety endpoint were reported. Associates of TEE use, efficacy endpoint and safety endpoint were explored using multivariable logistic regression.. In total, 589 patients from the edoxaban stratum and 594 from the enoxaparin-warfarin stratum were allocated to the TEE-guided strategy. Primary efficacy was similar regardless of TEE approach (P = .575). There were no significant differences in bleeding rates, regardless of TEE approach (P = .677). Independent predictors of TEE use were as follows: history of ischaemic stroke/ transient ischaemic attack, hypertension and valvular heart disease. Mean CHA. Thromboembolic and bleeding events were not different between patients undergoing TEE-guided strategy and in those undergoing an optimized conventional anticoagulation approach for ECV of AF.

Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Clinical Decision-Making; Duration of Therapy; Echocardiography, Transesophageal; Electric Countershock; Enoxaparin; Female; Heart Diseases; Humans; International Normalized Ratio; Male; Middle Aged; Pyridines; Randomized Controlled Trials as Topic; Stroke; Thiazoles; Thrombosis; Warfarin

Left ventricular (LV) thrombi can arise in patients with ischemic and nonischemic cardiomyopathies. Anticoagulation is thought to reduce the risk of stroke or systemic embolism (SSE), but there are no high-quality data on the effectiveness of direct oral anticoagulants (DOACs) for this indication.. To compare the outcomes associated with DOAC use and warfarin use for the treatment of LV thrombi.. A cohort study was performed at 3 tertiary care academic medical centers among 514 eligible patients with echocardiographically diagnosed LV thrombi between October 1, 2013, and March 31, 2019. Follow-up was performed through the end of the study period.. Type and duration of anticoagulant use.. Clinically apparent SSE.. A total of 514 patients (379 men; mean [SD] age, 58.4 [14.8] years) with LV thrombi were identified, including 300 who received warfarin and 185 who received a DOAC (64 patients switched treatment between these groups). The median follow-up across the patient cohort was 351 days (interquartile range, 51-866 days). On unadjusted analysis, DOAC treatment vs warfarin use (hazard ratio [HR], 2.71; 95% CI, 1.31-5.57; P = .01) and prior SSE (HR, 2.13; 95% CI, 1.22-3.72; P = .01) were associated with SSE. On multivariable analysis, anticoagulation with DOAC vs warfarin (HR, 2.64; 95% CI, 1.28-5.43; P = .01) and prior SSE (HR, 2.07; 95% CI, 1.17-3.66; P = .01) remained significantly associated with SSE.. In this multicenter cohort study of anticoagulation strategies for LV thrombi, DOAC treatment was associated with a higher risk of SSE compared with warfarin use, even after adjustment for other factors. These results challenge the assumption of DOAC equivalence with warfarin for LV thrombi and highlight the need for prospective randomized clinical trials to determine the most effective treatment strategies for LV thrombi.

Topics: Administration, Oral; Anticoagulants; Female; Heart Diseases; Heart Ventricles; Humans; Male; Middle Aged; Off-Label Use; Retrospective Studies; Thrombosis; Warfarin

We describe a patient with COVID-19 who developed simultaneous pulmonary, intracardiac and peripheral arterial thrombosis. A 58-year-old man, without major comorbidity, was admitted with a 14-day history of breathlessness. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection was confirmed by laboratory testing. Initial imaging revealed COVID-19 pneumonia but no pulmonary thromboembolism (PTE) on CT pulmonary angiography (CTPA). The patient subsequently developed respiratory failure and left foot ischaemia associated with a rising D-dimer. Repeat CTPA and lower limb CT angiography revealed simultaneous bilateral PTE, biventricular cardiac thrombi and bilateral lower limb arterial occlusions. This case highlights a broad range of vascular sequalae associated with COVID-19 and the fact that these can occur despite a combination of prophylactic and treatment dose anticoagulation.

Topics: Anticoagulants; Betacoronavirus; Clinical Deterioration; Computed Tomography Angiography; Coronavirus Infections; COVID-19; Enoxaparin; Heart Diseases; Heart Ventricles; Humans; Male; Middle Aged; Pandemics; Peripheral Arterial Disease; Pneumonia, Viral; Pulmonary Embolism; SARS-CoV-2; Thrombosis; Treatment Outcome; Warfarin

In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage.. We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations.. We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01-7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63-2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29-0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22-1.48]).. Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Brain Ischemia; Embolism; Female; Heart Diseases; Heparin, Low-Molecular-Weight; Humans; Incidence; Intracranial Hemorrhages; Male; Middle Aged; Neuroimaging; Recurrence; Registries; Retrospective Studies; Risk Assessment; Stroke; Treatment Outcome; United States; Warfarin

The need for anticoagulation treatment following bioprosthetic aortic valve replacement remains controversial. We investigated the associations of warfarin treatment with the risks of major adverse cardiac and cerebrovascular events, including mortality, bleeding incidents, and reoperation requirement after bioprosthetic aortic valve replacement surgery.. We identified 1086 patients who received first bioprosthetic aortic valve replacement between 2001 and 2010 using Taiwan's National Health Insurance Database. Patients were excluded for prior use of warfarin, warfarin use for >3 months, dual valve procedures, prior valve surgeries, or concomitant surgeries. Enrolled patients were divided into 2 groups according to whether they were warfarin-naïve or received warfarin for <3 months postsurgery. After propensity score matching, 282 patients not receiving warfarin were matched to 282 patients receiving warfarin for <3 months. Patients were followed-up for minimum 36 months.. Patients receiving warfarin were younger and showed less frequent kidney disease than those who did not use warfarin. The warfarin group demonstrated a gross decrease in major adverse cardiac and cerebrovascular events. Patients receiving warfarin for <30 days were at an even lower risk for major adverse cardiac and cerebrovascular events than those treated for ≥30 days. No significant difference in bleeding or reoperation risk was observed between warfarin users and warfarin nonusers. Similar findings remained after propensity-score matching but the benefit of short-term warfarin use diminished in a younger population.. Short-term use of postoperative warfarin (especially <30 days) following bioprosthetic aortic valve replacement may be associated with a reduction in MACCE compared with nonuse.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve; Bioprosthesis; Cerebrovascular Disorders; Databases, Factual; Drug Administration Schedule; Female; Heart Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Male; Middle Aged; Prosthesis Design; Retrospective Studies; Risk Assessment; Risk Factors; Taiwan; Time Factors; Treatment Outcome; Warfarin; Young Adult

The combination of warfarin and compound Danshen dripping pill (CDDP) is helpful for patients with both coronary heart disease (CHD) and atrial fibrillation (AF). The main adverse drug reaction of warfarin is bleeding because of its narrow therapeutic index. The safety of a combination therapy with warfarin and CDDP is always a concern. Our previous research showed that the combination of warfarin and CDDP improved the quality of life for patients with both CHD and AF. This study describes the changes in dose and concentration of warfarin necessary and evaluates bleeding risk when warfarin is given concomitantly with CDDP.. An ultra-performance liquid chromatography-MS/MS method with a chiral column was developed to assay the concentration of S-warfarin and R-warfarin in human plasma simultaneously. The method was applied to compare the concentration of warfarin in patients taking warfarin combined with CDDP and without CDDP. International normalized ratio (INR) values were monitored to evaluate bleeding risk. Paired t tests were then used to compare the dose and the concentration in 2 periods. Moreover, patients with VKORC1, CYP2C9*3, CYP4F2, EPHX1, and PROC gene polymorphisms were evaluated to determine interactions.. The results indicate that the dose of warfarin had no significant change with or without CDDP. Also, the peak concentrations of S-warfarin and total warfarin were significantly different in CYP4F2 C/C patients, but there was no significant difference identified in other genetic groups. No bleeding occurred in the study.. The dose of warfarin would be sustainable when combined with CDDP, because CDDP did not affect concentration of warfarin significantly in most patients and the change of INR was not significant.. ChiCTR-ONRC-13003523.

Topics: Camphanes; Cytochrome P450 Family 4; Drugs, Chinese Herbal; Heart Diseases; Hemorrhage; Herb-Drug Interactions; Humans; Panax notoginseng; Polymorphism, Genetic; Salvia miltiorrhiza; Warfarin

Non-vitamin K oral anticoagulants (NOACs) have emerged as alternatives to vitamin K antagonists in select situations. For left atrial (LA) appendage thrombus in nonvalvular atrial fibrillation (AF) or flutter, guidelines recommend oral anticoagulation (OAC) for at least 3 weeks prior to reassessment. Data comparing NOACs to warfarin in this scenario are scarce.. A retrospective study identified subjects with nonvalvular AF or flutter who were: a) noted to have LA thrombus detected on transesophageal echocardiography (TEE), b) previously not receiving long-term OAC; and c) evaluated for resolution of LA thrombus by follow-up TEE between 3 weeks to less than 1 year of the initial TEE.. In patients nonvalvular AF or flutter who were OAC naïve at the time of diagnosis with LA appendage thrombus, complete resolution was similar between NOACs and warfarin.

Topics: Administration, Oral; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Atrial Flutter; Female; Heart Diseases; Humans; Male; Middle Aged; Retrospective Studies; Thrombosis; Warfarin

A 74-year-old man with a past medical history of bradycardiac atrial fibrillation and an old cerebral infarction presented with dysarthria. He had been treated with warfarin and PT-INR on admission was 2.0. MRI of the head revealed an acute ischemic stroke involving the cerebellum and left occipital lobe. Because transesophageal cardiac echography showed a thrombus in the left atrial appendage, anticoagulant treatment with warfarin and heparin was initiated. The thrombus was enlarging; therefore, we changed the anticoagulant therapy to apixaban with heparin on day 11. On day 17, a hemorrhagic cerebral infarction occurred. After the hemorrhage diminished, we treated him with warfarin aiming for a PT-INR between 3 and 4. The thrombus gradually shrank and disappeared on day 110. Finally, a thoracoscopic left atrial appendectomy was performed as a secondary prevention, with no recurrence till date.

Topics: Aged; Anticoagulants; Cardiac Surgical Procedures; Cerebral Infarction; Drug Therapy, Combination; Heart Atria; Heart Diseases; Heparin; Humans; International Normalized Ratio; Male; Pyrazoles; Pyridones; Recurrence; Sick Sinus Syndrome; Thoracoscopy; Thrombosis; Treatment Outcome; Warfarin

Topics: Administration, Oral; Adult; Anticoagulants; Diagnosis, Differential; Echocardiography, Transesophageal; Heart Atria; Heart Diseases; Humans; Male; Rheumatic Fever; Thrombosis; Warfarin

Vascular calcification is highly prevalent in end-stage renal disease (ESRD) and is a significant risk factor for future cardiovascular events and death. Warfarin use results in dysfunction of matrix Gla protein, an inhibitor of vascular calcification. However, the effect of warfarin on vascular calcification in patients with ESRD is still not well characterized. Thus we investigated whether arterial calcification can be accelerated by warfarin treatment both in vitro and in vivo using a mouse remnant kidney model.. Human aortic smooth muscle cells (HASMC) were cultured in medium supplemented with warfarin and phosphate to investigate the potential role of this drug in osteoblast transdifferentiation. For in vivo study, adult male C57BL/6 mice underwent 5/6 nephrectomy were treated with active vitamin D3 plus warfarin to determine the extent of vascular calcification and parameters of cardiovascular function.. We found that the expressions of Runx2 and osteocalcin in HASMC were markedly enhanced in the culture medium containing warfarin and high phosphate concentration. Warfarin induced calcification of cultured HASMC in the presence of high phosphate levels, and this effect is inhibited by vitamin K2. Severe aortic calcification and reduced left ventricular ejection fractions were also noted in 5/6 nephrectomy mice treated with warfarin and active vitamin D3.. Warfarin treatment contributes to the accelerated vascular calcification in animal models of advanced chronic kidney disease. Clinicians should therefore be aware of the profound risk of warfarin use on vascular calcification and cardiac dysfunction in patients with ESRD and atrial fibrillation.

Topics: Animals; Anticoagulants; Cells, Cultured; Heart Diseases; Humans; Kidney Failure, Chronic; Male; Mice; Mice, Inbred C57BL; Myocytes, Smooth Muscle; Nephrectomy; Vascular Calcification; Warfarin

A 31-year-old man with Duchenne muscular dystrophy was admitted to our center, having infarctions in bilateral cerebral hemispheres and an occluded right middle cerebral artery. His right middle cerebral artery was spontaneous recanalization on the next day, and thrombus in the left ventricle vanished on the eighth day after giving warfarin.

Topics: Adult; Anticoagulants; Cerebral Infarction; Heart Diseases; Heart Ventricles; Humans; Male; Muscular Dystrophy, Duchenne; Thrombosis; Warfarin

Catheter-related right atrial thrombosis (CRAT) is an underreported but potentially life-threatening complication associated with the use of tunneled-cuffed catheters among hemodialysis (HD) patients. Because little is known about the evidence-based guidelines for the optimal management of CRAT among HD patients, this article reports findings based on 20 patients diagnosed with CRAT after catheter replacement and anticoagulation treatment.. The article retrospectively reviews the hospital records of 20 HD patients treated in the West China Hospital with diagnosis of CRAT from March 2013 to May 2016. Once CRAT was diagnosed, tunneled-cuffed catheters were exchanged over a guidewire in situ and the locations of the new catheter tips were adjusted to be away from the original sites. Immediately after the insertion of a new tunneled-cuffed catheter and at the end of each HD session, both ports of the catheters were locked with unfractionated heparin solution. Patients younger than 70 years of age were treated with warfarin at a target International Normalized Ratio of 1.5 to 1.9, whereas those older than 70 years were treated with dual antiplatelet therapy. All patients were on regular dialysis without thrombolysis or thrombectomy.. During the follow-up, two patients died of gastrointestinal massive hemorrhage and one died of acute myocardial infarction. No fatal pulmonary embolism or other CRAT complication-related deaths were observed. A total of eight patients had complete dissolution of CRAT, and 12 patients had reduction in thrombi size.. Maintenance of HD by replacing catheters and providing oral anticoagulation/antiplatelet therapies may be an effective strategy for treating HD patients with CRAT.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Catheterization, Central Venous; Catheters, Indwelling; Central Venous Catheters; China; Device Removal; Female; Heart Atria; Heart Diseases; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Renal Dialysis; Retrospective Studies; Risk Factors; Thrombosis; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; 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

A 59-year-old woman presented with a sudden onset of breathlessness and chest pain. An echocardiography and CT scan showed pulmonary embolism and infarction with a paradoxical thrombus visualised in both atria. For haemodynamically stable patients, the optimal management strategy is poorly defined. Three main strategies were considered: surgical thrombectomy, thrombolysis and anticoagulation. Surgery with reversal of anticoagulation may lead to further coagulation and increased risk of bleeding complications. The significant pulmonary hypertension and right ventricular infarction raised the prospect of difficult weaning from cardiopulmonary bypass following thrombectomy. Thrombolysis, which has significant mortality rate, and systemic embolisation including pulmonary infarction with haemorrhagic transformation were also contraindications. A multidisciplinary approach was adopted and anticoagulation was therefore believed to be the safest and effective approach. Here, the use of anticoagulation alone was fortunately successful but could as easily end in disaster. This approach should be considered the ideal paradigm to yield optimum outcomes.

Topics: Anticoagulants; Computed Tomography Angiography; Drug Therapy, Combination; Embolism, Paradoxical; Female; Heart Atria; Heart Diseases; Heparin; Humans; Middle Aged; Pulmonary Embolism; Pulmonary Infarction; Thrombosis; Treatment Outcome; Warfarin

We report cerebral embolism in 2 patients with Duchenne muscular dystrophy (DMD) after respiratory tract infection. A 31-year-old man (Case 1) was admitted to the hospital because of an upper respiratory tract infection, then suddenly developed left-sided hemiparesis. Transthoracic echocardiography revealed an intracardiac thrombus in the left ventricle, and, under assumption of cardioembolic stroke, oral anticoagulation was initiated. Case 2 was a 36-year-old man who developed dysphasia after increasing sputum. Based on brain CT scan findings, we confirmed a diagnosis of cerebral infarction. There was no recurrence in either case. Both cases developed cerebral infarction due to embolism after mild upper respiratory tract infections. DMD patients have various risk factors for thrombus and embolus, while physicians should also be aware of possible cerebral infarction and other coagulation disorders irrespective of respiratory and cardiac therapy.

Topics: Adult; Anticoagulants; Aspirin; Brain; Diffusion Magnetic Resonance Imaging; Echocardiography; Heart Diseases; Heart Ventricles; Heparin; Humans; Intracranial Embolism; Magnetic Resonance Angiography; Male; Muscular Dystrophy, Duchenne; Respiratory Tract Infections; Risk; Thrombosis; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Syncope is a complicated clinical condition involving various diseases. Syncope due to myxoma-like right atrial thrombus is rarely seen in patient without structural heart disease.. A 61-year-old ambulant old male visited our emergency department for sudden syncope.. After the exclusion of neurological and coronary diseases, a right atrial block mass with a stalk connected to the atrial septum was accidentally found by echocardiography. Pulmonary embolism was subsequently revealed by computed tomographic pulmonary angiography. Atrial myxoma was initially suspected and surgical removal was conducted. Surprisingly, histological examination showed that the pedicled block mass was actually thrombus.. The myxoma-like right atrial thrombus and the emboli in the bilateral pulmonary trunks were resected. This patient received anticoagulant treatment with warfarin for 6 months additionally.. The patient was successfully discharged and being continually followed.. This patient had a past medical history of right femoral neck fracture, which might be responsible for the formation of the myxoma-like right atrial thrombus. We should always consider echocardiography examination in syncope patient at risk of thrombus formation.

Topics: Anticoagulants; Cardiac Surgical Procedures; Computed Tomography Angiography; Diagnosis, Differential; Echocardiography; Femoral Neck Fractures; Heart Atria; Heart Diseases; Humans; Incidental Findings; Male; Middle Aged; Myxoma; Pulmonary Artery; Pulmonary Embolism; Syncope; Thrombosis; Treatment Outcome; Warfarin

Bleeding is a common complication in patients taking warfarin. We sought to compare the performance of nine prediction models for bleeding risk in warfarin-treated Brazilian outpatients.. The dataset was derived from a clinical trial conducted to evaluate the efficacy of an anticoagulation clinic at a public hospital in Brazil. Overall, 280 heart disease outpatients taking warfarin were enrolled. The prediction models OBRI, Kuijer et al., Kearon et al., HEMORR2HAGES, Shireman et al., RIETE, HAS-BLED, ATRIA and ORBIT were compared to evaluate the overall model performance by Nagelkerke's R2 estimation, discriminative ability based on the concordance (c) statistic and calibration based on the Hosmer-Lemeshow goodness-of-fit statistic. The primary outcomes were the first episodes of major bleeding, clinically relevant non-major bleeding and non-major bleeding events within 12 months of follow-up.. Major bleeding occurred in 14 participants (5.0%), clinically relevant non-major bleeding in 29 (10.4%), non-major bleeding in 154 (55.0%) and no bleeding at all in 115 (41.1%). Most participants with major bleeding had their risk misclassified. All the models showed low overall performance (R2 0.6-9.3%) and poor discriminative ability for predicting major bleeding (c <0.7), except Shireman et al. and ORBIT models (c 0.725 and 0.719, respectively). Results were not better for predicting other bleedings. All models showed good calibration for major bleeding.. Only two models (Shireman et al. and ORBIT) showed at least acceptable performance in the prediction of major bleeding in warfarin-treated Brazilian patients. Accurate models warrant further investigation to be used in similar populations.

Topics: Aged; Brazil; Female; Heart Diseases; Hemorrhage; Humans; Male; Middle Aged; Models, Biological; Outpatients; Risk Assessment; Risk Factors; ROC Curve; Treatment Outcome; Warfarin

Thromboembolic complications occur frequently in Fontan patients with atrial arrhythmias and are a cause of significant morbidity and all-cause mortality. We report the case of an adult woman with direct atriopulmonary connection and atrial arrhythmia who developed a right atrial thrombus. She was switched to apixaban therapy because of echocardiographic evidence of thrombus progression despite combined therapy with warfarin and aspirin. After 1 year of treatment, there was evidence of complete thrombus resolution, in the absence of bleeding events. Our case shows that direct oral anticoagulants can be effective and safe for the treatment of thrombosis in adult patients with complex CHD.

