warfarin and Hypertension

The main complications of elevated systemic blood pressure (BP), coronary heart disease, ischaemic stroke, and peripheral vascular disease, are related to thrombosis rather than haemorrhage. Therefore, it is important to investigate if antithrombotic therapy may be useful in preventing thrombosis-related complications in patients with elevated BP.. To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with elevated BP, including elevations in systolic or diastolic BP alone or together. To assess the effects of antiplatelet agents on total deaths or major thrombotic events or both in these patients versus placebo or other active treatment. To assess the effects of oral anticoagulants on total deaths or major thromboembolic events or both in these patients versus placebo or other active treatment.. The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to January 2021: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 12), Ovid MEDLINE (from 1946), and Ovid Embase (from 1974). The World Health Organization International Clinical Trials Registry Platform and the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) were searched for ongoing trials.  SELECTION CRITERIA: RCTs in patients with elevated BP were included if they were ≥ 3 months in duration and compared antithrombotic therapy with control or other active treatment.. Two review authors independently extracted data for inclusion criteria, our prespecified outcomes, and sources of bias. They assessed the risks and benefits of antiplatelet agents and anticoagulants by calculating odds ratios (OR), accompanied by the 95% confidence intervals (CI). They assessed risks of bias and applied GRADE criteria.  MAIN RESULTS: Six trials (61,015 patients) met the inclusion criteria and were included in this review. Four trials were primary prevention (41,695 patients; HOT, JPAD, JPPP, and TPT), and two secondary prevention (19,320 patients, CAPRIE and Huynh). Four trials (HOT, JPAD, JPPP, and TPT) were placebo-controlled and two studies (CAPRIE and Huynh) included active comparators. Four studies compared acetylsalicylic acid (ASA) versus placebo and found no evidence of a difference for all-cause mortality (OR 0.97, 95% CI 0.87 to 1.08; 3 studies, 35,794 participants; low-certainty evidence). We found no evidence of a difference for cardiovascular mortality (OR 0.98, 95% CI 0.82 to 1.17; 3 studies, 35,794 participants; low-certainty evidence). ASA reduced the risk of all non-fatal cardiovascular events (OR 0.63, 95% CI 0.45 to 0.87; 1 study (missing data in 3 studies), 2540 participants; low-certainty evidence) and the risk of all cardiovascular events (OR 0.86, 95% CI 0.77 to 0.96; 3 studies, 35,794 participants; low-certainty evidence). ASA increased the risk of major bleeding events (OR 1.77, 95% CI 1.34 to 2.32; 2 studies, 21,330 participants; high-certainty evidence). One study (CAPRIE; ASA versus clopidogrel) included patients diagnosed with hypertension (mean age 62.5 years, 72% males, 95% Caucasians, mean follow-up: 1.91 years). It showed no evidence of a difference for all-cause mortality (OR 1.02, 95% CI 0.91 to 1.15; 1 study, 19,143 participants; high-certainty evidence) and for cardiovascular mortality (OR 1.08, 95% CI 0.94 to 1.26; 1 study, 19,143 participants; high-certainty evidence). ASA probably reduced the risk of non-fatal cardiovascular events (OR 1.10, 95% CI 1.00 to 1.22; 1 study, 19,143 participants; high-certainty evidence) and the risk of all cardiovascular events (OR 1.08, 95% CI 1.00 to 1.17; 1 study, 19,143 participants; high-certainty evidence) when compared to clopidogrel. Clopidogrel increased the risk of major bleeding events when compared to ASA (OR 1.35, 95% CI 1.14 to 1.61; 1 study, 19,143 participants; high-certainty evidence). In one study (Huynh; ASA verus warfarin) patients with unstable angi

Topics: Aged; Anticoagulants; Aspirin; Clopidogrel; Fibrinolytic Agents; Hemorrhage; Humans; Hypertension; Middle Aged; Platelet Aggregation Inhibitors; Thromboembolism; Thrombosis; Warfarin

Ibrutinib is a new first-line drug for treating chronic lymphocytic leukemia (CLL), and could change frontline treatment of CLL from traditional IV chemotherapy to oral targeted therapy. Lymphocytosis often worsens with initiation of ibrutinib, but typically resolves over 6 to 18 months. Though patients generally tolerate ibrutinib well, the drug can cause adverse reactions including hypertension, atrial fibrillation, bleeding, and infections such as fungal pneumonia.