Topics: Administration, Oral; Adult; Anticoagulants; Dose-Response Relationship, Drug; Echocardiography; Female; Fontan Procedure; Heart Defects, Congenital; Heart Diseases; Humans; Postoperative Complications; Thrombosis; Warfarin

A 67-year-old woman developed weakness of the entire left side of the body and disturbance of consciousness, and was admitted to our hospital. She had atrial fibrillation (AF) on arrival at the hospital. Diffusion weighted magnetic resonance imaging showed high intensity area in the right basal ganglia, and magnetic resonance angiography showed occlusion of the right internal carotid artery (ICA). Thrombolytic therapy with intravenous tissue plasminogen activator (IV tPA) was administered 225 minutes after onset, and endovascular procedure also performed. After endovascular therapy, the patient had successful recanalization of the right ICA. Transesophageal echocardiography (TEE) showed a mass in the left atrium. Cardiac surgery for the excision of a left atrial mass and the maze procedure for atrial fibrillation were performed on the 29th hospital day. The mass was pathologically confirmed as thrombus. Follow up TEE after cardiac surgery revealed recurrence of thrombus at the both origin of pulmonary vein in the left atrium. Finally, the thrombus was disappeared at 6-month after onset with taking warfarin. She had no stroke events during the clinical course.

Topics: Aged; Anticoagulants; Arterial Occlusive Diseases; Atrial Fibrillation; Cardiac Surgical Procedures; Carotid Artery Diseases; Carotid Artery, Internal; Diffusion Magnetic Resonance Imaging; Echocardiography, Transesophageal; Endovascular Procedures; Female; Heart Atria; Heart Diseases; Humans; Intracranial Embolism; Magnetic Resonance Angiography; Recurrence; Thrombosis; 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

In cases of pulmonary embolism, the visualization of a free-floating right heart thrombus on conventional transthoracic echocardiography is extremely rare. Even rarer is an echocardiographic recording of migration of a free-floating clot from the right heart into the pulmonary vasculature leading to pulmonary embolism. We present a unique case of an elderly man who presented with dyspnoea, in whom a routine 2-D bed side transthoracic echo recorded the live transit of a free floating thrombus from the right heart into the pulmonary artery resulting in pulmonary embolism. The patient remained haemodynamically stable and was managed with anticoagulation. Our case objectively highlights the rare occurrence of free floating right heart thrombi and their association with pulmonary embolism and also focuses on the options of management of such thrombi.

Topics: Aged; Anticoagulants; Echocardiography; Heart Atria; Heart Diseases; Humans; Male; Pulmonary Artery; Thrombosis; Warfarin

Topics: Adult; Antiphospholipid Syndrome; Female; Heart Diseases; Humans; Pregnancy; Pregnancy Complications, Cardiovascular; Thrombectomy; Thrombosis; Treatment Outcome; Warfarin

Topics: Anticoagulants; Aortic Valve; Aortic Valve Stenosis; Cardiac Surgical Procedures; Cardiac Valve Annuloplasty; Echocardiography; Endarterectomy; Female; Heart Atria; Heart Diseases; Heart Valve Prosthesis Implantation; Humans; Middle Aged; Mitral Valve Stenosis; Rheumatic Heart Disease; Thrombosis; Treatment Outcome; Tricuspid Valve; Tricuspid Valve Insufficiency; Warfarin

LAA thrombi were found in 2.7% of Japanese NVAF patients scheduled for procedures despite ongoing oral anticoagulation therapy. Incidence of thrombi was similar for patients on DOAC and on warfarin.

Topics: Aged; Anticoagulants; Asian People; Atrial Appendage; Atrial Fibrillation; Echocardiography, Transesophageal; Female; Heart Diseases; Humans; Incidence; Male; Middle Aged; Retrospective Studies; Thrombosis; Warfarin

Patients with cyanotic congenital heart disease (CCHD) have an increased risk of bleeding and thrombotic complications. Prolonged conventional coagulation screening parameters, such as activated partial thromboplastin time or prothrombin time, are reported in less than 20% of CCHD patients.. The aim of this study was to determine the haemostatic abnormalities in 32 adult patients with CCHD by rotation thromboelastometry (ROTEM) with assessment of coagulation dynamic properties, as a guide for perioperative prophylaxis or haemostatic therapy. The control group consisted of 35 healthy subjects.. Our results suggest that CCHD patients, in comparison to healthy controls, had a tendency to hypocoagulate with delayed activation of haemostasis and clot formation, initiated by both intrinsic and extrinsic activators. The growth of the clot was slower and the clot firmness was decreased, which may additionally contribute to bleeding diathesis. Moreover, the clot lysis readings suggest higher clot stability in the CCHD group. All velocity parameters were markedly lower in the CCHD patients, indicating a decreased rate of clot formation. Although coagulation tests and platelet count were normal, the usefulness of rotation thromboelastometry in monitoring or guiding therapy in CCHD patients is demonstrated.. In conclusion, our results provide new insights into the data on hypocoagulation with impaired clot lysis in adult CCHD patients as determined by ROTEM. Our findings may assist in determining the optimal management of patients with CCHD undergoing surgery.

Topics: Adult; Aged; Anticoagulants; Blood Coagulation; Blood Coagulation Tests; Cyanosis; Female; Fibrinogen; Fibrinolysis; Heart Diseases; Hemorrhage; Hemostatic Techniques; Humans; Male; Middle Aged; Partial Thromboplastin Time; Perioperative Care; Prothrombin Time; Thrombelastography; Thrombosis; Warfarin; Young Adult

The use of anticoagulant therapy in paediatrics is common, with vitamin K antagonists remaining the most commonly prescribed therapy. There is a weak evidence base behind many of the recommendations for anticoagulant therapy in paediatric patients. One of the areas requiring further research is the management of anticoagulant therapy interruption. Interruption to anticoagulation is the period surrounding a planned invasive procedure whereby long term anticoagulation is ceased, and recommenced post procedure. The word bridging refers to the use of low molecular weight heparin or unfractionated heparin to anticoagulate during the period of sub therapeutic INR. To date institutional protocols for bridging anticoagulation are based on adult guidelines. However, there are currently no studies validating the extrapolation of these guidelines to paediatrics. This study seeks to review the clinical outcomes associated with current bridging practices employed at a tertiary metropolitan children's hospital.. The patient population was selected from the warfarin management registry of a Clinical Haematology service of a major metropolitan children's hospital. The admission history of these patients was queried to identify admissions where anticoagulation interruption would typically be required. Namely, these were dental extraction, cerebral or cardiac angiography, or cardiac catheterization. Data relating to demographics, anticoagulant therapy interruption plan, and clinical outcomes were recorded.. A total of 61 admissions for children aged between 1 year and 17 years and 11 months were analysed for this study. Congenital heart disease (CHD) was the primary underlying disease for which long-term oral anticoagulation with warfarin was indicated. Children with Moyamoya in this cohort were treated more consistently compared to the other disease groups. There were no instances of major bleeding (n=0) or thrombotic events (n=0).. This study describes the current practices and outcomes associated with anticoagulant therapy interruption at one institution thereby filling an evidence gap in the paediatric anticoagulant management. It achieved this by analysing the largest and most representative cohort to date. This project is a stepping stone from which future studies of safety and efficacy of paediatric anticoagulation interruption management can be developed.

Topics: Administration, Oral; Adolescent; Anticoagulants; Child; Child, Preschool; Female; Heart Diseases; Humans; Infant; Male; Moyamoya Disease; Treatment Outcome; Warfarin

As heart failure, coronary artery disease and atrial fibrillation all bring a risk of thrombosis, anti-thrombotic therapy is recommended. Despite such treatment, major cardiovascular events such as myocardial infarction and stroke still occur, implying inadequate suppression of thrombus formation. Accordingly, identification of patients whose haemostasis remains unimpaired by treatment is valuable. We compared indices for assessing thrombogenesis and fibrinolysis by two different techniques in patients on different anti-thrombotic agents, i.e. aspirin or warfarin. We determined fibrin clot formation and fibrinolysis by a microplate assay and thromboelastography, and platelet marker soluble P selectin in 181 patients with acute or chronic heart failure, coronary artery disease who were taking either aspirin or warfarin. Five thromboelastograph indices and four microplate assay indices were different on aspirin versus warfarin (p < 0.05). In multivariate regression analysis, only microplate assay indices rate of clot formation and rate of clot dissolution were independently related to aspirin or warfarin use (p ≤ 0.001). Five microplate assay indices, but no thrombelastograph index, were different (p < 0.001) in aspirin users. Three microplate assay indices were different (p ≤ 0.002) in warfarin users. The microplate assay indices of lag time and rate of clot formation were abnormal in chronic heart failure patients on aspirin, suggesting increased risk of thrombosis despite anti-platelet use. Soluble P selectin was lower in patients on aspirin (p = 0.0175) but failed to correlate with any other index of haemostasis. The microplate assay shows promise as a tool for dissecting thrombogenesis and fibrinolysis in cardiovascular disease, and the impact of antithrombotic therapy. Prospective studies are required to determine a role in predicting thrombotic risk.

Topics: Aspirin; Atrial Fibrillation; Clinical Laboratory Techniques; Coronary Artery Disease; Fibrinolysis; Fibrinolytic Agents; Heart Diseases; Heart Failure; Humans; Thrombelastography; Thrombosis; Tissue Array Analysis; 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

Topics: Blood Coagulation Disorders; Echocardiography, Transesophageal; Electrocardiography; Female; Follow-Up Studies; Heart Diseases; Humans; Magnetic Resonance Imaging, Cine; Middle Aged; Multimodal Imaging; Positron-Emission Tomography; Renal Dialysis; Renal Insufficiency, Chronic; Risk Assessment; Severity of Illness Index; Thrombosis; Treatment Outcome; Warfarin

Topics: Aged; Blood Coagulation Factors; Female; Heart Diseases; Humans; International Normalized Ratio; Thrombosis; Ultrasonography; Warfarin

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Electric Countershock; Embolism; Factor Xa Inhibitors; Heart Diseases; Hemorrhage; Humans; International Normalized Ratio; Middle Aged; Morpholines; Multicenter Studies as Topic; Myocardial Infarction; Prospective Studies; Randomized Controlled Trials as Topic; Research Design; Risk; Rivaroxaban; Stroke; Thiophenes; Thrombophilia; Time Factors; Treatment Outcome; Vitamin K; Warfarin

Atrial fibrillation and heart failure are factors predisposing to locally formed intracardiac thrombosis, which is usually localized in left-sided chambers. A case report. The authors present a case of a 50-year-old male with permanent atrial fibrillation and dilated cardiomyopathy in whom recurrent right atrial thrombus was observed. Initially, the lesion was detected in echocardiography while he was hospitalized due to extensive right-sided pneumonia. The thrombus was successfully treated with heparin, followed by warfarin. Even though the patient continued warfarin use properly, there was recurrence of the thrombus two years later during a new episode of heart failure exacerbation. Because the thrombus was resistant to intensified anticoagulation, cardiac surgery was needed. A large (30 x 25 mm) pedunculated thrombus, as well as two smaller ones (each of 10 x 10 mm) attached closely to the atrial wall and previously not detected either by echocardiography or by magnetic resonance imaging, were excited. A partially organized pattern of the thrombi in histological examination can explain lack of anticoagulation effectiveness.

Topics: Anticoagulants; Atrial Fibrillation; Cardiomyopathy, Dilated; Echocardiography; Heart Atria; Heart Diseases; Heart Failure; Heparin; Humans; Male; Middle Aged; Recurrence; Thrombosis; Warfarin

Topics: Anticoagulants; Heart Diseases; Humans; Male; Purpura, Thrombocytopenic, Idiopathic; Receptors, Fc; Recombinant Fusion Proteins; Thrombocytopenia; Thrombopoietin; Warfarin

Topics: Aged; Anticoagulants; Female; Foramen Ovale, Patent; Heart Diseases; Humans; Thrombosis; Warfarin

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

The clinical characteristics and long-term outcomes of patients presenting with acute pulmonary embolism (PE) during treatment with warfarin have not been described. Clinical details of all patients admitted to a tertiary institution from 2000-2007 with acute PE were retrieved retrospectively, baseline warfarin status and the international normalised ratio (INR) were recorded, and their outcomes tracked using a statewide death registry. Of 923 patients with clearly documented warfarin status included in this study, 83 (9%) were taking warfarin. Mean (± standard deviation) day-1 INR of those taking warfarin was 2.3 ± 0.9, with 67% of patients therapeutically anti-coagulated (INR ≥2.0) at presentation (49 patients with INR <2.5 and 34 with INR ≥2.5). Patients taking warfarin on admission were more likely to have heart failure, atrial fibrillation and valvular heart disease, with similar prevalence of malignancy and ischaemic heart disease, compared to patients not on warfarin. Total mortality of the cohort (mean follow-up 4.0 ± 2.5 years) was 31.6% (in-hospital mortality 1.5%), and was similar between warfarin and no warfarin groups. There was however a greater than four-fold increased risk of post-discharge death due to recurrent PE for the patients taking warfarin on admission (hazard ratio [HR] 4.43, 95% confidence interval [CI] 1.36-14.42, p=0.01). Among patients taking warfarin on admission, day-1 INR <2.5 significantly increased long-term all-cause mortality compared to INR ≥2.5 (adjusted HR 2.51, 95% CI 1.08-5.86, p=0.03). In conclusion, patients presenting with PE during treatment with warfarin have an increased risk of death from recurrent PE. Admission INR appears to have independent long-term prognostic importance in these patients.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Female; Follow-Up Studies; Heart Diseases; Heart Failure; Humans; International Normalized Ratio; Male; Middle Aged; Prognosis; Proportional Hazards Models; Pulmonary Embolism; Recurrence; Retrospective Studies; Time Factors; Treatment Outcome; Venous Thrombosis; Warfarin

We present the result of right atrial thrombectomy in a paediatric patient suffering from a right atrial thrombus due to amoebic liver abscess under total circulatory arrest. A 2-year old boy with amoebic liver abscess complicated by inferior vena cava (IVC) thrombus extending up to the right atrium (RA) was operated on in our institute. During the surgery, the thrombus was removed from the IVC and the RA under deep hypothermic circulatory arrest. After chest closure, open drainage of the abscess was performed. Metronidazole was given postoperatively for 2 weeks. The postoperative period was uneventful. There was rapid convalescence with complete resolution of the abscess. Anticoagulation with warfarin was started on the day following surgery and continued for 6 weeks. There was no recurrence of thrombosis or embolic events in the follow-up period. Extension of thrombus into the right atrium mandates an aggressive surgical approach which may prove life saving. It is crucial in the prevention of pulmonary embolism or Budd-Chiari syndrome, which may have an overall poor outcome.

Topics: Anticoagulants; Child, Preschool; Circulatory Arrest, Deep Hypothermia Induced; Drainage; Heart Diseases; Humans; Liver Abscess, Amebic; Male; Thrombectomy; Thrombosis; Treatment Outcome; Vena Cava, Inferior; Venous Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Cardiac Surgical Procedures; Echocardiography, Transesophageal; Equipment Design; Heart Diseases; Humans; Male; Surgical Equipment; Suture Techniques; Thrombosis; Time Factors; Treatment Outcome; Warfarin

Topics: Aged; Blood Platelets; Heart Diseases; Humans; Male; Platelet Count; Purpura, Thrombocytopenic, Idiopathic; Receptors, Fc; Recombinant Fusion Proteins; Thrombopoietin; Warfarin

This study investigated the relationship between CHADS2 scores and the rate of antithrombotic drug use and clinical outcomes in patients with an initial cardioembolic stroke who had nonvalvular atrial fibrillation (NVAF).. In 234 patients (135 men and 99 women; mean age [± SD] 76 ± 11 years) with initial cardiogenic cerebral embolism with NVAF who were admitted to our hospital between April 2007 and March 2011, the CHADS2 score, use of warfarin, and clinical outcomes were retrospectively investigated.. CHADS2 scores were as follows: 0 points, n = 21 (9%); 1 point, n = 72 (31%); 2 points, n = 92 (39%); 3 points, n = 47 (20%); and 4 points, n = 2 (1%). The overall warfarin use rate was low (14.1%; n = 33), and it was significantly (P = .023) lower for paroxysmal atrial fibrillation (8%) than for chronic atrial fibrillation (18.5%). The clinical outcomes evaluated by the modified Rankin Scale (mRS) score after 3 months were: CHADS2 score 0 points, mRS 0 to 2 (81%) and 3 to 6 (19%); 1 point, mRS 0 to 2 (46%) and 3 to 6 (54%); 2 points, mRS 0 to 2 (46%) and 3 to 6 (54%); and ≥ 3 points, mRS 0 to 2 (29%) and 3 to 6 (71%). The clinical outcome worsened as the CHADS2 score increased (P = .002). Logistic regression analysis revealed that being ≥ 75 years of age and having a high National Institutes of Health Stroke Scale (NIHSS) score on admission were related to a poor outcome (P < .001).. The overall warfarin use rate was low in initial cardioembolic stroke patients with NVAF. Clinical outcomes deteriorated with increases in the CHADS2 score, age ≥ 75 years, and NIHSS score on admission were related to a poor clinical outcome.

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Chi-Square Distribution; Disability Evaluation; Drug Utilization Review; Female; Fibrinolytic Agents; Heart Diseases; Humans; Intracranial Embolism; Logistic Models; Male; Patient Admission; Patient Selection; Practice Patterns, Physicians'; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome; Warfarin

The aim of this study was to assess the agreement of four renowned interaction lists on potentially severe warfarin drug interactions (DI) in outpatients at a university hospital in Brazil, specifically in subgroups of Trypanosoma cruzi-infected and non-infected patients and those with previous bleeding episodes.. This was a cross-sectional study in which adult outpatients with heart disease and indications for chronic warfarin use were enrolled. The occurrence of potentially severe warfarin DI was evaluated based on the lists provided by three compendia, i.e., Drug Interaction Facts (DIF), Drug Interactions: Analysis and Management (DIAM) and DRUG-REAX, and by the World Health Organization (WHO) Model Formulary. A kappa coefficient was used to calculate the agreement among the sources.. A total of 280 patients were studied. Most patients were female (54.6 %) with an average age of 56.8 (standard deviation 13.1) years. The agreement among the four sources was fair (Fleiss' kappa coefficient = 0.295). T. cruzi-infected individuals were less likely to have severe warfarin DI than non-infected patients (p < 0.05 for DIAM, DRUG-REAX and the WHO Model Formulary). Potentially severe DI were more frequent in patients with previous bleeding episodes, based on the DIF compendia (p = 0.007).. This evaluation of warfarin DI revealed that the disagreement between compendia is also observed in clinical practice. T. cruzi infection is associated with a lower prevalence of potentially severe warfarin DI, but with a wider variation in its detection. Our results suggest a wide spectrum of discrepancies in detecting heart disease patients at higher risk for severe warfarin DI and a possible heterogeneity in clinical guidance.

Topics: Adverse Drug Reaction Reporting Systems; Anticoagulants; Brazil; Chagas Disease; Cross-Sectional Studies; Drug Interactions; Female; Heart Diseases; Hemorrhage; Hospitals, University; Humans; Male; Middle Aged; Outpatients; Polypharmacy; Prevalence; Trypanosoma cruzi; Warfarin

Managing vitamin K antagonist (VKA) therapy is challenging in children because of a narrow therapeutic range and wide inter- and intra-individual variability in dose response. Only a few small studies have investigated the effect of nongenetic and genetic factors on the dose response to VKAs in children. In a cohort study including 118 children (median age 9 years; range, 3 months-18 years) mostly with cardiac disease, we evaluated by multivariate analysis the relative contribution of nongenetic factors and VKORC1/CYP2C9/CYP4F2 genotypes on warfarin (n = 83) or fluindione (n = 35) maintenance dose and the influence of these factors on the time spent within/above/below the range. The results showed that height, target international normalized ratio and VKORC1 and CYP2C9 genotypes were the main determinants of warfarin dose requirement, accounting for 48.1%, 4.4%, 18.2%, and 2.0% of variability, respectively, and explaining 69.7% of the variability. Our model predicted the warfarin dose within 7 mg/wk in 86.7% of patients. None of the covariates was associated with the time spent above or below the international normalized ratio range. Whether this model predicts accurately the effective maintenance dose is currently being investigated.