Topics: Adenine; Administration, Oral; Antineoplastic Agents; Atrial Fibrillation; Hemorrhage; Humans; Hypertension; Leukemia, Lymphocytic, Chronic, B-Cell; Lung Diseases, Fungal; Lymphocytosis; Piperidines; Warfarin

Topics: Atrial Fibrillation; Blood Pressure; Humans; Hypertension; Pyridines; Thiazoles; Warfarin

Topics: Asian People; Case-Control Studies; China; Cytochrome P450 Family 4; Female; Gene Frequency; Genetic Association Studies; Genetic Predisposition to Disease; Genotype; Haplotypes; Humans; Hypertension; Male; Odds Ratio; Polymorphism, Single Nucleotide; Promoter Regions, Genetic; Risk Factors; Sex Factors; Warfarin

The optimal antithrombotic therapy for atrial fibrillation (AF) patients undergoing coronary stenting is unknown. The present meta-analysis sought to investigate the efficacy and safety of triple therapy (TT; warfarin, clopidogrel and aspirin) vs dual antiplatelet therapy (DAPT; clopidogrel plus aspirin) in those patients.. PubMed and Cochrane Library were searched for studies enrolling AF patients undergoing coronary stenting on TT and DAPT up to September 2016, and fourteen studies were included. Efficacy outcomes included ischemic stroke, stent thrombosis, major adverse cardiovascular event (MACE), all-cause mortality and myocardial infarction (MI); safety outcome was major bleeding. We conducted meta-analysis and used odds ratio (OR) with 95% confidence intervals (CI) to compare TT and DAPT. Meta-regression, sensitivity and subgroup analysis were taken to investigate the source of heterogeneity in the outcome of major bleeding.. 14 eligible observational studies with 11,697 subjects were identified. Compared with DAPT, TT had decreased the risk of ischemic stroke [OR = 0.74, 95% CI (0.59, 0.93), P = 0.009] and stent thrombosis [OR = 0.40, 95% CI (0.18, 0.93), P = 0.033]. While, there was an increased risk of major bleeding [OR = 1.55, 95% CI (1.16, 2.09), P = 0.004] associated with TT. The risk of MACE, all-cause mortality and MI had no significant statistical difference between TT and DAPT. Furthermore, the results of univariate and multivariate meta-regression analysis implicated that there were no obvious correlations between certain baseline characteristics (age, gender, race, hypertension, study design) and risk of major bleeding. Also of major bleeding, the findings of sensitivity analysis were generally robust, and a prespecified subgroup analysis of race demonstrated that the source of heterogeneity might attribute to Asian studies mostly.. TT reduced the risk of ischemic stroke and stent thrombosis with an acceptable major bleeding risk compared with DAPT, and TT was considered as a valid alternative in AF patients undergoing coronary stenting. Further prospective randomized trials are needed to ensure the reliability of these data and find the optimal therapeutic strategy in this setting of patients.

Topics: Aspirin; Atrial Fibrillation; Clopidogrel; Drug Combinations; Drug-Related Side Effects and Adverse Reactions; Female; Fibrinolytic Agents; Hemorrhage; Humans; Hypertension; Male; Myocardial Infarction; Platelet Aggregation Inhibitors; Risk Factors; Stents; Stroke; Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Clinical Trials as Topic; Creatinine; Diabetes Complications; Drugs, Investigational; Europe; Female; Heart Failure; Hemorrhage; Humans; Hypertension; Myocardial Infarction; North America; Observational Studies as Topic; Pyrazoles; Pyridones; Registries; Renal Insufficiency, Chronic; Severity of Illness Index; Stroke; Tachycardia; Thrombophilia; Treatment Outcome; Warfarin

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

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

Chronic kidney disease and atrial fibrillation (AF) commonly coexist, and data suggest that renal patients have AF rates in excess of double that encountered in the general population. These patients are at increased risk of stroke, regardless of the presence or absence of AF. Furthermore, a lower GFR causes increased thromboembolic risk in patients with AF - independent of other risk factors. The dilemma facing clinicians treating this cohort of patients is that renal insufficiency confers both a thromboembolic and a bleeding risk. Renal disease also commonly coexists with other risk factors for stroke and bleeding such as hypertension and advanced age. Furthermore, bleeding risk tracks stroke risk and many risk factors are common to both thromboembolism and haemorrhage. Patients with severe renal impairment are also actively excluded from the majority of trials for stroke prevention in AF, including those trials which informed the development of stroke risk factor scoring schemes. Therefore, patients with renal disease and AF present a unique management challenge. The available data suggests that the benefit from warfarin in terms of stroke reduction is not as clear as in the general population, and there is an increased risk of bleeding complications and even ectopic vascular calcification. Thus, it is problematic to extrapolate the benefits of warfarin in the general population to a subgroup that has been actively excluded from clinical trials. The new oral anticoagulants have relatively little data in patients with severe renal impairment, and all have an element of renal excretion. There is a need for large randomised control trials in patients with renal insufficiency and on haemodialysis to provide a bank of high-quality scientific data on which clinicians can base their management decisions. Until then, we must adopt a pragmatic approach which involves careful consideration of the relative risk of stroke and bleeding in each individual patient.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Clinical Trials as Topic; Comorbidity; Dabigatran; Disease Management; Embolism; Female; Fibrinolytic Agents; Hemorrhage; Humans; Hypertension; Intracranial Embolism; Male; Morpholines; Patient Selection; Pyrazoles; Pyridones; Renal Insufficiency, Chronic; Risk; Risk Factors; Rivaroxaban; Severity of Illness Index; Stroke; Thiophenes; Thrombophilia; Warfarin