Topics: Adolescent; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Body Height; Child; Child, Preschool; Cohort Studies; Cytochrome P-450 CYP2C9; Cytochrome P-450 Enzyme System; Cytochrome P450 Family 4; DNA; Dose-Response Relationship, Drug; Female; Genotype; Heart Diseases; Humans; Infant; International Normalized Ratio; Male; Mixed Function Oxygenases; Models, Statistical; Polymerase Chain Reaction; Polymorphism, Genetic; Vitamin K; Vitamin K Epoxide Reductases; Warfarin

The goal of this study was to evaluate the performance of four warfarin pharmacogenetic algorithms in a real clinical setting, namely the algorithms of Gage et al., Michaud et al., Wadelius et al. and the International Warfarin Pharmacogenetics Consortium algorithm.. Data was obtained retrospectively for 605 patients who had initiated warfarin therapy at the Montreal Heart Institute. Warfarin dosing and International Normalized Ratio history were obtained from hospital charts and CYP2C9 and VKORC1 polymorphisms were genotyped.. The four algorithms produced similar accuracy with mean absolute error ranging from 1.36-1.52 mg/day and adjusted R(2) from 40-44%. Gage's algorithm and Wadelius' algorithm predicted the largest proportion of patients within ± 20% of their observed stable warfarin dose. For patients requiring low doses, Gage's algorithm provided the highest proportion of patients within ideal dose range (36.3%), while Wadelius' algorithm performed the best for patients requiring high doses (37.3% of patients within ideal dose range).. Our study demonstrates the value of published pharmacogenetic dosing algorithms for the prediction of warfarin doses, in particular for patients with low or high therapeutic dose requirements.

Topics: Adult; Aged; Aged, 80 and over; Algorithms; Aryl Hydrocarbon Hydroxylases; Atrial Fibrillation; Clinical Medicine; Cohort Studies; Cytochrome P-450 CYP2C9; Dose-Response Relationship, Drug; Female; Genotype; Heart Diseases; Humans; International Normalized Ratio; Male; Middle Aged; Mixed Function Oxygenases; Pharmacogenetics; Vitamin K Epoxide Reductases; Warfarin

Topics: Adult; Anticoagulants; Echocardiography; Echocardiography, Transesophageal; Electrocardiography; Heart Atria; Heart Diseases; Heparin; Homozygote; Humans; Male; Methylenetetrahydrofolate Reductase (NADPH2); Mutation; Pulmonary Embolism; Thrombosis; Tomography, X-Ray Computed; Warfarin

A 76 -year-old lady with a recent diagnosis of rheumatic heart disease (RHD), and a history of repeated lower respiratory tract infections, came with symptoms of gastritis unrelated to the primary disease but further diagnostic study in the hospital revealed poorly controlled atrial fibrillation, grossly dilated left atrium with two large left atrial thrombi and mitral valve area<1 cm(2). It was decided that the best approach in our patient would be mitral valve replacement with mechanical prosthesis. Despite the usual trend of using bioprosthesis in the elderly, our decision was influenced by the fact that the patient would need chronic anticoagulation for atrial fibrillation in any case. The purpose of our case presentation is to illustrate a late-presenting case of RHD with unusual associations and the challenges to choose the best possible management.

Topics: Aged; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiomegaly; Female; Gastritis; Heart Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Stenosis; Radiography; Rheumatic Fever; Thrombosis; Warfarin

Within the Asian populations, Indian patients had been reported to require higher warfarin dose compared with the Chinese and Malay patients, and this could not entirely be explained by cytochrome P450 (CYP)2C9 gene variants. Genetic variants of vitamin K epoxide oxidase reductase complex subunit 1 (VKORC1) has been well established as one of key determinants in the different responses of warfarin amongst patients. Adult patients who attended an anticoagulation clinic with stable INR were recruited. VKORC1 and CYP2C9 genotype were sequenced, and clinical characteristics were assessed. A total of 91 Malays, 96 Chinese, and 46 Indian patients were recruited. The mean age was 55 years and 51.5% were males. The mean dose of warfarin for all patients was 3.7 mg, and the mean daily dose of warfarin was significantly higher in Indians compared with the Chinese and Malay patients, 4.9 versus 3.5 and 3.3 mg, respectively (p < 0.001). VKORC1 GG genotype was more commonly seen in Indian patients. The mean warfarin dose in patients with GG genotype required a significant higher warfarin dose compared with those with AG and AA genotype (4.9 vs. 3.7 vs. 3.1 mg, respectively; p < 0.001). CYP2C9*2 and *3 is associated with a lower maintenance dose, 2.9 versus 3.7 mg in CYP2C9*1; p < 0.01. In multivariate analysis, age, ethnic groups, and genotypes had a significant influence on the required warfarin dose. In conclusion, VKORC1 and CYP2C9 polymorphism contribute to the difference dose requirement amongst the patients but other additional possible factors may play a role in the Indian race.

Topics: Adult; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Asian People; Cytochrome P-450 CYP2C9; Dose-Response Relationship, Drug; Ethnicity; Female; Genetics, Population; Genotype; Heart Diseases; Heart Valve Prosthesis Implantation; Humans; India; Malaysia; Male; Middle Aged; Mixed Function Oxygenases; Pharmacogenetics; Polymorphism, Single Nucleotide; Pulmonary Embolism; Vitamin K Epoxide Reductases; Warfarin

Topics: Administration, Oral; Anticoagulants; Aspirin; Clopidogrel; Drug Therapy, Combination; Heart Diseases; Humans; Meta-Analysis as Topic; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Stents; Stroke; Thromboembolism; Ticlopidine; Warfarin

Topics: Adult; Anticoagulants; Diagnosis, Differential; Disease Progression; Echocardiography; Follow-Up Studies; Fontan Procedure; Heart Defects, Congenital; Heart Diseases; Humans; Male; Severity of Illness Index; Thrombosis; Time Factors; Warfarin

Warfarin is an important therapy for children with heart disease. We assessed the impact of a computerized warfarin-dosing software program on measured INR values using a historical case-control design. Children (infant to 20 years of age) with cardiac disease managed with warfarin between September 1, 2006, and August 31, 2009 were included in the analysis. Warfarin therapy was tailored to specific underlying conditions based on consensus guidelines. Before the use of dosing software, medication adjustments were made by physicians using published guidelines. After software implementation, dosing adjustments were based on the software algorithm. There were 86 subjects in this analysis, and the most common indication for warfarin was prosthetic valve. Overall, the incidence of adverse bleeding events was 1.3% per patient-year. An analysis of patient-related factors associated with a low percentage of time within goal range demonstrated that both female sex (P = 0.048) and nonwhite race (P = 0.037) were significantly associated with less time in the target range. Use of the software program was associated with an increase in the percentage of time during which the INR was within the target range from 41.4 to 53.1% (P < 0.001). Incorporation of a computerized software program to assist dosing can improve the percentage of time that children with cardiac disease requiring warfarin remain within the target therapeutic range. Strategies to improve management and decrease sex and racial disparities in this population are needed.

Topics: Adolescent; Anticoagulants; Child; Child, Preschool; Female; Heart Defects, Congenital; Heart Diseases; Heart Valve Prosthesis; Humans; Infant; International Normalized Ratio; Male; Risk Factors; Software; Warfarin; Young Adult

Topics: Anticoagulants; Cardiovascular Diseases; Defibrillators, Implantable; Echocardiography, Transesophageal; Heart Atria; Heart Diseases; Heart Transplantation; Humans; Magnetic Resonance Imaging; Thrombosis; Tomography, X-Ray Computed; Warfarin

Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Echocardiography, Transesophageal; Heart Atria; Heart Diseases; Humans; Male; Prostheses and Implants; Thrombosis; Warfarin

We report a patient with congenital interruption of the inferior vena cava complicated by pulmonary embolism. In this study, we review the clinical and imaging features of this entity and also present a review of the literature on this topic. This rare pulmonary embolism complication can be easily detected on multidetector computed tomography using a wider scan range.

Topics: Aged; Anticoagulants; Contrast Media; Diagnosis, Differential; Heart Diseases; Heparin; Humans; Iohexol; Male; Pulmonary Embolism; Radiographic Image Enhancement; Tomography, X-Ray Computed; Vena Cava, Inferior; Warfarin

Topics: Adult; Anticoagulants; Canada; Drug Therapy, Combination; Heart Diseases; Humans; Incidence; Myocardial Infarction; Outcome Assessment, Health Care; Platelet Aggregation Inhibitors; Population Surveillance; Practice Patterns, Physicians'; Thrombosis; Warfarin

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT * CYP2C9 single nucleotide polymorphisms (SNPs) are important in safe and effective oral anticoagulation with warfarin use. * Although CYP2C9*2 and *3 are important genetic factors for the warfarin dose, one of the CYP2C9 SNPs, IVS-65G>C, has been suggested to be associated with warfarin sensitivity. However, as of yet, there has been no explanation about the possible mechanism and linkage analysis. WHAT THIS PAPER ADDS * New information on CYP2C9 SNPs and their occurrences in common haplotype structures in healthy unrelated Koreans and in individuals who require low warfarin dose after mechanical heart valve replacements (MHVRs) were studied. * Additional evidence showed that an Asian dominant haplotype consisting of -1565C>T, -1188T>C, IVS3+197G>A, IVS3-334C>T, IVS3-65G>C, IVS4-115A>G and IVS5-73A>G could be associated with a low warfarin maintenance dose in mechanical heart valve replacement (MHVR) patients. AIMS The objectives of this study were to determine the distribution of CYP2C9 variants in Koreans and investigate their association with warfarin dose requirements in patients who received MHVRs. METHODS All nine exons, intron-exon junction, and promoter region of CYP2C9 were amplified and directly sequenced in 50 healthy normal Koreans. Additional direct DNA sequencing of the CYP2C9 gene was conducted in 36 of the 267 MHVR patients who required low maintenance warfarin doses without carrying CYP2C9*3 and VKORC1 1173T mutations. The effects of CYP2C9 genetics on warfarin maintenance dose were assessed in 267 MHVR patients. RESULTS Thirty-nine single nucleotide polymorphisms (SNPs) including seven previously unidentified SNPs were identified in 50 Koreans by direct DNA sequencing. One of the CYP2C9 haplotypes exhibited an association with warfarin low dose requirement. The adjusted odds ratio for the haplotype between the low dose group and the normal subjects was 2.5 (95% confidence interval 1.05, 6.16). This haplotype consisting of -1565C>T, -1188T>C, IVS3+197G>A, IVS3-334C>T, IVS3-65G>C, IVS4-115A>G, and IVS5-73A>G was found in 15% of 36 MHVR patients who required low warfarin doses, while 4% of 50 normal healthy subjects exhibited this haplotype. One of the SNPs comprising this haplotype, -1565C>T, apparently changed a protein binding pattern as observed in electrophoretic mobility shift assay. CONCLUSION The haplotype including -1565C>T, -1188T>C, IVS3+197G>A, IVS3-334C>T, IVS3-65G>C, IVS4-115A>G, and I

Topics: Anticoagulants; Aryl Hydrocarbon Hydroxylases; Asian People; Cytochrome P-450 CYP2C9; DNA Mutational Analysis; Exons; Gene Frequency; Genotype; Heart Diseases; Heart Valve Prosthesis Implantation; Humans; Introns; Korea; Polymorphism, Single Nucleotide; Promoter Regions, Genetic; Sequence Analysis, DNA; Warfarin

Topics: Acanthosis Nigricans; Anti-Bacterial Agents; Anticoagulants; Child; Drug Therapy, Combination; Echocardiography, Doppler; Heart Atria; Heart Diseases; Heparin, Low-Molecular-Weight; Humans; Male; Metabolic Syndrome; Obesity; Penicillanic Acid; Piperacillin; Positive-Pressure Respiration; Tazobactam; Thrombosis; Treatment Outcome; Warfarin

The CoaguChek XS international normalized ratio (INR) assay was compared to INR assay by a standard laboratory method in children with heart disease on anticoagulant therapy. The data comprised 120 pairs of INR values for 42 patients (age <16 yr) who attended a cardiology clinic between 1 May 2007 and 30 January 2008. Parallel INR assays by the CoaguChek XS and the standard method were performed within 1 hr by a single qualified technician and the paired results were evaluated by linear regression and Bland-Altman analysis. The mean difference in the INR values was -0.08 +/- 0.04 units (p = 0.63); the difference between the two results was consistently <0.5 INR units. The slope of the regression line was 0.98 (95% CI: 0.96 to 1.01) and the y-intercept was 0.014 (95% CI: -0.01 to 0.04). In the Bland-Altman analysis, the mean difference in INR between the two methods was 0.08 units and values for 99.4% of the patients fell within the limit of agreement (-0.17 to 0.28 units). In summary, INR assays in children by the CoaguChek XS device are as accurate as the standard method, but faster and more convenient.

Topics: Adolescent; Anticoagulants; Child; Child, Preschool; Drug Monitoring; Female; Heart Diseases; Humans; International Normalized Ratio; Male; Point-of-Care Systems; Prothrombin Time; Reference Standards; Treatment Outcome; Warfarin

Topics: Administration, Oral; Angioplasty, Balloon, Coronary; Anticoagulants; Blood Coagulation; Cardiac Catheterization; Cerebrovascular Disorders; Coronary Angiography; Femoral Artery; Heart Diseases; Hemorrhage; Humans; International Normalized Ratio; Platelet Aggregation Inhibitors; Radial Artery; Risk Assessment; Risk Factors; Treatment Outcome; Warfarin

Topics: Anticoagulants; Echocardiography, Transesophageal; Heart Atria; Heart Diseases; Heart Ventricles; Humans; Male; Middle Aged; Thrombolytic Therapy; Thrombosis; Treatment Outcome; Venous Thrombosis; Warfarin

Calciphylaxis is a rare complication that occurs in 1% of patients with end-stage renal disease (ESRD) each year. Extensive microvascular calcification and occlusion/thrombosis lead to violaceous skin lesions, which progress to nonhealing ulcers with secondary infection, often leading to sepsis and death. The lower extremities are predominantly involved (roughly 90% of patients). Although most calciphylaxis patients have abnormalities of the calcium-phosphate axis or elevated levels of parathyroid hormone, these abnormalities do not appear to be fundamental to the pathophysiology of the disorder. We report on a case of histologically proven calciphylaxis in a 54-year-old woman with normal renal function and normal calcium-parathyroid homeostasis. She had a history of alcoholic cardiomyopathy, and was treated with warfarin anticoagulation. She has been successfully treated with antibiotics, i.v. biophosphonates and intensive local wound care. We recorded a complete wound healing in contrast to what is reported in other series.

Topics: Alcoholism; Anti-Bacterial Agents; Anticoagulants; Calciphylaxis; Clindamycin; Diphosphonates; Female; Heart Diseases; Humans; Kidney Failure, Chronic; Meropenem; Middle Aged; Risk Factors; Thienamycins; Vancomycin; Warfarin

Previous cost-effectiveness analyses analyzed warfarin for stroke prevention in randomized trial settings. Given the complexities of warfarin treatment, cost-effectiveness should be examined within a real-world setting.. Our model followed patients with atrial fibrillation at moderate to high risk of stroke through primary and recurrent ischemic stroke, hemorrhages--intracranial and extracranial, and the resulting disability. Four scenarios were examined: (1) all patients start on warfarin with perfect control, that is, international normalized ratio (INR) values always within range; (2) all patients start on warfarin with trial-like control, where INR can fall outside the recommended range; (3) all patients start on warfarin with real-world INR control; and (4) real-world prescription (and control) of warfarin, aspirin, or neither for warfarin-eligible patients. Reported warfarin discontinuation rates were used. Main outcomes were total number of events, quality adjusted life years, and costs in a US setting.. The total number of primary and recurrent ischemic strokes in a 1,000-patient cohort (age 70 years, lifetime analysis) was 626, 832, 984, and 1,171 in scenarios 1 to 4, respectively. The corresponding mean quality adjusted life years per patient were 7.21, 6.92, 6.75, and 6.67 for scenarios 1 to 4, respectively. Costs per patient were $68,039, $77,764, $84,518, and $87,248 in scenarios 1 to 4, respectively. If "perfect" adherence to warfarin was assumed, except for discontinuations for clinical reasons, strokes would decrease to 503, 737, 909, and 1,120 in scenarios 1 to 4, respectively.. Clinical and cost outcomes are strongly dependent on the quality of anticoagulation and rates of warfarin discontinuation. Clinicians should work to improve both. Policy makers should use real-world INR control and warfarin discontinuation rates when assessing cost-effectiveness.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Cost-Benefit Analysis; Heart Diseases; Humans; Models, Cardiovascular; Platelet Aggregation Inhibitors; Stroke; Thrombosis; Warfarin

We report a very rare case of giant left atrial thrombus (size: 7.2 x 4.5 mm(2)) associated with radiofrequency catheter ablation for atrial tachycardia in a 72-year-old man. After 4 weeks of anticoagulation with warfarin, a repeat echocardiogram demonstrated partial resolution of the thrombus (size: 4.5 x 2.6 mm(2)) without systemic embolization.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Heart Atria; Heart Diseases; Humans; Male; Thrombosis; Treatment Outcome; Warfarin

Topics: Anticoagulants; Echocardiography; Heart Diseases; Heart Ventricles; Humans; Male; Middle Aged; Thrombosis; Treatment Outcome; 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

To evaluate the efficiency and safety of clopidogrel treatment in children with heart disease.. We conducted single center retrospective chart review of children with heart disease at the University Hospital, Leuven, Belgium, in whom clopidogrel was used. The indication, dosage, duration of therapy, and adverse events were examined. Clinical efficacy was defined by an absence of thrombotic events.. 46 children were identified. The mean age of first clopidogrel dose was 4.9 +/- 4.1 years. The study dosage ranged from 0.1 to 0.7 mg/kg/day clopidogrel. Almost all patients received concomitant aspirin therapy. No thrombotic events developed. Skin bruising developed in almost every patient, suggesting that clopidogrel has an anti-platelet effect. 2 patients who were treated with concomitant warfarin had bleeding complications (severe epistaxis and gastrointestinal bleeding). Hematological abnormalities were documented in 1 patient who received clopidogrel for 1 year; they reversed with medication cessation.. Clopidogrel therapy in a pediatric population appears to be relatively safe and effective; however, randomized, controlled prospective studies are needed to determine the true efficacy and safety of clopidogrel in children.

Topics: Adolescent; Aspirin; Child; Child, Preschool; Clopidogrel; Female; Heart Diseases; Hemorrhage; Humans; Infant; Infant, Newborn; Male; Platelet Aggregation Inhibitors; Retrospective Studies; Ticlopidine; Warfarin

Left ventricular mobile thrombi carry high risk of embolism and need early treatment in which the appropriate treatment is still controversial. Because most patients with mobile thrombi have low ejection fraction and also accompanying heart failure symptoms, decision of surgical treatment is not always easy and thus effective medical treatment is crucial.. In this paper we present, treatment and follow-up of seven patients with mobile thrombi who underwent fibrinolytic treatment between 2002 and 2006.. In four cases, mobile thrombi disappeared completely while echocardiographically regressed to lower size with decreased mobility in the other three patients. On 6th month follow-up, complete lysis of the thrombi in six patients was observed with warfarin treatment. No major complications were seen in the patients.. In case of mobile left ventricular thrombi with concomitant low ejection fraction and heart failure fibrinolytic treatment might be a therapeutic option.

Topics: Adult; Aged; Anticoagulants; Fibrinolytic Agents; Heart Diseases; Humans; Male; Middle Aged; Retrospective Studies; Streptokinase; Stroke Volume; Thrombolytic Therapy; Thrombosis; Tissue Plasminogen Activator; Treatment Outcome; Ultrasonography; Ventricular Function, Left; Warfarin

We report successful surgical management of a 31-year-old man with a left ventricular thrombus following heart failure due to cardiac sarcoidosis. Preoperative echocardiography showed diffuse hypokinesis and a mobile ball-like thrombus in the left ventricle. Computed tomography revealed a left ventricular tumor and bilateral hilar lymphadenopathy, while MRI of the brain showed small infarctions in the occipital lobe. Postoperative pathologic examination of a specimen from the left ventricular free wall and a mediastinal lymph node revealed non-caseating granulomas consistent with cardiac sarcoidosis. The patient was referred to a cardiologist for further treatment with prednisolone. This is a rare case of surgical removal of a left ventricular ball-like thrombus in a patient with cardiac sarcoidosis.