Warfarin is widely prescribed for patients with atrial fibrillation. In addition to unexpected bleeding, allergic skin reaction is one of its uncommon adverse effects. We herein report an 89-year-old man who, after taking warfarin for 4 years, suffered extensive skin eruptions. The skin biopsy disclosed leukocytoclastic vasculitis. The causal relationship between skin lesions and warfarin was confirmed after re-challenge of warfarin. A literature review revealed only 13 such cases reported from 1980 to 2011. Clinicians should be aware of this potential adverse effect of warfarin.

Topics: Acute Kidney Injury; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Coronary Disease; Drug Eruptions; Heart Failure; Humans; Hypertension; Male; Proteinuria; Taiwan; Thrombophilia; Vasculitis, Leukocytoclastic, Cutaneous; Warfarin

Atrial Fibrillation (AF) is the most common clinically significant sustained cardiac arrhythmia, and Hypertension (HTN) is the most common cardiovascular disorder. AF is a major risk factor for strokes whether it is symptomatic or silent. Recent publications have shed light on the role of antihypertensive regiments in prevention of AF, while others have provided data on the efficacy and safety of novel antiarrhythmic drugs such as dronedarone and vernakalant. The older CHADS(2) score and its more refined modern counterparts are well validated to determine stroke risk and guide antithrombotic therapy, but haemorrhagic risk has to be respected as well, and scores such as HAS-BLED should be widely used. Novel classes of anticoagulants that overcome many of the drawbacks of warfarin have been introduced with promising results and pose new questions that need to be answered in the near future.

Topics: Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Disease Progression; Fibrinolytic Agents; Humans; Hypertension; Renin-Angiotensin System; Risk Factors; Warfarin

To determine the strength of evidence supporting an accentuated bleeding risk when patients with CHADS(2) risk factors (chronic heart failure, hypertension, advanced age, diabetes, and prior stroke/transient ischemic attack) receive warfarin.. A systematic literature search of MEDLINE (January 1, 1950, through December 22, 2009) and Cochrane CENTRAL (through December 22, 2009) was conducted to identify studies that reported multivariate results on the association between CHADS(2) covariates and risk of bleeding in patients receiving warfarin. Each covariate was evaluated for its association with a specific type of bleeding. Individual evaluations were rated as good, fair, or poor using methods consistent with those recommended by the Agency for Healthcare Research and Quality. The strength of the associations between each CHADS(2) covariate and a specific type of bleeding was determined using Grading of Recommendations Assessment, Development and Evaluation criteria as insufficient, very low, low, moderate, or high for the entire body of evidence.. Forty-one studies were identified, reporting 127 multivariate evaluations of the association between a CHADS(2) covariate and bleeding risk. No CHADS(2) covariate had a high strength of evidence for association with any bleeding type. For the vast majority of evaluations, the strength of evidence between covariates and bleeding was low. Advanced age was the only covariate that had a moderate strength of evidence for association; this was the strongest independent positive predictor for major bleeding. Similar findings were observed regardless of whether all included studies, or only those evaluating patients with atrial fibrillation, were assessed.. The associations between CHADS(2) covariates and increased bleeding risk were weak, with the exception of age. Given the known association of the CHADS(2) score and stroke risk, the decision to prescribe warfarin should be driven more by patients' risk of stroke than by the risk of bleeding.