Topics: Adult; Anticoagulants; Cardiomyopathies; Cerebral Infarction; Glucocorticoids; Heart Diseases; Heart Failure; Heart Ventricles; Humans; Lymphatic Diseases; Magnetic Resonance Imaging; Male; Occipital Lobe; Prednisolone; Sarcoidosis; Thrombectomy; Thrombosis; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

With the recent increase in the use of antithrombotic therapy, intracerebral hemorrhage (ICH) has been found to be a common complication. We determined whether the use of oral antithrombotic therapy and the patients' preexisting comorbidities were predictive of cerebellar hemorrhage (CH; previously reported to be associated with anticoagulants) as compared to other ICH, and whether antithrombotic therapy affected the clinical severity of CH.. A study of 327 consecutive patients hospitalized in our institute within 3 days after the onset of ICH, including 38 patients with a CH.. CH accounted for 12% of all ICH, 75% of which occurred in patients on warfarin therapy with an international normalized ratio (INR) for prothrombin time >2.5 (p < 0.0001), and 33% of which occurred in patients on ticlopidine therapy (p = 0.017). Warfarin therapy with an INR >2.5 and high blood glucose on admission were independently predictive of CH as compared to other ICH. In addition, previous ischemic stroke (p = 0.002) and heart diseases (p = 0.018) were more prevalent in patients with CH than in those with other ICH. The number of major arteriosclerotic comorbidities and risk factors was also independently predictive of CH risk.. We confirmed that warfarin therapy with an INR >2.5 is associated with CH. Patients with CH frequently had arteriosclerotic comorbidities requiring antithrombotic therapy that can complicate their acute management.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Arteriosclerosis; Aspirin; Blood Glucose; Cerebellar Diseases; Female; Fibrinolytic Agents; Heart Diseases; Humans; Intracranial Hemorrhages; Japan; Male; Middle Aged; Odds Ratio; Platelet Aggregation Inhibitors; Predictive Value of Tests; Prospective Studies; Registries; Risk Assessment; Risk Factors; Stroke; Ticlopidine; Time Factors; Warfarin

A 75-year-old woman came to our emergency clinic complaining of abdominal pain. Acute cholecystitis was diagnosed, and parenteral antibiotic therapy was initiated. Because of palpitation, she had a consultation with the cardiology clinic. Echocardiography showed a 2.7 x 2.2 cm mobile thrombus attached to the apex of the right ventricle. Since no thromboembolic complications were present, we decided to begin administering heparin and oral anticoagulant. After the administration of unfractionated heparin for 48 hours, the patient was shifted to low-molecular weight heparin because it is easier to use and requires no follow-up. The patient received low-molecular weight heparin in addition to sodium warfarin for 5 days. Administration of heparin was then stopped and treatment was continued with sodium warfarin. In the series of weekly echocardiography evaluations, a gradual reduction was noted in the apical mass, which was initially considered to be a thrombus, and 3 weeks later evaluation revealed that the thrombus in the right ventricle had disappeared completely. No thromboembolic complications were observed during the follow-up period.

Topics: Aged; Anticoagulants; Female; Heart Diseases; Heparin; Humans; Thrombosis; Ultrasonography; Warfarin

Warfarin anticoagulation significantly reduces the risk of thromboembolism in patients with atrial fibrillation (AF). However, there are many patients with AF who begin anticoagulation only after left atrial thrombus (LAT) is detected by transesophageal echocardiography (TEE). The impact of anticoagulation in these patients has not been clearly described. The purpose of this study was to investigate the incidence of cerebrovascular accident (CVA) among AF patients who began warfarin before LAT was detected by TEE compared to those who began warfarin only after TEE demonstrated LAT and those did not receive warfarin at any point.. Of the 90 consecutive AF patients with LAT (male 48, female 42, age 71.5 +/- 10.1 years), 49 began warfarin more than 3 weeks before TEE (Group I); 29 began warfarin after TEE (Group II); and 12 did not receive warfarin at all (Group III).. The incidence of CVA in Group I (14%, 7/49, prior CVA 5, new CVA after TEE 2) was significantly lower than Group II (45%, 13/29, prior CVA 10, new CVA after TEE 3, P = 0.006) and III (42%, 5/12, prior CVA 3, new CVA after TEE 2, P = 0.047). Patients with persistent LAT had significantly higher incidence (64% vs 23%, P = 0.024) of CVA and lower CVA free survival than those with resolved LAT.. The incidence of CVA among AF patients, who began warfarin before LAT detection, is significantly lower than those who began warfarin after LAT detection as well as those who did not receive warfarin at all.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Echocardiography, Transesophageal; Female; Heart Atria; Heart Diseases; Humans; Incidence; Male; Middle Aged; Risk; Stroke; Thromboembolism; Thrombosis; Time Factors; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Echocardiography, Doppler, Pulsed; Fatigue; Heart Atria; Heart Diseases; Humans; Imaging, Three-Dimensional; Male; Middle Aged; Pacemaker, Artificial; Pulmonary Embolism; Thrombolytic Therapy; Thrombosis; Tomography, Spiral Computed; Tricuspid Valve; Ventricular Dysfunction, Left; Warfarin

A right-to-left shunt in the presence of normal pulmonary artery pressure is an unusual cause of hypoxemia in an adult who has a patent foramen ovale. We report a rare case of such a shunt-the result of a right atrial thrombus that formed in a hypercoagulable patient after placement of an indwelling central venous catheter for chemotherapy. In order to ascertain the nature of the right atrial mass and to decrease the risk of systemic embolization, the thrombus was surgically removed with the patient on cardiopulmonary bypass.

Topics: Anticoagulants; Blood Pressure; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Catheterization, Central Venous; Coronary Circulation; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Heart Atria; Heart Diseases; Heart Septal Defects, Atrial; Humans; Hypoxia; Male; Middle Aged; Protein C Deficiency; Pulmonary Artery; Thrombectomy; Thrombosis; Treatment Outcome; Warfarin

Myocarditis and dilated cardiomyopathy is characterized by dilatation of all four cardiac chambers and decreased systolic function of the heart, especially in the left ventricle. In this report we presented a patient with myocarditis or dilated cardiomyopathy and deficiency of protein C and protein S with biventricular multiple intracardiac thrombi. Standard heparin infusion and acetyl salicylic acid was begun. On the 10th day of hospitalization the right ventricular thrombus disappeared, and on the 24th day all thrombi in the left ventricle disappeared. During the treatment we did not observe any complication such as hemorrhagia or embolism. We think that patients with dilated cardiomyopathy or myocarditis should be evaluated for hemostatic disorders, and should be anticoagulated if any of these disorders are presented.

Topics: Anticoagulants; Aspirin; Cardiomyopathy, Dilated; Child, Preschool; Female; Fibrinolytic Agents; Heart Diseases; Heart Ventricles; Heparin; Humans; Protein C Deficiency; Protein S Deficiency; Thrombosis; Treatment Outcome; Ultrasonography; Warfarin

Behçet's syndrome is a chronic multisystem disease that presents with recurrent oral and genital ulceration and recurrent uveitis. Cardiac involvement is an extremely rare manifestation of this disorder. A 33-year-old man with Behçet's syndrome was admitted to our department with a history of cough, fever, chest pain, hemoptysis, and weight loss. Transthoracic and transesophageal echocardiography revealed a right ventricular thrombus. After 1 month of treatment with warfarin, cyclophosphamide, and corticosteroid, the intracardiac thrombus resolved.

Topics: Adult; Anticoagulants; Behcet Syndrome; Cyclophosphamide; Drug Therapy, Combination; Glucocorticoids; Heart Diseases; Heart Ventricles; Humans; Immunosuppressive Agents; Male; Methylprednisolone; Pulmonary Embolism; Recurrence; Thrombophlebitis; Thrombosis; Ultrasonography; Warfarin

In recent decades, there have been several studies on the correlation between periodontal disease (PD) and cardiovascular disease, but the influence of PD on the effect of oral anticoagulant drugs has not been reported.. To assess the influence of PD on oral anticoagulation in patients with heart disease.. Dental treatment for patients of the Anticoagulation Clinic of the Instituto Nacional de Cardiologia Laranjeiras (INCL), receiving warfarin as a prophylactic treatment for thromboembolic events, was performed without suspending the drug and according to the INCL's "Protocol of dental treatment for patients with acquired coagulopathy". A therapeutic anticoagulation level was maintained and was assessed using the international normalized ratio (INR) on the of the patient's visit. The patient was thus protected against thromboembolic events and could undergo dental treatment, even oral surgery. Our study comprised 40 patients who underwent prospective oral assessment and were divided into two groups: Group I--20 patients with PD; and Group II--20 patients without PD. Dental treatment was performed in the two groups as follows: PD control in Group I and treatment of dental caries in Group II. The INR of the patients was assessed before each dental consultation, to guarantee hemostasis during the procedures and to monitor the anticoagulation level obtained. INR prior to the dental intervention was then compared with that after the intervention in both groups. An INR increase of > or =50% was considered significant.. In Group I, all patients showed an increase in INR after the dental treatment, which was significant in 15 (75%). In Group II, only 8 patients had increased INR, which was significant in 5 (25%) (p = 0.002). Considering the oral health of the two groups,. the extent of tissue injury in the oral cavity was not significant compared to the INR increase; however, comparison between the two groups showed significant INR increase mainly in patients with PD (p = 0.002).. This study showed that dental treatment in patients with any type of PD significantly increases INR.

Topics: Adult; Anticoagulants; Female; Fibrinolytic Agents; Heart Diseases; Humans; International Normalized Ratio; Male; Middle Aged; Periodontal Diseases; Prospective Studies; Warfarin

Topics: Anticoagulants; Atrial Appendage; Atrial Fibrillation; Diagnosis, Differential; Echocardiography, Doppler, Pulsed; Echocardiography, Transesophageal; Female; Heart Diseases; Heart Neoplasms; Humans; Hypertension; Middle Aged; Myxoma; Thrombosis; Warfarin

To assess the impact of a computerised system to support decision-making concerning the management of warfarin used in maintenance of anti-coagulation.. Retrospective case series study comparing manual and computerised records of prescribing.. A tertiary paediatric cardiology department in a teaching hospital.. The 26 children receiving warfarin to maintain anticoagulation at the time of introduction of a computerised system to support decision-making.. A rules-based computerised system to support decisions, based on existing departmental guidelines, for management of anticoagulation using warfarin was introduced to aid prescribing physicians.. We assessed the stability of the International Normalised Ratio, along with the number of checks made of the ratio, and the adjustments of dosage. Dosages, and recheck interval prescriptions, were compared to the guidelines established by our department.. We compared 274 prescriptions made manually, and 608 made using the computerised system to support decision-making, covering periods of 4, and 11, months respectively. The mean proportion of time spent by the patients within their target range for the International ratio was maintained during the period studied, at 76 percent versus 79 percent (p = 0.79). The median number of checks of the ratio made for each patient over a period of 28 days was unchanged, at 1.9 versus 2.1 (p = 0.58). There was a significant change in prescribing practices, which more closely followed the departmental guidelines.. The introduction of a computerised system to support decision-making maintained the stability of the International ratio using warfarin, without increasing the number of checks or adjustments of dosages, in a point-of-care service for anticoagulation in children.

Topics: Administration, Oral; Adolescent; Anticoagulants; Child; Child, Preschool; Decision Making, Computer-Assisted; Drug Prescriptions; Female; Follow-Up Studies; Heart Diseases; Humans; Male; Practice Guidelines as Topic; Retrospective Studies; Treatment Outcome; Warfarin

Thrombophilic diathesis may cause severe problems in cardiac surgical patients. Among these, protein S deficiency is a coagulation disorder associated with recurrent thromboembolic events. We analyzed our experience with 7 patients with protein S deficiency who underwent cardiac surgery.. We retrospectively reviewed the clinical data, operative and postoperative courses, and the long-term results of 7 patients who were diagnosed to have protein S deficiency. Six of them were operated on using cardiopulmonary bypass, one was operated on with an off-pump procedure.. Procedures performed were emergent pulmonary embolectomy (patient 1), aortic valve replacement and coronary artery bypass grafting (CABG, patient 2), re-CABG (patients 3 and 7), and CABG (patients 4, 5, and 6). In patients 1, 2, 3, and 7, the diagnosis was made perioperatively. Patients 4, 5, and 6 were treated with a modified regimen of warfarin or protamine. All of the latter 3 patients had an uneventful perioperative course without thromboembolic complication. At follow-up, all but 1 of the 7 patients were on continuous warfarin, and were well and without any further thromboembolic events.. In patients with a past medical history of thromboembolic events or with a perioperative thromboembolic complication, elaborate laboratory investigation should lead to a definite diagnosis. For instance, patients with protein S deficiency undergoing cardiac surgery belong to a high-risk subgroup. Although rare, this and other coagulation disorders can be a critical issue in cardiac surgery. In such patients, we suggest perioperative warfarin therapy with a target international normalized ratio of 2.0 and incomplete protamine antagonism to minimize the risk of a perioperative thromboembolic event.

Topics: Adult; Aged; Anticoagulants; Cardiac Surgical Procedures; Coronary Artery Bypass; Embolectomy; Heart Diseases; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Protein S Deficiency; Pulmonary Embolism; Retrospective Studies; Thrombophilia; Warfarin

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

Chagas disease (CD) is frequently associated with cardioembolic stroke in South America. Our objective was to identify the predictors of stroke in a region where CD is endemic.. We screened 305 consecutive cardiopathy patients. Significant predictors of stroke in univariable analyses were included in a multivariable model.. Stroke was more frequent in CD (15.0%) compared with other cardiopathies (6.3%; P=0.015). Other predictors of stroke in univariable analyses were previous diabetes or cardioversion and use of amiodarone, antiplatelet agents, and warfarin. In multivariable analysis, remaining predictors of stroke were CD (odds ratio [OR], 1.09; 95% CI, 1.02 to 1.17), cardioversion (OR, 1.07; 95% CI, 1.02 to 1.13), and diabetes (OR, 1.12; 95% CI, 1.01 to 1.24).. In conclusion, CD is a risk factor for stroke, independent of systolic dysfunction or presence of cardiac arrhythmias.

Topics: Adult; Aged; Amiodarone; Anti-Arrhythmia Agents; Anticoagulants; Chagas Disease; Cohort Studies; Female; Heart Diseases; Humans; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Platelet Aggregation Inhibitors; Regression Analysis; Risk Factors; Stroke; Warfarin

To evaluate the association of VKORC1 genetic variants with warfarin dose requirements in a Hong Kong Chinese patient population.. A retrospective study of Hong Kong Chinese patients chronically maintained on warfarin was conducted. Single nucleotide polymorphisms (SNPs) in VKORC1 and CYP2C9 were genotyped. Stable warfarin dose data were retrieved from patient medical records.. Sixty-nine patients were included in the analysis. VKORC1 haplotypes H1 (group A) and H7 (group B) were most common, accounting for 86% and 13% of all haplotypic variation in this cohort. Patients carrying at least one copy of a VKORC1 group B haplotype (n = 16) required a significantly higher stable warfarin dose (5.17+/-1.53 mg/day) than patients that were homozygous for group A haplotypes (n = 53; 2.93+/-1.22 mg; P < 0.001). In the VKORC1 A/A group, four patients (5.8%) were heterozygous for CYP2C9*3 and had a lower dose requirement (1.94+/-0.43 mg) than patients that exhibited the CYP2C9 *1/*1 genotype (3.01+/-1.23 mg), P = 0.004. In multivariate analysis, VKORC1 and CYP2C9 explained 31% and 7.9% of the variability in warfarin dose, respectively.. VKORC1 genotype is the dominant genetic influence on inter-individual variability in warfarin dose in Hong Kong Chinese. The lower mean dose of warfarin in Chinese, relative to Europeans, appears to be a reflection of their preponderance of the 'low-dose' VKORC1 H1/H1 (homozygous group A) genotype.

Topics: Anticoagulants; Aryl Hydrocarbon Hydroxylases; Asian People; Cohort Studies; Cytochrome P-450 CYP2C9; Female; Genetic Variation; Genotype; Haplotypes; Heart Diseases; Homozygote; Hong Kong; Humans; Male; Middle Aged; Mixed Function Oxygenases; Polymerase Chain Reaction; Polymorphism, Single Nucleotide; Retrospective Studies; Vitamin K Epoxide Reductases; Warfarin

Dilated cardiomyopathy and the resultant left ventricular dysfunction are risk factors for thrombus formation in the heart, reflecting the intimate relationship between structure and function in this vital organ. Once formed, depending on size, location, and mobility, left ventricular thrombi have the tendency to embolize, sometimes with dire consequences. Proper management of these thrombi is still controversial. We present a case of an unusual large thrombus, which resolved with anticoagulation therapy alone, giving hope that more invasive intervention can safely be circumvented.

Topics: Adult; Anticoagulants; Cardiomyopathy, Dilated; Drug Administration Schedule; Echocardiography, Transesophageal; Follow-Up Studies; Heart Diseases; Heart Ventricles; Heparin; Humans; Infusions, Intravenous; Male; Severity of Illness Index; Thrombosis; Treatment Outcome; Warfarin

In this study, patients with heart diseases were classified into 2 groups: Warfarin user and Warfarin non-user, and six salivary components were determined to assess intraoral pathologic conditions. Groups of healthy subjects and patients with periodontal disease without receiving any medication were set as control groups, and they were compared with those of the 2 groups with heart diseases. In patients with heart diseases in both the groups, albumin (ALB) level was found to be significantly higher compared to that in the control groups, and it was significantly higher in the patient group receiving Warfarin user and Warfarin non-user compared to that in the patient group with periodontal disease. C-reactive protein (CRP) levels were found to be higher in both the groups with heart diseases than those in the healthy group. Correlations between various salivary components and the clinical parameters were examined, showing significant correlations between ALB and gingival index (GI) and clinical attachment level (CAL), and between alanine aminotransferase (ALT) and GI, probing depth (PlI), bleeding on probing (BOP) and CAL. Significant correlations were also found between creatine kinase (CK) and PlI, GI and BOP. Thus, it was suggested that ALB and CRP might serve as the markers of intraoral pathologic conditions, and CK and ALT might serve as those alternative to GI.

Topics: Adult; Aged; Alanine Transaminase; Albumins; Anticoagulants; Aspartate Aminotransferases; Biomarkers; C-Reactive Protein; Cardiovascular Agents; Creatine Kinase; Dental Plaque Index; Gingival Hemorrhage; Heart Diseases; Humans; Middle Aged; Periodontal Attachment Loss; Periodontal Diseases; Periodontal Index; Periodontal Pocket; Saliva; Salivary Proteins and Peptides; Warfarin

Topics: Age Factors; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Cholesterol, HDL; Cholesterol, LDL; Cholinergic Antagonists; Cough; Electric Countershock; Heart Diseases; Humans; Walking; Warfarin

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

Topics: Amiodarone; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiac Output, Low; Echocardiography, Doppler; Echocardiography, Transesophageal; Electrocardiography; Female; Heart Atria; Heart Diseases; Heart Valve Prosthesis Implantation; Heparin; Humans; Hypotension; Middle Aged; Mitral Valve; Postoperative Complications; Thrombosis; Time Factors; Warfarin

A 79-year-old woman was admitted for treatment of bronchial asthma. ST-segment elevation in the precordial leads (V4-V6) and T-wave inversion in leads II, III, and aVF was recognized. Transthoracic echocardiography and emergent cardiac catheterization demonstrated two large mobile thrombi (1.2 x 1.3 cm, 0.7 x 1.0 cm) attached to the left ventricular wall. There was no organic stenosis. Left ventriculography revealed anterolateral, apical and inferior dyskinesis, and basal hyperkinesis. The clinical diagnosis was ampulla cardiomyopathy. Anticoagulant therapy was started. Prothrombin time-international normalized ratio was remained at 2.5-3 and partial thromboplastin time was controlled at 1.5-2 times compared with the normal value. Repeated echocardiography showed the mass reduced gradually and had disappeared about 2 weeks later.

Topics: Aged; Anticoagulants; Cardiomyopathies; Echocardiography; Female; Heart Diseases; Heart Ventricles; Heparin; Humans; Thrombosis; Warfarin

Topics: Anticoagulants; Echocardiography, Transesophageal; Female; Heart Atria; Heart Diseases; Humans; Middle Aged; Thrombosis; Warfarin

Atrial fibrillation (AF) is widely accepted as a direct cause of cardioembolic stroke from left atrial (LA) thrombus formation. However, the relationship between LA thrombus and transient ischemic attack (TIA) in patients with AF is less well established.. Two hundred sixty-one adult patients (mean age 66 +/- 11 years, 220 men and 41 women) with AF undergoing transesophageal echocardiography (TEE) were prospectively followed up for TIA (mean duration 30.3 +/- 20.6 months).. LA thrombus was present in 18% (n = 46) and LA spontaneous echocardiographic contrast in 50% (n = 131) of the group. Nineteen of 261 patients had TIA during follow-up. Multivariate logistic regression showed congestive heart failure (CHF) as the only predictor of TIA when a model of clinical variables was constructed (odds ratio [OR] 2.7, P =.04). Age, sex, hypertension, and use of warfarin or aspirin were not predictors. When TEE variables were added to the model, LA thrombus became the only predictor of TIA (OR 7.7, P =.0001). Survival free of TIA (Kaplan-Meier) was significantly less (P =.0001) in patients with LA thrombus compared with those without, and the annual TIA event rate was 9.2% per year versus 1.9% per year (P <.0001), respectively.. To our knowledge, this is the first prospective study documenting an association between LA thrombus and TIA in patients with AF. Other TEE variables, including aortic atheromata, and clinical parameters were not independently predictive. These data support a likely thromboembolic mechanism for TIA from LA thrombus in patients with AF.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Atrial Fibrillation; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Humans; Ischemic Attack, Transient; Male; Middle Aged; Platelet Aggregation Inhibitors; Prospective Studies; Regression Analysis; Risk Factors; Thrombosis; Warfarin

A 74-year-old woman with hypertension and bronchial asthma had chest discomfort at rest and 4 days later was admitted to her nearby hospital because of the sudden onset of right hemiparesis. The hemiparesis had almost disappeared within 24 h of onset, but because an electrocardiogram showed sinus tachycardia and diffuse symmetrical T-wave inversion, she was referred for cardiac examination. Coronary angiography did not reveal any significant coronary artery stenosis, but left ventriculography revealed severe hypokinesis of the left ventricular apical region, which contained a 4 x 4-mm solid thrombus moving freely with a wavy motion. Moreover, the activity of both protein C and protein S had decreased. The thrombus disappeared after 2 weeks of anticoagulant treatment with warfarin. Her clinical course suggested that the transient cerebral ischemic attack was caused by embolism of the left ventricular thrombus associated with 'tako-tsubo-like left ventricular dysfunction'.

Topics: Aged; Anticoagulants; Female; Heart Diseases; Heart Ventricles; Humans; Ischemic Attack, Transient; Radiography; Syndrome; Thrombosis; Ventricular Dysfunction, Left; Warfarin

Appropriate anticoagulation after transcatheter device placement is controversial. Patients with no history of thromboembolism or neurologic event typically receive antiplatelet therapy for several months while the device endothelializes. For patients with a history of stroke, there are no established guidelines for postdevice anticoagulation. Most patients receive warfarin, antiplatelet therapy, or a combination. Thrombus formation after transcatheter device placement has been reported for most commercially available devices. We describe a patient who developed a left atrial thrombus after closure of a patent foramen ovale with a CardioSEAL device. The patient had a normal hypercoaguable laboratory evaluation prior to device placement. Thrombosis occurred despite warfarin therapy before and after device placement. The patient's international normalized ratio was checked every 2 weeks after device placement and ranged between 2.0 and 2.8. She had no clinical arrhythmia during this time period. The left atrial thrombus was detected on routine follow-up transthoracic echocardiogram performed 6 months after device deployment. A subsequent transesophageal echocardiogram demonstrated no residual shunt, appropriate positioning of the device, flat against the septum, and a 1 x 2 cm thrombus attached to the superior and posterior left atrial arm near the junction with the native septum. A fluoroscopic image demonstrated no arm fractures. The device and thrombus were subsequently removed at surgery without complication. This case is perplexing in that the patient received appropriate anticoagulation had a negative hypercoaguable work-up, no residual shunt, and a well-positioned device.

Topics: Adult; Balloon Occlusion; Cardiac Catheterization; Device Removal; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Heart Septal Defects, Atrial; Humans; Prosthesis Failure; Recurrence; Risk Assessment; Stents; Stroke; Thrombosis; Treatment Outcome; Warfarin

A 64-year-old woman with hypertension presented with a left atrial giant mass during the treatment of congestive heart failure. She was admitted to our hospital for intensive treatment. Transesophageal echocardiography demonstrated a cauliflower-like, large (3 x 2 cm), mobile echogenic mass attached to the left atrial wall. There were no signs of systemic embolism. Anticoagulant therapy was started. Repeated echocardiography showed the mass was reduced gradually and had diminished on the 10th day. She remained asymptomatic during the anticoagulant therapy. The diagnosis was thrombus based on the response to treatment. Surgical removal should be considered for such a large thrombus, but the present case of giant thrombus was successfully treated by anticoagulants without systemic complication.

Topics: Anticoagulants; Echocardiography, Transesophageal; Female; Heart Atria; Heart Diseases; Heparin; Humans; Middle Aged; Thrombosis; Warfarin

Heparin-induced thrombocytopenia and thrombosis syndrome (type II) is associated with thromboembolic complications and a mortality rate up to 30%. We describe a patient who developed intracardiac and aortic Dacron prosthesis heparin-induced thrombosis after aortic root conservative surgery. Successive transoesophageal echocardiographies demonstrated a progressive regression of intracardiac thrombosis with oral anticoagulation by warfarin and antiplatelet therapy combining aspirin and clopidogrel.

Topics: Aged; Anticoagulants; Aortic Aneurysm, Thoracic; Aspirin; Blood Vessel Prosthesis; Clopidogrel; Drug Therapy, Combination; Echocardiography, Transesophageal; Follow-Up Studies; Heart Diseases; Heparin, Low-Molecular-Weight; Humans; Risk Assessment; Severity of Illness Index; Thrombocytopenia; Thrombosis; Ticlopidine; Treatment Outcome; Warfarin

Atrial fibrillation (AF) is a recurrent problem that frequently requires repeat cardioversion. Transesophageal echocardiography (TEE) is indicated before cardioversion in patients who are underanticoagulated (warfarin therapy <3 weeks or international normalized ratio [INR] <2.0). It remains uncertain if TEE should be repeated in underanticoagulated patients who had no atrial thrombi detected by previous TEE. Methods and results From January 1996 to June 2001, 76 patients (43 men, 33 women; mean age, 68.8 +/- 10.4 years) who were underanticoagulated and had no atrial thrombi in previous TEE underwent repeat TEE before cardioversion of recurrent AF. The duration of recurrent AF at the time of the second TEE was 5.1 +/- 9.3 months (1 day to 4 years). The underlying diseases included coronary artery disease (n = 30), hypertension (n = 22), valvular heart diseases (n = 8), dilated cardiomyopathy (n = 4), hypertrophic cardiomyopathy (n = 2), and others (n = 10). Eight (10.5%) patients (2 men, 6 women; mean age, 68.6 +/- 6.6 years) were found to have intra-atrial thrombi on the second TEE. Of these 8 patients, 3 had coronary artery disease, 1 had hypertension, 2 had dilated cardiomyopathy, 1 had hypertrophic cardiomyopathy, and 1 had AF of unknown cause. The duration of recurrent AF in patients with and without thrombi was not significantly different (3.6 +/- 4.7 versus 5.3 +/- 9.7 months, P =.22). Of the 8 patients with intra-atrial thrombi on the second TEE, 5 had been taking warfarin for 3 to 4 weeks but had subtherapeutic INR and 3 were taking aspirin only. Compared with patients without intra-atrial thrombi, patients with intra-atrial thrombi had lower ejection fraction (32.5% +/- 18.1% versus 49.9% +/- 14.1%, P =.015), slower left atrial appendage empty velocity (0.22 +/- 0.08 versus 0.41 +/- 0.17 m/s, P <.01), and higher prevalence of spontaneous echo contrast (87.5%) than in patients without intra-atrial thrombi (19.1%, P <.05) but similar left atrial size (49.5 +/- 5.3 versus 47.3 +/- 7.1 mm, P =.15). Cardioversion was cancelled in all patients with atrial thrombi.. In underanticoagulated patients, repeat TEE is necessary before cardioversion of recurrent AF even if the previous TEE showed no atrial thrombi.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Echocardiography, Transesophageal; Electric Countershock; Female; Heart Atria; Heart Diseases; Humans; International Normalized Ratio; Male; Middle Aged; Recurrence; Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Beverages; Fatal Outcome; Food-Drug Interactions; Gastrointestinal Hemorrhage; Heart Diseases; Hemorrhage; Humans; International Normalized Ratio; Male; Pericardium; Vaccinium macrocarpon; Warfarin

The antiphospholipid syndrome (APS) has been associated with multiple cardiac abnormalities. The present report describes a case of right ventricle thrombus in a 51-year-old woman with a history of autoimmune haemolytic anemia and antiphospholipid antibodies. Transthoracic echocardiography demonstrated the presence of a right ventricle mass, mimicking a myxoma. She underwent open heart removal of the mass and was started on indefinitely anticoagulant therapy. At 2 years follow-up she was free of symptoms.

Topics: Anemia, Hemolytic, Autoimmune; Anticoagulants; Antiphospholipid Syndrome; Diagnosis, Differential; Echocardiography; Female; Heart Diseases; Heart Neoplasms; Humans; Middle Aged; Myxoma; Thrombosis; Warfarin

Protein C deficiency is an inherited thrombophilia presented in adults with venous thrombosis at different sites. Symptomatic biatrial thrombus presentation of protein C deficiency has not, to my knowledge, been described. This report investigates a man with protein C deficiency who presented with dyspnea and recurrent attacks of dizziness associated with biatrial thrombus. Complete disappearance of the symptoms and thrombi was observed within less than 3 weeks of anticoagulation.

Topics: Adolescent; Anticoagulants; Echocardiography, Transesophageal; Heart Atria; Heart Diseases; Humans; Male; Protein C Deficiency; Thrombosis; Warfarin

Topics: Aged; Aged, 80 and over; Anticoagulants; Heart Atria; Heart Diseases; Humans; Magnetic Resonance Angiography; Male; Thrombosis; Warfarin

After thromboembolectomy, patients with acute limb ischemia often receive anticoagulant therapy to prevent recurrent events. Patients with atrial fibrillation or cardiac thrombus have a higher risk of recurrent emboli than those without these risk factors. This study examines the importance of long-term anticoagulation in these 2 groups.. A review of patients presenting with acute limb ischemia over a 5-year period (1994-1999).. A university-affiliated medical centre.. Fifty patients divided into 2 groups: 19 (38%) patients with atrial fibrillation (group 1) and 31 (62%) patients with no atrial fibrillation or cardiac thrombus (group 2) as confirmed by transthoracic echocardiography.. All patients underwent surgical thromboembolectomy and received postoperative anticoagulant therapy.. Mortality, limb loss, further thromboembolic events and bleeding complications as determined by telephone survey.. There was a significant difference in 5-year survival (group 1, 84%; group 2, 64%) and early limb loss (group 1, 0%; group 2, 13%). Further thromboembolic events and bleeding complications were rare but were more common in group 1. In group 2 there were no instances of recurrent thromboemboli and no bleeding complications although only 39% of patients in this group were taking angicoagulants at the end of the study period.. Patients with extremity thromboemboli without atrial fibrillation or cardiac thrombus may not be at the same risk for recurrent events as those with these risk factors, and long-term anticoagulant therapy may not be as necessary in this group.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Extremities; Female; Heart Diseases; Humans; Ischemia; Male; Middle Aged; Recurrence; Retrospective Studies; Risk Factors; Thrombectomy; Thromboembolism; Thrombosis; Time Factors; Treatment Outcome; Warfarin

The interaction between amiodarone and warfarin has only been described in patients being followed up for relatively short time periods. The objectives of this study were to characterize the interaction between these two agents in a clinical situation over a longer period of time in a larger cohort of patients, and to determine the relationship between the maintenance dose of amiodarone and the resultant need to adjust the dose of warfarin.. This was an observational trial of a cohort of patients receiving a stable warfarin regimen in whom oral amiodarone was initiated. Patients received both amiodarone and warfarin for at least 1 year, and the dosage of warfarin was adjusted as clinically necessary to achieve an international normalized ratio of 2 to 3. Data from a total of 43 patients were analyzed.. At baseline, prior to initiation of amiodarone, the warfarin dose was 5.2 +/- 2.6 mg/d. The magnitude of the interaction between these two agents peaked at 7 weeks, which resulted in a 44% mean maximum reduction in the warfarin dose. The warfarin dose inversely correlated with the maintenance dose of amiodarone (r(2) = 0.94, p < 0.005). Minor bleeding episodes occurred in five patients (12%). For patients receiving amiodarone maintenance doses of 400, 300, 200, or 100 mg/d, it is recommended that the daily warfarin dose be reduced by approximately 40%, 35%, 30%, or 25%, respectively.. The magnitude of the amiodarone/warfarin interaction is highly dependent on the maintenance dose of amiodarone. This relationship can aid clinicians in adjusting the dose of warfarin patients receiving long-term amiodarone treatment.

Topics: Aged; Amiodarone; Dose-Response Relationship, Drug; Drug Interactions; Drug Therapy, Combination; Female; Heart Diseases; Hemorrhage; Humans; Long-Term Care; Male; Middle Aged; Retrospective Studies; Risk Factors; Tachycardia; Warfarin

A subepicardial aneurysm became evident in a male patient after anticoagulant therapy. On admission, it appeared to be an old anterior infarction accompanied by a mural thrombus. After warfarin administration, the thrombus disappeared and an echo-free space emerged outside the apical myocardial wall. The echo-free space communicated with the left ventricular cavity through the apical myocardial wall. Emergency surgery was undertaken and the patient survived. The aneurysm was covered with epicardium and there was an endomyocardial rupture of the muscle in the apical wall, which was the entrance of the aneurysm. This case suggests that cautious follow-up with echocardiography is necessary when anticoagulant therapy is selected for thrombi following myocardial infarction.

Topics: Anticoagulants; Diagnosis, Differential; Echocardiography, Doppler, Color; Heart Aneurysm; Heart Diseases; Humans; Male; Middle Aged; Myocardial Infarction; Thrombosis; Warfarin

Behçet's disease (BD) is a chronic relapsing systemic vasculitis in which orogenital ulceration is a prominent feature. The disease affects many systems and causes hypercoagulability. We present a 27-year-old male patient who exhibited widespread great vessel thrombosis including right atrial and ventricular thrombi in the setting of right-sided infectious endocarditis and orogenital aphthous ulcerations and erythema nodosum due to BD. We reviewed the enigmatic prothrombotic state of BD, and discuss our prior experiences in this field.

Topics: Adult; Anti-Bacterial Agents; Anticoagulants; Axillary Vein; Behcet Syndrome; Drug Therapy, Combination; Endocarditis, Bacterial; Endothelium, Vascular; Erythema Nodosum; Heart Atria; Heart Diseases; Heart Ventricles; Heparin; Humans; Male; Pulmonary Veins; Stomatitis, Aphthous; Streptokinase; Superior Vena Cava Syndrome; Thrombectomy; Thrombolytic Therapy; Thrombophilia; Thrombosis; Tissue Plasminogen Activator; Tricuspid Valve; Venous Thrombosis; Warfarin

Behçet's disease is recognised as a chronic multisystem disorder with vasculitis as its underlying pathological process. Cardiac involvement is rare and often associated with poor prognosis. A case of a 33 year old man with Behçet's disease, presenting with a large right ventricle and right atrial thrombus, is reported. Two dimensional (cross sectional), colour Doppler, and transoesophageal echocardiography, angiography, computed tomography, and magnetic resonance imaging were used to diagnose the disease. With cyclophosphamide and dexamethasone treatment, the cardiac lesions progressively resolved.

Topics: Adult; Anti-Inflammatory Agents; Anticoagulants; Behcet Syndrome; Colchicine; Cyclophosphamide; Dexamethasone; Drug Therapy, Combination; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Heart Atria; Heart Diseases; Heart Ventricles; Humans; Immunosuppressive Agents; Male; Thrombosis; Warfarin

The presence of left atrial thrombus (LAT) is associated with an increased risk of embolic stroke. However, it has yet to be established definitively whether low-intensity warfarin therapy (INR: 1.5-2.0) can prevent LAT formation in patients with nonvalvular atrial fibrillation (NVAF). The present study analyzed the clinical and transesophageal echocardiography (TEE) features of 123 such patients to identify risk factors for LAT formation and the efficacy of prophylactic low-intensity warfarin therapy. Left atrial thrombi were found in 35 patients (28%) in whom systemic hypertension (49% vs 23%; p<0.01) and ischemic heart disease (17% vs 3%; p<0.01) were more frequent. Left ventricular ejection fraction (54+/-14% vs 60+/-11%; p<0.05), left ventricular end-diastolic dimension (51+/-7 mm vs 48+/-5 mm; p<0.05), spontaneous echo contrast (2.2+/-0.7 vs 1.4+/-0.9; p<0.01), left atrial diameter (50+/-6 mm vs 43+/-7 mm; p<0.01), left atrial appendage blood velocity (22.3+/-8.7 cm/s vs 37.2+/-21.5 cm/s; p<0.01) and the incidence of left ventricular hypertrophy (37% vs 15%; p<0.01) were also significantly different between the groups. Fourteen patients received continuous warfarin therapy (target INR: 1.5-2.0) and on the follow-up TEE study the left atrial thrombus resolved in 10 (71%). There were no thromboembolic events or major hemorrhagic complications in these patients, so it was concluded that low-intensity warfarin therapy is efficacious in treating LAT formation in patients with NVAF.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Diabetes Complications; Drug Evaluation; Echocardiography, Transesophageal; Female; Heart Atria; Heart Diseases; Humans; Hypertension; Hyperthyroidism; International Normalized Ratio; Male; Middle Aged; Myocardial Ischemia; Thrombosis; Treatment Outcome; Ventricular Function, Left; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Contraindications; Echocardiography, Transesophageal; Electric Countershock; Heart Diseases; Humans; Thrombosis; Warfarin

Behçet's disease is a chronic multi-system disease presenting with recurrent oral and genital ulceration, and relapsing uveitis. Cardiac involvement is an extremely rare manifestation of this disorder. We report an unusual case of Behçet's disease characterized by a mural cardiac thrombi in the right atrium and right ventricle along with transient protein C and S deficiency.

Topics: Adult; Atrial Function, Right; Behcet Syndrome; Echocardiography; Heart Diseases; Humans; Immunosuppressive Agents; Male; Protein C Deficiency; Protein S Deficiency; Thrombosis; Ventricular Dysfunction, Right; Warfarin

Topics: Anticoagulants; Aspirin; Atrial Fibrillation; Drug Therapy, Combination; Heart Diseases; Humans; Practice Patterns, Physicians'; Retrospective Studies; Thromboembolism; Thrombolytic Therapy; Thrombosis; Warfarin

The value of warfarin in preventing stroke in patients with chronic atrial fibrillation is well established. However, the prevalence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfarin treatment.. Between 1990 and 1998, 1027 patients were discharged with chronic or persistent atrial fibrillation. This population was composed of (1) patients with cardiac prosthetic valves (n=48), (2) those with increased bleeding risks (n=152), (3) physically or mentally handicapped patients (n=317), and (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfarin use.. The respective rates of warfarin use on discharge in the 4 groups were 93.7%, 30.9%, 17.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatment rates increased with each consecutive triennial period (29.7%, 53.6%, and 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, and being hospitalized in a given medical department emerged as independent variables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI 0.17 to 0.55); P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and availability of echocardiographic information, regardless of the findings, each increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0001, OR 3.52 [95% CI 2.16 to 5.72], respectively).. Old age, language difficulties, insufficient doctor alertness to warfarin benefit, and patient disability produced reluctance to treat. Warfarin use still lags behind requirements.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Atrial Fibrillation; Chronic Disease; Communication Barriers; Comorbidity; Drug Prescriptions; Drug Utilization; Echocardiography; Female; Heart Diseases; Hospital Departments; Hospitalization; Humans; Israel; Lung Diseases, Obstructive; Male; Middle Aged; Physician-Patient Relations; Physicians; Practice Patterns, Physicians'; Recurrence; Refusal to Treat; Retrospective Studies; Risk Factors; Stroke; Thyrotoxicosis; Warfarin

Topics: Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Drug Administration Schedule; Drug Therapy, Combination; Echocardiography; Heart Diseases; Humans; Myocardial Infarction; Polypharmacy; Thrombosis; Warfarin

Twenty patients with right atrial thrombi were identified through the use of transthoracic and transesophageal echocardiography. Transesophageal echocardiography identified right atrial thrombi in all 20 cases. Transthoracic echocardiography showed definite thrombi in only 6 (30%) cases and suggested thrombus in another 2 (10%) patients. Thus transthoracic echocardiography results were false-negative for right atrial thrombus in 60% of cases. All 3 thrombi found within the right atrial appendage and 2 of 3 thrombi on pacemaker wires were missed by transthoracic echocardiography. There was no significant difference in the mean size between those thrombi seen (1.37 +/- 0.6 cm) and those missed (1.5 +/- 0.9 cm) by transthoracic echocardiography. Transesophageal echocardiography also significantly affected treatment. Anticoagulation was initiated or amplified in 13 patients. In 8 of these 13, thrombi were seen only by transesophageal echocardiography. Surgery was performed to remove thrombi in 7 cases, and in 3 (43%) cases it was because of thrombi seen only by transesophageal echocardiography. This study suggests that transesophageal echocardiography should be performed whenever right atrial thrombi are suspected. Transesophageal echocardiography has a significant effect on the diagnosis and management of patients with right atrial thrombi.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Echocardiography; Echocardiography, Transesophageal; False Negative Reactions; Female; Heart Atria; Heart Diseases; Humans; Male; Middle Aged; Pacemaker, Artificial; Retrospective Studies; Sensitivity and Specificity; Survival Rate; Thrombectomy; Thrombosis; Warfarin

Percutaneous balloon mitral valvuloplasty (PBMV) described by Inoue et al, is a safe FDA (Food and Drug Administration) approved procedure in patients with severe mitral stenosis. One of the contraindications of the procedure is presence of a left atrial thrombus; however, it has been reported that intense warfarin therapy may led to dissolution of the thrombus. The authors report a patient who was referred for PBMV and was found to have a left atrial thrombus. After intense warfarin therapy, successful PBMV was undertaken without complications.

Topics: Anticoagulants; Catheterization; Contraindications; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Humans; International Normalized Ratio; Middle Aged; Mitral Valve Stenosis; Rheumatic Heart Disease; Thrombosis; Warfarin

We assessed the serum concentration of gamma-carboxylated osteocalcin (OC), total OC, and full-length OC in a clinical setting of 37 patients on continuous warfarin treatment (international normalized ratio 2.0-3.8). A comparison was done with the results from 30 untreated age-matched controls. Four monoclonal antibodies, previously generated and characterized as to their ability to recognize different human OC forms and fragments, were used in three two-site immunofluorometric assays. The warfarin-treated patients had significantly lower levels of carboxylated OC 4.9 +/- 3.8 (+/- 1 SD) ng/ml compared with the controls 13.1 +/- 9.7 (p < 0.0001). There was no difference in the levels of total OC or full-length OC between the two groups of patients. A strong correlation was found between the serum concentration of carboxylated OC and total OC, both for the warfarin-treated patients (r = 0.98) and for the controls (r = 0.99). There was a distinct cut-off level at 0.80, in the quotient carboxylated OC/total OC, at which all warfarin-treated patients fell below and all controls above this level. Hence, the concentration or ratio of serum gamma-carboxylated OC in clinical settings such as warfarin-treated patients could be measured using two-site immunoassays.

Topics: Aged; Aged, 80 and over; Antibodies, Monoclonal; Anticoagulants; Carboxylic Acids; Case-Control Studies; Female; Fractures, Bone; Heart Diseases; Humans; Male; Middle Aged; Osteocalcin; Risk Factors; Thromboembolism; Warfarin

The authors present an unusual case of multiple large atrial thrombi attached to permanent pacemaker leads identified by transesophageal echocardiography. Pathogenesis, clinical implications, and therapeutic options of pacemaker thrombi are discussed.

Topics: Aged; Aged, 80 and over; Anticoagulants; Echocardiography, Transesophageal; Electrodes, Implanted; Female; Heart Atria; Heart Diseases; Humans; Pacemaker, Artificial; Stroke; Thrombosis; Warfarin

The authors report a case of angiographically documented multiple coronary neovascularizations originating from the left circumflex artery (LCX) and coursing toward multiple thrombi located in the left atrium in a patient with severe mitral stenosis. The thrombi as well as the neovascularizations underwent near-complete resolution with 4 weeks' anticoagulation therapy with warfarin maintaining an international normalization ratio of 3.5. Percutaneous mitral balloon valvuloplasty was performed successfully without complications.

Topics: Anticoagulants; Catheterization; Coronary Angiography; Coronary Vessels; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Humans; International Normalized Ratio; Middle Aged; Mitral Valve Stenosis; Neovascularization, Pathologic; Remission Induction; Thrombosis; Warfarin

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

In general, aspirin is indicated to prevent thrombosis in conditions associated with high shear rates (i.e., atherosclerosis) and warfarin is indicated to prevent thrombosis in conditions associated with stasis (i.e., atrial fibrillation). While aspirin and warfarin should generally not be used together, their combined use is beneficial in selected patients (e.g., some patients with mechanical valve prostheses). Aspirin in a dose of 75-150 mg per day is indicated to prevent vascular events in patients with ischaemic heart disease and also in patients at high risk of ischaemic heart disease. All patients with atrial fibrillation should be considered for oral anticoagulant therapy, with the decision for its use based on an assessment of the balance between the risk of thromboembolism and bleeding. The recommended therapeutic INR (international normalised ratio) range in non-valvular atrial fibrillation is 2.0-3.0. Warfarin is contraindicated in pregnancy, particularly during the first trimester; however, it may still need to be used in the second and third trimesters in patients with mechanical valve prostheses.

Topics: Aged; Anticoagulants; Aspirin; Embolism; Female; Heart Diseases; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Pregnancy; Pregnancy Complications, Cardiovascular; Risk Factors; Thrombosis; Warfarin

This study assesses the efficacy of oral anticoagulation in resolving left atrial appendage (LAA) thrombi and evaluates clinical outcomes of percutaneous mitral valvuloplasty after resolution of LAA thrombi compared with mitral valve replacement. Warfarin therapy is successful in resolving LAA thrombi; percutaneous mitral valvuloplasty after resolution of LAA thrombi is an effective alternative to surgical treatment.

Topics: Aged; Anticoagulants; Catheterization; Contraindications; Disease-Free Survival; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve Stenosis; Thrombosis; Treatment Outcome; Warfarin

Thromboembolism is rarely considered in discussions of the complications of blunt chest trauma. The few cases of thromboembolism that have been reported in this setting have occurred in association with significant myocardial damage. A previously fit 23 year old woman was admitted to the intensive care unit following a road traffic accident. A day later, left atrial thrombus was demonstrated by transoesophageal echocardiography in the absence of any other evidence of important myocardial injury. Anticoagulation with heparin was cautiously introduced in spite of her extensive injuries, and there were no consequent bleeding complications. At hospital discharge on day 18 she was entirely well. Full anticoagulation with warfarin was continued for a further eight weeks at which time follow up transoesophageal echocardiography showed complete resolution of the thrombus.

Topics: Accidents, Traffic; Adult; Anticoagulants; Echocardiography, Transesophageal; Female; Heart Diseases; Humans; Thrombosis; Warfarin; Wounds, Nonpenetrating

A multicenter, retrospective study was undertaken to determine the prevalence of and risk factors for thromboembolism and efficacy of therapy in patients with atrial fibrillation. The primary prevention group consisted of 1,819 Japanese patients (mean age 64 years). During the mean follow-up period of 4.6 years. 158 patients developed cerebral thromboembolism or peripheral embolism (1.9%/year). The annual rate of thromboembolic complications was 0.9% for patients without underlying heart disease which was significantly lower compared with that for patients with underlying heart disease (p < 0.001). The annual rate was 1.4% among patients treated with aspirin (alone and in combination with other drugs except for warfarin), 1.4% with warfarin (alone and in combination with other drugs) and 1.1% with ticlopidine. The risk was lower for patients receiving these drugs (2.2%/year, p < 0.001). Among 801 patients not receiving treatment for thromboembolism, the annual rate was 0.9% for patients without underlying heart disease, which was significantly lower compared with patients with underlying heart diseases (e.g., 2.5% for ischemic heart disease and 2.1% for mitral valve disease, p < 0.001). Multivariate analysis using quantification method II revealed hypertension, sick sinus syndrome and left ventricular dysfunction (> or = NYHA class II) as risk factors for embolism. Although limited due to its retrospective nature, the present study suggests that the risk for embolism seems low in patients with atrial fibrillation but is not associated with underlying heart diseases or other risk factors, and antiplatelet treatment seems beneficial for these patients.

Topics: Anticoagulants; Aspirin; Atrial Fibrillation; Dipyridamole; Female; Heart Diseases; Humans; Male; Middle Aged; Multivariate Analysis; Platelet Aggregation Inhibitors; Prevalence; Prognosis; Retrospective Studies; Risk Factors; Thromboembolism; Ticlopidine; Warfarin

Little is known about the incidence and consequences of drug interactions in patients receiving warfarin. Hence, drug interactions as a cause of overanticoagulation and bleedings were determined in Chinese patients admitted to our medical unit during a 9-month period in 1994/95. Only patients with an admission international normalized ratio (INR) of > 3.0 (target range 2.0-2.5) were included since the drug interactions, if present, were more likely to be of clinical significance. Of 35 patients reviewed, 7 had a predisposing condition such as peptic ulcer and 19 received drugs or folk medicines that can interact with warfarin. Based on the temporal relationship between the initiation of the interacting agent(s) and the rise in INR/onset of bleedings, drug-warfarin interactions were definitely (n = 6) or possibly (n = 1) responsible in 7 patients (drugs for common cold 2, piroxicam plus piroxicam gel 2, medicated oil (15% methyl salicylate) plus Salvia miltiorrhiza Bge 1, "analgesic balm" (50% methyl salicylate) 1, diclofenac gel 1). These agents were prescribed by their physicians (n = 1), family doctors (n = 1) and other specialists (n = 1) or bought over-the-counter (n = 2). One other patient used the drugs from previous consultations. Five of the 7 patients developed bleedings. Drug interactions accounted for 20% of all patients with an INR of > 3.0 and 5 (36%) of 14 patients with bleedings. Patients receiving warfarin should be warned about the danger of self-medication. When prescribing warfarin, physicians should be aware of other medications that their patients are taking.

Topics: Adult; Aged; Blood Coagulation; China; Drug Interactions; Female; Heart Diseases; Hemorrhage; Hong Kong; Humans; Male; Medicine, Chinese Traditional; Middle Aged; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Cost-Benefit Analysis; Decision Support Techniques; Decision Trees; Fibrinolytic Agents; Heart Diseases; Hemorrhage; Humans; Mitral Valve Stenosis; Quality-Adjusted Life Years; Thromboembolism; Warfarin

Using a decision-analytic model, we sought to examine the cost-effectiveness of three strategies for cardioversion of patients admitted to the hospital with atrial fibrillation.. Transesophageal echocardiographic (TEE)-guided cardioversion has been proposed as a method for early cardioversion of patients with atrial fibrillation. The cost-effectiveness of this approach, relative to conventional therapy, has not been studied.. We ascertained the cost per quality-adjusted life-year (QALY) of three strategies: 1) conventional therapy--transthoracic echocardiography (TTE) and warfarin therapy for 1 month before cardioversion; 2) initial TTE, followed by TEE and early cardioversion if no thrombus is detected; 3) initial TEE, with early cardioversion if no thrombus is detected. With strategies 2 and 3, if a thrombus is seen, follow-up TEE is performed. If no thrombus is seen, cardioversion is then performed. All strategies utilized anticoagulation before and extending for 1 month after cardioversion. Life expectancy, utilities (quality-of-life weights) and event probabilities were ascertained from published reports. Cost estimates were based on published data and hospital accounting information.. Transesophageal echocardiographic-guided early cardioversion (strategy 3: cost $2,774, QALY 8.49) dominates TTE/TEE-guided cardioversion (strategy 2: cost $3,106, QALY 8.48) and conventional therapy (strategy 1: cost $3,070, QALY 8.48) because it is the least costly with similar effectiveness. Sensitivity analyses demonstrated that TEE-guided cardioversion (strategy 3) dominates conventional therapy if the risk of stroke after TEE negative for atrial thrombus is slightly less than that after conventional therapy (baseline estimate 0.8%). The results also depend on the risk of major hemorrhage but are less sensitive to baseline estimates of morbidity from TEE, cost of TTE, cost of hospital admission for cardioversion and utilities for health states.. On the basis of a decision-analytic model, TEE-guided early cardioversion, without TTE, is a reasonable cost-saving alternative to conventional therapy for patients admitted to the hospital with atrial fibrillation. Such a strategy appears particularly beneficial for patients with an increased risk of hemorrhagic complications. Future clinical studies examining the TEE strategy should consider eliminating initial TTE and carefully assess both the thromboembolic and hemorrhagic risk.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Cerebrovascular Disorders; Cost-Benefit Analysis; Costs and Cost Analysis; Decision Support Techniques; Echocardiography; Echocardiography, Transesophageal; Electric Countershock; Female; Heart Diseases; Hemorrhage; Humans; Male; Quality-Adjusted Life Years; Risk Factors; Sensitivity and Specificity; Thrombosis; Time Factors; Warfarin

Patients with left atrial thrombus are considered at high risk for thromboembolic events. The actual prognosis of these patients and the features most predictive of future events are unclear. We performed transesophageal echocardiograms in 2,894 patients over a 6 1/2-year period; 94 (age 69 +/- 11 years, 59 men, 83 in atrial fibrillation) were found to have left atrial thrombus. The thrombi were considered mobile in 45 patients and 33 patients had thrombus with a maximum dimension > or = 1.5 cm. Seven of the 94 patients with prosthetic valves were excluded from follow-up analysis. Over a follow-up period of 25.3 +/- 19.2 months, 17 patients had suffered a stroke or embolic event (event rate 10.4% per year) and 27 had died (mortality 15.8% per year). Cox proportional hazard regression analysis identified a maximum thrombus dimension > or = 1.5 cm (RR 19, p = 0.002), history of thromboembolism (RR 4.2, p = 0.038), and mobile thrombus (RR 5.3, p = 0.02) as predictors of subsequent thromboembolism. Moderate or severe left ventricular dysfunction was the only significant predictor of death (RR 2.9, p = 0.04). Gender, age, warfarin therapy at follow-up, atrial fibrillation, location (cavity vs appendage) of thrombus, and spontaneous echocardiographic contrast were not significant. Aggressive antithrombotic therapy may be indicated in these high-risk patients.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Cerebrovascular Disorders; Echocardiography, Transesophageal; Embolism; Female; Fibrinolytic Agents; Follow-Up Studies; Forecasting; Heart Atria; Heart Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Prognosis; Proportional Hazards Models; Risk Factors; Sex Factors; Survival Rate; Thromboembolism; Thrombosis; Ventricular Dysfunction, Left; Warfarin

Topics: Atrial Fibrillation; Echocardiography, Transesophageal; Electric Countershock; Heart Diseases; Hemorrhage; Humans; Intracranial Embolism and Thrombosis; Premedication; Thrombosis; Warfarin

Topics: Aged; Comorbidity; Depressive Disorder; Drug Interactions; Female; Heart Diseases; Humans; Male; Selective Serotonin Reuptake Inhibitors; Warfarin

Two cases of patients on warfarin who developed intracranial haematoma after an apparently minor head injury are described. There is a 10-fold increase in the likelihood of developing an intracranial haematoma in these patients. Recommendations are made regarding the management of this type of patient seen in the accident and emergency department.

Topics: Aged; Anticoagulants; Cerebral Hemorrhage; Craniocerebral Trauma; Emergency Service, Hospital; Female; Heart Diseases; Humans; Male; Risk Factors; Warfarin

A 75-year-old woman was admitted with transient left hemiparesis accompanied by diminished level of consciousness in September 1994. Holter electrocardiography showed transient atrial fibrillation, and transesophageal echocardiography (TEE) revealed an atrial septal aneurysm, spontaneous echo contrast, and a thrombus in the left atrial appendage. The patient received anticoagulant treatment with warfarin, and follow-up TEE showed thrombus resolution. However, after the warfarin was discontinued, symptoms recurred in October 1995 and TEE showed a club-like left atrial thrombus (21 x 40 mm) originating in the left atrial appendage and extending to the center of the left atrium. Follow-up TEE after warfarin therapy showed resolution at the neck of the thrombus but the head threatened detachment. The thrombus was subsequently excised surgically. Follow-up TEE was critical for detecting the risk of significant embolization during anticoagulant therapy.

Topics: Aged; Anticoagulants; Echocardiography, Transesophageal; Embolism; Female; Heart Atria; Heart Diseases; Humans; Thrombosis; Warfarin

Transcranial Doppler sonography (TCD) has been used to detect microembolic signals in a variety of clinical situations. We studied the prevalence of TCD-detected microemboli in 38 acute stroke patients.. Consecutive patients with acute anterior circulation stroke were stratified into high-risk (group 1), medium-risk (group 2), and low-risk (group 3) groups based on their risk factors for cerebral embolism.. Microemboli were detected in 11% of patients. They were present in 17% of group 1, 10% of group 2, and 0% of group 3 patients. Emboli were present in patients with mechanical prosthetic valves, carotid stenosis (> 70%), and mitral valve strands with a patent foramen ovale. Patients with microemboli more frequently had a history of cerebral ischemia compared with patients without microemboli (P < .05). They also more frequently had recent (< 3 months) symptoms compared with patients without microemboli (P < .05). In patients with a cardiac source of embolization, the number of microemboli detected was directly proportional to the acuity of previous symptoms.. These data suggest that TCD-detected microemboli are associated with an increased prevalence of prior cerebrovascular ischemia. The presence of TCD-detected microemboli could be a risk factor for cerebrovascular ischemia.

Topics: Acute Disease; Aged; Atrial Fibrillation; Brain Ischemia; Carotid Stenosis; Cerebrovascular Disorders; Female; Fibrinolytic Agents; Heart Diseases; Heart Failure; Heart Septal Defects, Atrial; Heart Valve Diseases; Heart Valve Prosthesis; Heparin; Humans; Intracranial Embolism and Thrombosis; Ischemic Attack, Transient; Male; Mitral Valve; Myocardial Infarction; Risk Factors; Thrombosis; Ultrasonography, Doppler, Transcranial; Warfarin

We sought to validate the safety of transesophageal echocardiographically guided early cardioversion in conjunction with short-term anticoagulation as a strategy for guiding early cardioversion in hospitalized patients with atrial fibrillation.. Because atrial thrombi are poorly seen by conventional imaging techniques, several weeks of prophylactic anticoagulation is routinely prescribed before cardioversion. Transesophageal echocardiography is a superior test for identifying atrial thrombi; preliminary feasibility studies have supported its use to guide early cardioversion for patients in whom no thrombus is observed, but safety has not been validated in any large series.. All patients admitted to hospital with atrial fibrillation during a 4.5-year period were screened. The inclusion criterion was a clinical duration of atrial fibrillation > 2 days or of unknown duration. Patients received anticoagulation with heparin/warfarin and underwent conventional transthoracic echocardiography followed by transesophageal study. Patients in whom transesophageal echocardiography revealed no atrial thrombus underwent pharmacologic or electrical cardioversion followed by warfarin therapy for 1 month. Cardioversion was deferred in patients with evidence of atrial thrombi, and they received prolonged warfarin treatment.. Two hundred thirty-three patients (86% of those eligible) agreed to participate, and 230 underwent transesophageal echocardiography. Transesophageal echocardiography identified 40 atrial thrombi (left atrium 34, right atrium 6) in 34 patients (15%). One hundred eighty-six (95%) of 196 patients without thrombi had successful cardioversion to sinus rhythm, all without prolonged anticoagulation, and none (0%, 95% confidence interval 0% to 1.6%) experienced a clinical thromboembolic event. Eighteen patients with atrial thrombi underwent uneventful cardioversion after prolonged anticoagulation.. Compared with smaller series that have shown only feasibility, this large prospective and consecutive study of patients undergoing transesophageal echocardiographically facilitated early cardioversion in conjunction with short-term anticoagulation validates the safety of this strategy. This treatment algorithm has a safety profile similar to conventional therapy and minimizes both the period of anticoagulation and the overall duration of atrial fibrillation.

Topics: Adult; Aged; Aged, 80 and over; Analysis of Variance; Atrial Fibrillation; Echocardiography, Transesophageal; Electric Countershock; Female; Heart Atria; Heart Diseases; Heparin; Humans; Male; Middle Aged; Predictive Value of Tests; Prospective Studies; Risk Factors; Sensitivity and Specificity; Thromboembolism; Warfarin

Topics: Aged; Atrial Fibrillation; Cost-Benefit Analysis; Echocardiography, Transesophageal; Electric Countershock; Heart Atria; Heart Diseases; Humans; Sensitivity and Specificity; Technology Assessment, Biomedical; Thromboembolism; Warfarin

An increased referral of patients with anticoagulation related haemorrhages necessitated an analysis of causes and outcome of these complications in a patient group that reflected Swedish therapeutic traditions of anticoagulation treatment. Prospectively, all patients from Stockholm evaluated for warfarin related intracranial haemorrhage occurring during 1987 were analysed and their 6 month outcome recorded. Sixty-eight patients were included. The results of intracranial haemorrhagic complications were catastrophic with a 77% mortality rate. Their incidence was much higher than expected. Forty-one patients had non-traumatic intracerebral haematomas, 1 had a non-traumatic subarachnoid haemorrhage and 26 had traumatic injuries. In the 42 patients with non-traumatic haemorrhages, the indications for anticoagulation were cerebral ischaemic events in a majority (27/42). The remaining 15 patients had different indications for anticoagulation. They also had an increased frequency of hypertension (p < 0.05). In the 26 patients with traumatic haematomas, only 6/26 patients had previous cerebral ischaemic injuries (p < 0.01). Valvular heart prosthesis was their most common indication (11/26) for anticoagulation. Caution in instituting anticoagulation therapy in patients with hypertension or cerebrovascular disease, which is an important indication for anticoagulation in Sweden, is mandatory. Adherence to strict treatment regimens and their continuous reevaluation may help to avoid complications. The finding of more patients than expected with haemorrhagic complications is not compatible with the risk evaluations used to justify anticoagulation therapy in the patient groups studied. Clinical practice must have changed with time, showing that risk evaluations from controlled trials or retrospectively collected clinical data from selected patients are not necessarily applicable for long-term clinical practice.

Topics: Adult; Aged; Brain; Cerebral Hemorrhage; Female; Heart Diseases; Heart Valve Prosthesis; Humans; Male; Prospective Studies; Survival Rate; Sweden; Warfarin

We report a case of left ventricular thrombus which caused systemic embolism during warfarin therapy. A 66-year-old man admitted to our hospital with intermittent loss of consciousness and incomplete palsy. The patient had a past history of cerebral infarction, hypertension and diabetes mellitus. Electrocardiography showed abnormal Q waves at II, III, and aVF. Echocardiography showed a mobile protruding thrombus at the left ventricular apex. Left ventricular cineangiography showed a filling defect at the left ventricle. Coronary angiography confirmed total occlusion of the right coronary artery and significant stenosis of the left coronary artery. After administration of warfarin, the patient suddenly fell down to the comatose state. His left arm became pale without pulsation. The thrombus in the left ventricle disappeared by echocardiography and systemic embolism was suspected. Thromboembolectomy from his left arm was performed. Two weeks after the day brain computed tomography showed low density area at the posterior lobe of the cerebrum. Although the eyesight of the patient was lost, he could stand and walk with some help two months later. This is a rare case of systemic embolism during warfarin therapy due to left ventricular thrombus whose process was constantly observed by echocardiography.

Topics: Aged; Anticoagulants; Echocardiography; Embolectomy; Heart Diseases; Heart Ventricles; Heparin; Humans; Intracranial Embolism and Thrombosis; Male; Thrombosis; Warfarin

All patients (285) undergoing mitral valve replacement (MVR) with a Carpentier-Edwards (C-E) bioprosthesis +/- coronary bypass grafts (CABG) were reviewed (109 men and 176 women with a median age of 70 years). Overall, the 5-year survival rate was 58.9%, 62.7% for MVR (199 patients) and 50.1% for MVR+CABG (86 patients). Late survival was adversely affected by the operative time variables of NYHA class IV, older (> or = 70 years) age, low (> or = 56%) ejection fraction (EF), and the additional performance of associated procedures+CABG with MVR (P < or = 0.001). The 5-year freedom from stroke rate was 89.2%, 89.1% for MVR and 90.2% for MVR +/- CABG. Advanced heart class was the only significant variable associated with a greater risk of late stroke (P < or = 0.01). Neither chronic preoperative atrial fibrillation nor operative obliteration of the left atrial appendage increased or decreased the late risk of stroke in patients following MVR. Hazard function for stroke occurring in the first postoperative year (first 48 h excluded to discount intraoperative events) demonstrated the highest rate within the first month (40%), rapidly diminishing thereafter. This pattern was reproduced in the 12-year hazard function in that the rate of stroke occurrence was greatest in the first year (6.7%) following implantation. The mean stroke rate over 12 years was 2.5%. Strokes following MVR +/- CABG are more likely to occur in older and more compromised patients, and the higher early rate is not reflected in the mean rate. A more aggressive approach to early anticoagulation with IV heparin, Coumadin, and possibly antiplatelet therapy is advocated to reduce this complication rate.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Bioprosthesis; Cerebrovascular Disorders; Child; Child, Preschool; Chronic Disease; Cohort Studies; Coronary Artery Bypass; Disease-Free Survival; Female; Follow-Up Studies; Heart Diseases; Heart Valve Prosthesis; Heparin; Humans; Intraoperative Complications; Male; Middle Aged; Mitral Valve; Platelet Aggregation Inhibitors; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk Factors; Stroke Volume; Survival Rate; Warfarin

Topics: Catheterization; Diagnosis, Differential; Echocardiography, Transesophageal; Female; Heart Diseases; Humans; Middle Aged; Mitral Valve Stenosis; Thrombosis; Warfarin

A patient with biventricular thrombus formation in dilated cardiomyopathy suffered massive combined systemic and pulmonary embolization shortly after oral anticoagulation was started. Although this can be coincidental, it can also suggest that the basis of a thrombus may dissolve first with any, including oral, anticoagulation. In unusual conditions surgical removal of thrombi in dilated cardiomyopathy may be a safer alternative.

Topics: Adult; Cardiomyopathy, Dilated; Embolism; Female; Heart Diseases; Humans; Pulmonary Embolism; Thrombosis; Warfarin

Paradoxical embolism through a patent foramen ovale is a recognized cause of stroke, but clinical predictors, recurrence rate, and prevention of brain infarcts in patients with patent foramen ovale have not been determined. We reviewed transesophageal echocardiographic records to ascertain echocardiographic predictors and optimal prophylaxis for patent foramen ovale-related infarcts.. A patent foramen ovale was identified in 74 patients during 615 transesophageal echocardiograms by color Doppler or saline contrast during a 60-month period. On the basis of final clinical situation, the patients were divided into the following groups: group 1, infarct with patent foramen ovale a likely cause (n = 16); group 2, infarct with patent foramen ovale an unlikely cause (n = 23); and group 3, no infarct (n = 35). Transesophageal echocardiograms were reviewed to assess patent foramen ovale characteristics and associated cardio-embolic sources without knowledge of clinical details or group assignment. Follow-up after a patent foramen ovale-related infarct was obtained by telephone or written correspondence in 15 of 16 group 1 patients.. Atrial septal aneurysms were more common in group 1 (38%) compared with group 2 (10%) and group 3 (8%) (P = .02). Contrast right-to-left shunting occurred in 88% of group 1 (P = .06) and 86% of group 2 (P = .07) compared with 60% of group 3. Prevention of recurrence in subjects with presumed patent foramen ovale-related brain infarcts varied. Aspirin was usually chosen after initial brain ischemia. Warfarin and patent foramen ovale closure were usually reserved for subjects with symptoms of brain ischemia while taking aspirin or those who required warfarin or cardiac surgery for other indications. No recurrent infarcts occurred in 15 patients during a mean follow-up period of 28 months.. Atrial septal aneurysm and right-to-left shunt may be predictive of a patent foramen ovale that predisposes a patient to stroke. Aspirin may provide sufficient infarct prophylaxis after initial ischemia. Warfarin and surgical correction should likely be reserved for those in whom aspirin is not effective or those who require warfarin or cardiac surgery for other reasons until prospective studies are available.

Topics: Adult; Aged; Aspirin; Cerebral Infarction; Cerebrovascular Disorders; Echocardiography, Transesophageal; Embolism; Female; Heart Aneurysm; Heart Diseases; Heart Septal Defects, Atrial; Heart Septum; Humans; Male; Middle Aged; Recurrence; Warfarin

Topics: Aged; Carotid Arteries; Cerebrovascular Disorders; Endarterectomy; Epidemiologic Methods; Female; Heart Diseases; Humans; Hypertension; Male; Middle Aged; Risk Factors; Smoking; Survival Analysis; Warfarin

Transesophageal echocardiography (TEE) improves the diagnostic accuracy of transthoracic echocardiography in the identification of potential cardiac sources of embolus. However, there are few studies of the impact of TEE on the medical management of patients with focal cerebral ischemia. The records of 52 consecutive, hospitalized patients undergoing both TEE and transthoracic echocardiography for suspected cardiac source of embolus were reviewed to determine the influence of TEE on the decision to anticoagulate patients. Of 52 patients, 39 had focal cerebral ischemia (transient ischemic attack, n = 9; acute cerebral infarction, n = 30). In 4 of these 39 patients (10%), the TEE results changed the management of anticoagulation. In 19 of 39 patients (49%), the TEE results helped confirm anticoagulation decisions, and in 16 (41%), the results had no effect on anticoagulation decisions, because of overriding clinical information. Ten of the latter 16 patients had TEE evidence for a possible source of an embolus, but were not anticoagulated; 5 of these were poor candidates for long-term anticoagulation, and the others had right-to-left shunting across a patent foramen ovale or an interatrial septal aneurysm. Clinical variables (atrial fibrillation, TEE findings and pre-TEE anticoagulation status) were considered as possible predictors of post-TEE anticoagulation status using logistic regression analysis; the strongest predictor of post-TEE anticoagulation status was pre-TEE anticoagulation status (p < 0.0005). Despite the selection of patients presumed to receive maximal benefit from TEE, this study suggests that TEE findings are not predictive of subsequent anticoagulation management. However, TEE is at least confirmatory of anticoagulation decisions in most cases.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Cerebral Infarction; Decision Making; Diagnostic Imaging; Echocardiography; Echocardiography, Transesophageal; Female; Forecasting; Heart Diseases; Heparin; Humans; Intracranial Embolism and Thrombosis; Ischemic Attack, Transient; Male; Middle Aged; Thrombosis; Warfarin

In a prospective non-randomized study, 229 patients with a verified first acute anterior myocardial infarction (AAMI) underwent echocardiography before discharge in order to study left ventricular (LV) thrombus formation. Antithrombotic therapy was given according to the routine of each centre. Patients receiving high-dose heparin had few LV thrombi, irrespective of warfarin therapy (6/32 vs 3/25, P ns). In patients not given heparin, however, a significantly higher prevalence of LV thrombi was found in a subgroup of patients treated with warfarin as compared to those who did not receive warfarin (8/13 vs 17/68, P 0.02). A similar, but non-significant difference was observed in patients given low-dose heparin (42% vs 27%, P ns). Within the non-heparin and low-dose heparin groups, age, infarct size, occurrence of Q-wave infarction, congestive heart failure and LV wall motion impairment did not differ between those treated or not treated with warfarin. In conclusion, high-dose heparin seems effective in the prevention of LV thrombosis irrespective of warfarin therapy after AAMI. The start of warfarin therapy in patients not receiving heparin was, however, associated with an increased prevalence of LV thrombosis.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Aspirin; Dose-Response Relationship, Drug; Drug Therapy, Combination; Echocardiography; Female; Heart Diseases; Heparin; Humans; Male; Middle Aged; Myocardial Infarction; Prospective Studies; Thrombosis; Ventricular Function, Left; Warfarin

We describe the unusual evolution of a left ventricular thrombus following acute anterior myocardial infarction despite adequate anticoagulation. Serial echocardiographic examinations demonstrated the evolution from swirling in the left ventricle through a solid apical mass gradually dislodging into a mobile, pedunculated mass that was removed surgically to prevent embolization. This report emphasizes the need to follow echocardiographically left ventricular thrombi during treatment with anticoagulants, and to identify morphologic changes that may predict embolization. This case suggests that left ventricular thrombectomy should be considered in selected patients in whom a very high-risk thrombus morphology is detected.

Topics: Anticoagulants; Echocardiography; Heart Diseases; Heart Ventricles; Heparin; Humans; Male; Middle Aged; Myocardial Infarction; Streptokinase; Thrombolytic Therapy; Thrombosis; Warfarin

Serum level of vitamin K1 (= phylloquinone, hereinafter K1) and K dependent blood coagulation factors were determined by HPLC in normal subject, liver cirrhosis, hepatocellular carcinoma, acute hepatitis, chronic hepatitis, chronic renal failure with hemodialysis and patients under warfarin therapy. Normal range of serum K1 concentration was decided on 0.20-2.30 (0.87 +/- 0.53, n = 96) ng/ml. Serum K1 level showed no significant differences among normal subject, various diseases and warfarin therapy. Correlation between serum K1 level and F-VII (r = 0.879, p less than 0.001) or protein C activity (r = 0.839, p less than 0.01) was found in patients whose thrombotest was 20% and less. However serum K1 level didn't correlate with any K dependent coagulation factors in patients if thrombotest was over 20%.

Topics: Adolescent; Adult; Blood Coagulation Factors; Female; Heart Diseases; Humans; Kidney Failure, Chronic; Liver Diseases; Male; Protein C; Vitamin K 1; Warfarin

A case of rheumatic heart disease, mitral stenosis, large left atrium, and chronic atrial fibrillation is reported and discussed. This patient was shown, by means of two-dimensional echocardiography, to have a massive left atrial thrombus, and after the initiation of anticoagulation with warfarin, complete resolution of the clot was seen in less than two months. The use of two-dimensional echocardiography was valuable in the follow-up of this patient, and it is suggested that further prospective studies are necessary for better understanding the natural history of left atrial thrombus.

Topics: Aged; Atrial Fibrillation; Chronic Disease; Echocardiography; Female; Heart Atria; Heart Diseases; Humans; Mitral Valve Stenosis; Remission Induction; Thrombosis; Warfarin

Left atrial (LA) thrombi sometimes occur in patients with mitral stenosis (MS) and the systemic embolization due to thrombi causes a serious, occasionally fatal complication. Several clinical techniques have been used to estimate the presence of LA thrombi. However, the hitherto available methods, even an echocardiography which has been most widely used, still have some drawbacks, depending on the size and location of thrombi. The author measured D-dimer, fibrinopeptide A (FPA) and thrombin-antithrombin III complex (TAT) in the patients with MS and evaluated the diagnostic value of these molecular markers to estimate the presence of LA thrombi. Twenty six patients with MS who had undergone cardiac operation were studied. Atrial fibrillation was found in all the patients. Episode of obvious thromboembolic diseases is a criteria of exclusion. Blood was drawn from the brachial vein several days (3 +/- 1 days: mean +/- SD) before the operation. The presence or absence of thrombus was confirmed at the surgery in all the cases. 1) Both levels of D-dimer and TAT were significantly higher in the patients with thrombi than those in the patients without thrombus or those in normal controls (mean: 378, 93 and 64 ng/ml, respectively; p less than 0.01 for both and 9.1, 2.0 and 1.7 ng/ml, respectively; p less than 0.01 for both). However, levels of FPA were not significantly different among the three groups (mean: 7.9, 4.9 and 3.7 ng/ml, respectively; NS for both). 2) both levels of D-dimer and TAT were significantly correlated with the weights of LA thrombus (r = 0.87, p less than 0.01: r = 0.79, p less than 0.01, respectively). 3) LA thrombi (ca. greater than or equal to 2 g) were always confirmed at the surgery in the patients who had levels of D-dimer higher than 200 ng/ml and/or TAT higher than 4 ng/ml. The plasma levels of D-dimer and TAT were further followed after the surgery in the same 18 patients (8 patients who had thrombus, the rest who didn't). 1) In the patients who had thrombi, levels of D-dimer were significantly decreased after the surgery (mean: from 267 ng/ml to 73 ng/ml, p less than 0.05). Levels of TAT were slightly but not significantly decreased (mean: from 82 ng/ml to 76 ng/ml, NS).(ABSTRACT TRUNCATED AT 400 WORDS)

Topics: Aged; Antithrombin III; Female; Fibrin Fibrinogen Degradation Products; Fibrinopeptide A; Heart Atria; Heart Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve Stenosis; Peptide Hydrolases; Thrombosis; Warfarin

Topics: Adult; Cardiomyopathy, Dilated; Echocardiography; Heart Diseases; Heparin; Humans; Male; Thrombosis; Time Factors; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Blood Coagulation; Cardiomyopathy, Dilated; Coronary Disease; Heart Diseases; Heparin; Humans; Platelet Aggregation Inhibitors; Thromboembolism; Warfarin

Topics: Adult; Echocardiography; Female; Heart Atria; Heart Diseases; Humans; Middle Aged; Mitral Valve Stenosis; Thrombosis; Time Factors; Warfarin

A man with congestive heart failure, atrial fibrillation and increasing dyspnoea on exertion was shown to have a large right atrial thrombus and multiple pulmonary emboli. The patient was anticoagulated and a subsequent echocardiogram showed that the thrombus was no longer present. This report demonstrates the need for echocardiography in patients presenting with pulmonary emboli and questions the value of anticoagulation in patients with intracavitary thrombi.

Topics: Aged; Echocardiography; Heart Atria; Heart Diseases; Humans; Male; Pulmonary Embolism; Thrombosis; Warfarin

A case of mitral stenosis with left atrial thrombus which rapidly arose and reduced within a month was reported. A 61-year-old female was admitted to our hospital on November 14, 1986 because of a syncopal attack due to ventricular tachycardia. On admission she had typical auscultatory signs of mitral stenosis, mild hepatomegaly and no neurological abnormality. Laboratory findings included coagulation studies were normal, and atrial fibrillation was noted on ECG. Heart catheterization revealed low cardiac output, the mitral orifice area to be 2.4 cm2 and left ventriculography showed mild mitral regurgitation. Ventricular tachycardia was controlled following improvement of heart failure. On two-dimensional echocardiography performed on December 24, left atrial thrombus was revealed which was not detected on December 3. Through the continuous administration of warfarin and aspirin to prevent the thrombus' growth, it markedly reduced in size, from 3 x 2 x 4.5 cm on December 24, 1986 to 1.5 x 1 x 2.5 cm on January 30, 1987 without systemic embolism. Then a mitral valve replacement and a left atrial thrombectomy were performed on February 3, with the removal of a red thrombus, partially organized, measuring 1 x 0.7 x 2.5 cm. This case is unique in its clinical outcome and further investigation is necessary for the management of patients as our case.

Topics: Aspirin; Female; Heart Atria; Heart Diseases; Humans; Middle Aged; Mitral Valve Stenosis; Thrombosis; Ultrasonography; Warfarin

The diagnostic and therapeutic approach to the problem of mural thrombi after acute myocardial infarction is uncertain. It is clear that the main therapeutic goal is the prevention of embolic strokes. Although it is known that the incidence of thrombi is greatest after anterior wall infarctions, there is uncertainty concerning (1) the probability of a mural thrombus; (2) the sensitivity and specificity of echocardiography in making the diagnosis; (3) the probability that a thrombus will embolize and result in a cerebrovascular accident (CVA); (4) the efficacy of warfarin in preventing embolization; and (5) the probability of bleeding with and without warfarin. To study this problem in patients who have had an anterior wall myocardial infarction, a model was created in which reasonable estimates for the unknown parameters were determined from published medical studies. The model was designed to consider patients if they were or were not treated during the initial hospitalization with heparin. The probability of thrombus was estimated at 0.30, sensitivity and specificity of echocardiography at 0.85 and 0.85, probability that a thrombus will embolize at 0.15, efficacy of anticoagulation of 0.75, probability of bleeding with warfarin at 0.03 and probability of bleeding without warfarin at 0.005. Probabilities of a CVA and of bleeding with and without warfarin were determined if all patients were anticoagulated, if patients with positive echocardiographic results were treated, if patients with negative echocardiographic results were treated and if echocardiographically guided therapy was instituted in which patients with positive echocardiographic results are treated and patients with negative results are not treated.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Decision Support Techniques; Echocardiography; Heart Diseases; Heparin; Humans; Intracranial Embolism and Thrombosis; Myocardial Infarction; Thrombosis; Warfarin

Topics: Adult; Catheterization; Echocardiography; Female; Heart Diseases; Humans; Middle Aged; Mitral Valve Stenosis; Thrombosis; Warfarin

We examined hematological complications in 415 patients having valve replacement with the St. Jude mechanical prosthesis (212, aortic valve replacement [AVR]; 159, mitral valve replacement [MVR]; and 44, AVR + MVR). There were 164 men and 251 women with a mean age of 59 years (range, 20 to 88 years). Preoperatively 386 patients were in New York Heart Association functional classes III and IV. There were 154 associated procedures (37%), the most common being myocardial revascularization. Overall hospital mortality was 7.5% (31/415), 7% after AVR, 8% after MVR, and 7% after AVR + MVR. All operative survivors were anticoagulated with Coumadin (crystalline warfarin sodium) to maintain the prothrombin time at 1.5 times control. During a mean follow-up of 21 months (range, 6 to 60 months), there were 29 late deaths (7.6%) and 5 patients (1.3%) lost to follow-up. No patient experienced structural valve degeneration. At 48 months, actuarial freedom from thromboembolism was 87% +/- 3% after AVR and 91% +/- 9% after MVR; from anticoagulation-related hemorrhage, 97% +/- 3% after AVR and 91% +/- 3% after MVR; and from hemolysis, 100% after AVR and 98% +/- 2% after MVR. Freedom from all valve-related morbidity at 4 years was 82% +/- 5% after AVR and 75% +/- 10% after MVR. Actuarial survival at 48 months was 80% +/- 4% after AVR and 65% +/- 7% after MVR.

Topics: Adult; Aged; Aged, 80 and over; Aortic Valve; Drug Administration Schedule; Female; Follow-Up Studies; Heart Diseases; Heart Valve Prosthesis; Hematologic Diseases; Hemolysis; Hemorrhage; Humans; Male; Middle Aged; Mitral Valve; Thromboembolism; Warfarin

This study evaluated the influence of thrombolysis followed by full anticoagulation on the frequency of left ventricular (LV) thrombi after acute myocardial infarction (AMI). Nineteen consecutive patients with a first anterior wall AMI who received 1,500,000 IU of streptokinase within 3 hours of symptom onset, followed by full anticoagulation, underwent echocardiographic studies within 24 hours of symptoms, and then on days 2, 3, 5, 7, 12, 30 and 90. Forty-four patients, with comparable clinical features and echocardiographic protocol but without antithrombotic therapy, served as the control group. LV thrombi developed in 4 of 19 (21%) treated patients and in 23 of 44 (52%) control subjects (p = 0.02). LV aneurysm or major wall motion abnormalities were noted in 8 of 19 (42%) treated patients and in 30 of 44 (68%) control subjects (p less than 0.05). No significant difference was found between treated and untreated patients when comparing the incidence of thrombi in the subgroups of patients with aneurysm or major wall motion abnormalities (3 of 8 vs 21 of 30) and in the subgroups with less extensive LV dysfunction. Thrombi disappeared during hospitalization in 3 of 4 treated patients, but in none of the controls. Fewer patients treated with intravenous streptokinase followed by full anticoagulation developed LV thrombi compared to patients treated with conventional therapy. This difference may be related to a reduced occurrence of major LV wall motion abnormalities. Resolution of thrombi frequently occurs in the hospital phase of AMI; therefore, only frequent echocardiographic examinations can assess the true frequency of LV thrombi.

Topics: Echocardiography; Female; Follow-Up Studies; Heart Diseases; Heparin; Humans; Male; Middle Aged; Myocardial Contraction; Myocardial Infarction; Streptokinase; Thrombosis; Warfarin

Heparin induced thrombocytopenia (HIT) is a relatively common complication of heparin therapy, occurring in approximately 5% of patients treated with this drug. HIT may be associated with diffuse arterial and venous thrombosis. The case of a patient without underlying heart disease who developed a right ventricular thrombus and recurrent pulmonary emboli in association with and possibly as a complication of HIT is reported. Ancrod was used as an alternative to heparin for the time required to obtain an effective oral anticoagulant effect. The patient recovered completely and has no residual right ventricular thrombus.

Topics: Adult; Ancrod; Echocardiography; Female; Heart Diseases; Heparin; Humans; Thrombocytopenia; Thrombosis; Warfarin

To determine whether two-dimensional echocardiography can identify patients with left ventricular thrombus after myocardial infarction who are prone to embolism, clinical and echocardiographic variables in 541 patients with a first infarction between 1979 and 1983 were studied prospectively. The first echocardiogram showed definite thrombus in 115 patients (Group 1, 21%) and no thrombus in 426 (Group 2, control). In Group 1, 27 patients (23%) had clinical evidence of systemic embolism related to the thrombus before referral (Group 1a) and 88 did not (Group 1b); these two groups were similar in age, gender and infarct location, but more Group 1a patients were within 1 month of the acute infarction. In both Groups 1a and 1b, the thrombus was found in apical views over asynergic zones, with no difference (p greater than 0.05) between the two groups in the size (average area from two views being 5.3 versus 4.5 cm2), type (protruding in apical views 30% versus 27%), location (apical 83% versus 86%; septal 11% versus 11%; posterior 4% versus 2%), extent of asynergy (31% versus 33%) and ejection fraction (33% versus 34%). However, the frequency of anticoagulant therapy was less (26% versus 63%, p less than 0.005), adjacent hyperkinesia greater (100% versus 49%, p less than 0.005) and thrombus mobility greater (81% versus 19%, p less than 0.005) in Group 1a than in Group 1b. Serial echocardiograms revealed a decreased size of the thrombus by 6 months in both Groups 1a and 1b, and little or no trace in 85% by 24 months. Thus, ventricular thrombus size, location and protrusion in apical views on echocardiography did not correlate with embolism. In contrast, thrombus mobility, the presence of adjacent hyperkinesia and thrombus protrusion assessed in multiple views appeared to be strong discriminators of thrombus prone to embolism. These echocardiographic features might provide a guide for the duration of anticoagulant therapy.

Topics: Adult; Aged; Echocardiography; Electrocardiography; Embolism; Female; Follow-Up Studies; Heart Diseases; Heparin; Humans; Male; Middle Aged; Myocardial Infarction; Prospective Studies; Thrombosis; Tomography, X-Ray Computed; Warfarin

Cardiac patients are often on drugs. They invariably benefit from a rehabilitation programme where they may be seen more frequently than in a routine follow-up clinic. Rehabilitation units must keep alert for drug-induced adverse effects or symptomatic deterioration, as well as the more usual psychological and physical benefits they induce.

Topics: Adrenergic beta-Antagonists; Anti-Arrhythmia Agents; Calcium Channel Blockers; Cardiovascular Agents; Digoxin; Diuretics; Heart Diseases; Humans; Nitrates; Warfarin

Topics: Breast Neoplasms; Echocardiography; Female; Heart Atria; Heart Diseases; Humans; Middle Aged; Thrombosis; Warfarin

Twenty patients in whom intracardiac thrombi were detected by indium-111 platelet scintigraphy (the first platelet scintigraphy) were prospectively studied to examine the effect of warfarin therapy under full dose on the intracardiac thrombogenicity. Eleven patients (group I) who received 2-6 mg/day of warfarin and 9 patients (group II) who did not receive warfarin had the second platelet scintigraphies 14-71 days after the first platelet scintigraphies. In group I, 10 platelet scintigraphies became negative and one remained positive for intracardiac thrombi after administration of warfarin, while in group II 8 platelet scintigraphies remained positive and only one changed to negative. The incidence of negative image at the second platelet scintigraphy was significantly lower in group II than that in group I. In group I, the degree of accumulation of platelets onto the surface of the thrombus (%IE), showed significant reduction (0.69 +/- 0.48 to 0.11 +/- 0.21) after warfarin therapy, while in group II %IE at the second scintigraphy (1.07 +/- 1.03) were not significantly different from those at the first scintigraphy (1.13 +/- 0.79). These results indicated that warfarin therapy under full dose inhibited the deposition of platelets on the intracardiac thrombi and thrombogenicity in the patients with intracardiac thrombi which were detected by indium-111 platelet scintigraphy.

Topics: Adult; Aged; Blood Platelets; Drug Evaluation; Female; Heart; Heart Diseases; Humans; Indium Radioisotopes; Male; Middle Aged; Prospective Studies; Prothrombin Time; Radionuclide Imaging; Thrombosis; Warfarin

Although left ventricular thrombi are associated with an increased embolic risk in the first few weeks after acute myocardial infarction, the long-term risk remains undefined. To ascertain the incidence of strictly defined systemic emboli, we followed 85 patients with echocardiographically documented left ventricular thrombi. At the time of the entry echocardiogram, most patients (n = 57) had remote myocardial infarction, while 19 had recent (less than 1 month) infarction, and nine had idiopathic cardiomyopathy. Because of the difficulty in classifying events as embolic in patients with advanced atherosclerosis, a matched control group of 91 patients without thrombi was also studied. The thrombus and control groups were similar with regard to recent myocardial infarction, remote infarction, anterior infarction, ejection fraction, atrial fibrillation, echocardiographic referral for source of emboli, and warfarin therapy. During a mean follow-up of 22 months after echocardiography, embolic events occurred in 13% (11 of 85) of patients with thrombi compared with 2% (two of 91) control patients (p less than .01). The actuarial probability of being embolus free at 2 years after echocardiography was 86% in patients with thrombi compared with 97% in control patients (p less than .01). All embolic events occurred greater than 1 month after myocardial infarction (range 1 to 96 months). The only clinical or echocardiographic features predictive of embolization were protrusion and mobility of thrombus (both p less than .02). We conclude that the incidence of embolic events is definitely increased in patients with left ventricular thrombi compared with control subjects during long-term follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Echocardiography; Embolism; Follow-Up Studies; Heart Diseases; Humans; Middle Aged; Prospective Studies; Risk; Thrombosis; Time Factors; Warfarin

A patient with a right atrial thrombus and recurrent pulmonary emboli secondary to permanent pacemaker insertion is described. Possible precipitating factors were damage to the subclavian vein, congestive heart failure, paroxysmal atrial fibrillation, and immobilization. Venography demonstrated a large atrial thrombus in the superior vena cava and right atrium. The patient was successfully treated with heparin and subsequently with warfarin and dipyridamole.

Topics: Aged; Aged, 80 and over; Dipyridamole; Female; Heart Atria; Heart Diseases; Heparin; Humans; Pacemaker, Artificial; Pulmonary Embolism; Recurrence; Thrombosis; Warfarin

Topics: Adult; Echocardiography; Heart Diseases; Heparin; Humans; Male; Myocardial Infarction; Thrombosis; Warfarin

Five patients with pulmonary embolism, in whom right-sided intracardiac thromboembolus was detected by echocardiography and confirmed by either angiography, surgery or postmortem examination, are described. One of these patients died from massive pulmonary embolism after right heart catheterization. In two patients treated medically, either partial or total lysis of the thromboembolus was demonstrated echocardiographically; in another two patients, the right atrial thromboembolus was successfully removed surgically. Typical locations and echocardiographic characteristics of right-sided thromboemboli are described. The potential usefulness of two-dimensional echocardiography in both the diagnosis and the management of patients with right-sided intracardiac thromboembolism is discussed.

Topics: Adolescent; Adult; Aged; Cardiac Catheterization; Echocardiography; Heart Atria; Heart Diseases; Heparin; Humans; Male; Pulmonary Embolism; Streptokinase; Thromboembolism; Warfarin

Topics: Administration, Oral; Adult; Blood Coagulation Tests; Female; Heart Diseases; Heparin; Humans; Male; Prothrombin Time; Thrombin Time; Thrombosis; Warfarin

Anticoagulant therapy has stood the test to time. Full-dose heparin and warfarin prevent recurring pulmonary embolism and deep venous thrombosis. Their use is indicated in patients who have experienced venous thromboembolism unless contraindications are compelling. Low-dose heparin is successful in preventing the initial episode of venous thrombosis in most patients at high risk for the development of thrombophlebitis. Warfarin reduces the incidence of systemic embolization in patients with heart disease and atrial fibrillation and in patients with artificial heart valves. Evidence is accumulating to suggest that warfarin may still retain an important role in the management of patients with myocardial infarction. However, bleeding remains an inevitable risk in patients receiving anticoagulant therapy. The risk, however, can be diminished when both the physician and patient understand the mechanism of action of the drugs and the factors that predispose to bleeding.

Topics: Heart Diseases; Heparin; Humans; Injections, Intravenous; Thromboembolism; Warfarin

Among 54 consecutive patients with acute nonseptic embolic brain infarction, there was CT evidence of hemorrhagic infarction in 1 patient (2%). None had clinical or CT evidence of massive brain hemorrhage even when anticoagulation therapy was used immediately. Seven patients (13%) had recurrent brain emboli, all within 7 days of the initial stroke. None of these patients was adequately anticoagulated at the time of recurrence. Immediate anticoagulation therapy should be employed after nonseptic embolic brain infarction if CT does not show hemorrhage and there is a persistent cardiac source of emboli.

Topics: Cerebral Hemorrhage; Cerebral Infarction; Female; Heart Diseases; Heparin; Humans; Intracranial Embolism and Thrombosis; Male; Middle Aged; Recurrence; Tomography, X-Ray Computed; Warfarin

A retrospective review of the hospital course of 44 patients with embolic cerebral infarction was carried out. Eleven patients (25%) suffered recurrent embolic infarction. Three of the recurrences were fatal. Two patients suffered a recurrence within 48 hours of the initial event, and an additional patient suffered a recurrence 6 days after the initial event. Sixteen embolic infarctions were managed with therapeutic anticoagulation within 48 hours without adverse effect. The clinical and experimental data concerning early anticoagulation after embolic infarction were reviewed. It appears that the risk of early anticoagulation is less than the risk of recurrent embolic infarction.

Topics: Adult; Aged; Cerebral Infarction; Female; Heart Diseases; Heparin; Humans; Male; Middle Aged; Recurrence; Warfarin

Topics: Abnormalities, Drug-Induced; Abortion, Therapeutic; Endocarditis, Bacterial; Female; Heart Diseases; Heart Failure; Heart Valve Prosthesis; Humans; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

The compliance to anticoagulants of a group of patients with prosthetic heart valves has been assessed in the present study. It was found that the level of compliance to these agents was of the order of 90%. Additional compliance data were generated in relation to cardiac drugs and diuretics, which were taken concurrently by the patients. Significant differences were noted between the three categories, the diuretics being the group for which compliance was least. It is postulated that the formal routine adopted by clinics managing patients on anticoagulants greatly enhances compliance with these drugs. The inconvenience of the mode of action of diuretics is no doubt a significant factor in the poor compliance found with them.

Topics: Adult; Aged; Anticoagulants; Antidepressive Agents; Antihypertensive Agents; Diuretics; Female; Heart Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Patient Compliance; Phenindione; Potassium; Warfarin

Topics: Anesthesia, Dental; Anesthesia, General; Anesthetics, Local; Anti-Bacterial Agents; Anticoagulants; Antihypertensive Agents; Cardiovascular Diseases; Dental Care; Endocarditis, Subacute Bacterial; Heart Diseases; Humans; Medical History Taking; Mouth; Nitroglycerin; Time Factors; Vasoconstrictor Agents; Warfarin

Patients with transient ischemic attacks (TIAs) due to atherosclerosis were studied by aortocranial arteriography. Onset of TIAs was before age 55 in 24% and between 55 and 64 in 47%. Men exceeded women by two to one. Of 160 patients, 77 were treated medically and 82 surgically. Five died in the immediate postoperative period. In the survivors, mortality has been the same in the medically and surgically managed groups. For patients with multiple lesions, surgical reconstruction of the carotid arteries was associated with very high surgical risk. In the medically treated group, anticoagulant therapy reduced the frequency of TIAs, but did not appear to protect patients from stroke. Mortality was 23% at four years, 57% of deaths being attributable to myocardial infarction and 38% to stroke.

Topics: Adult; Aged; Arteriosclerosis; Cerebrovascular Disorders; Diabetes Complications; Endarterectomy; Female; Follow-Up Studies; Heart Diseases; Humans; Hypertension; Ischemic Attack, Transient; Male; Middle Aged; Prognosis; Prospective Studies; Radiography; Risk; Warfarin

Topics: Aged; Drug Synergism; Heart Diseases; Humans; Male; Prothrombin Time; Pulmonary Embolism; Sulfisoxazole; Warfarin

A 56-year-old male patient diagnosed as a case of procainamide-induced systemic lupus erythematosus (SLE) was found to have a lymphoproliferative disorder at postmortem examination.Contrary to other immune disorders, the association of SLE with neoplasia is a rare occurrence. The present case raises the question of whether a relationship exists between the lupus diathesis and lymphoreticular neoplasia. The study of the incidence of neoplasia in families of patients with SLE may prove helpful in establishing this relationship.

Topics: Aortic Diseases; Autopsy; Blindness; Bone Marrow; Digoxin; Drug Therapy, Combination; Heart Diseases; Heparin; Humans; Immunologic Deficiency Syndromes; Kidney; Lupus Erythematosus, Systemic; Lymph Nodes; Lymphoma; Male; Middle Aged; Procainamide; Quinidine; Retinal Artery; Spleen; Thromboembolism; Warfarin

Topics: Acetohexamide; Adult; Agglutination; Angina Pectoris; Anticholesteremic Agents; Arteriosclerosis; Body Weight; Butyrates; Chlorpropamide; Cholesterol; Conjunctiva; Diabetes Complications; Diabetic Neuropathies; Diet, Reducing; Female; Heart Diseases; Humans; Hypercholesterolemia; Hyperlipidemias; Male; Middle Aged; Phenformin; Triglycerides; Warfarin; Xanthomatosis

Topics: Adult; Aged; Angiography; Female; Follow-Up Studies; Heart Diseases; Heparin; Humans; Male; Middle Aged; Pulmonary Embolism; Radionuclide Imaging; Thrombophlebitis; Warfarin

Topics: Anticoagulants; Cerebral Angiography; Cerebrovascular Disorders; Heart Diseases; Hematoma; Hematuria; Hemorrhage; Humans; Pulmonary Embolism; Retroperitoneal Space; Toxicology; Warfarin

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

Topics: Anticoagulants; Drug Therapy; Geriatrics; Heart Diseases; Warfarin

Topics: Anti-Arrhythmia Agents; Anticoagulants; Cardiology; Coumarins; Heart Diseases; Humans; Warfarin