Topics: Aging; Anticoagulants; Atrial Fibrillation; Chronic Disease; Confounding Factors, Epidemiologic; Diabetes Complications; Heart Failure; Hemorrhage; Humans; Hypertension; Ischemic Attack, Transient; Observer Variation; Risk Factors; Stroke; Warfarin

Elevated systemic blood pressure results in high intravascular pressure but the main complications, coronary heart disease (CHD), ischaemic strokes and peripheral vascular disease (PVD), are related to thrombosis rather than haemorrhage. Some complications related to elevated blood pressure, heart failure or atrial fibrillation, are themselves associated with stroke and thromboembolism. Therefore it is important to investigate if antithrombotic therapy may be useful in preventing thrombosis-related complications in patients with elevated blood pressure.. To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with high blood pressure, including those with elevations in both systolic and diastolic blood pressure, isolated elevations of either systolic or diastolic blood pressure, to address the following hypotheses: (i) antiplatelet agents reduce total deaths and/or major thrombotic events when compared to placebo or other active treatment; and (ii) oral anticoagulants reduce total deaths and/or major thromboembolic events when compared to placebo or other active treatment.. Electronic databases (MEDLINE, EMBASE, DARE, CENTRAL, Hypertension Group specialised register) were searched up to January 2011. The reference lists of papers resulting from the electronic searches and abstracts from national and international cardiovascular meetings were hand-searched to identify missed or unpublished studies. Relevant authors of studies were contacted to obtain further data.. Randomised controlled trials (RCTs) in patients with elevated blood pressure were included if they were of at least 3 months in duration and compared antithrombotic therapy with control or other active treatment.. Data were independently collected and verified by two reviewers. Data from different trials were pooled where appropriate.. Four trials with a combined total of 44,012 patients met the inclusion criteria and are included in this review. Acetylsalicylic acid (ASA) did not reduce stroke or 'all cardiovascular events' compared to placebo in primary prevention patients with elevated blood pressure and no prior cardiovascular disease. In one large trial ASA taken for 5 years reduced myocardial infarction (ARR 0.5%, NNT 200), increased major haemorrhage (ARI 0.7%, NNT 154), and did not reduce all cause mortality or cardiovascular mortality. In one trial there was no significant difference between ASA and clopidogrel for the composite endpoint of stroke, myocardial infarction or vascular death. In two small trials warfarin alone or in combination with ASA did not reduce stroke or coronary events. The ATC meta-analysis of antiplatelet therapy for secondary prevention in patients with elevated blood pressure reported an absolute reduction in vascular events of 4.1% as compared to placebo. Data on the 10,600 patients with elevated blood pressure from the 29 individual trials included in the ATC meta-analysis was requested but could not be obtained.. Antiplatelet therapy with ASA for primary prevention in patients with elevated blood pressure provides a benefit, reduction in myocardial infarction, which is negated by a harm of similar magnitude, increase in major haemorrhage.The benefit of antiplatelet therapy for secondary prevention in patients with elevated blood pressure is many times greater than the harm.Benefit has not been demonstrated for warfarin therapy alone or in combination with aspirin in patients with elevated blood pressure. Ticlopidine, clopidogrel and newer antiplatelet agents such as prasugrel and ticagrelor have not been sufficiently evaluated in patients with high blood pressure. Newer antithrombotic oral drugs such as dabigatran, rivaroxaban, apixaban and endosaban are yet to be tested in patients with high blood pressure.Further trials of antithrombotic therapy including with newer agents and complete documentation of all benefits and harms are required in patients with elevated blood pressure.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Clopidogrel; Humans; Hypertension; Myocardial Infarction; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Thromboembolism; Ticlopidine; 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

Clinical trials during the past 20 years have revolutionized the antithrombotic management of atrial fibrillation. Based on consideration of 30 randomized trials involving 29,017 participants, adjusted-dose warfarin remains the most efficacious prophylaxis against stroke for atrial fibrillation patients at moderate-to-high risk (compared with antiplatelet agents, warfarin reduces stroke by about 40%). The optimal INR for prevention of stroke for most atrial fibrillation patients is probably 2.0-2.5; INRs of 1.6-1.9 provide substantial protection, 80-90% of that afforded by higher intensities. Warfarin-associated intracerebral hemorrhage is an increasing problem as more elderly patients with atrial fibrillation are anticoagulated. Modest reductions in blood pressure results in large decreases in this most dreaded complication of warfarin; anticoagulation of elderly atrial fibrillation patients should be accompanied by a firm commitment to control hypertension. Warfarin-associated intracerebral hemorrhage has a 50% early mortality. A wide range of acute treatments to urgently reverse anticoagulation have been recommended by experts, but prevention is a far better option than treatment of this devastating problem.

Topics: Anticoagulants; Atrial Fibrillation; Cerebral Hemorrhage; Humans; Hypertension; Stroke; Warfarin

Wider use of oral anticoagulants has led to an increasing frequency of warfarin-related intracerebral hemorrhage (ICH). The high early mortality of approximately 50% has remained stable in recent decades. In contrast to spontaneous ICH, the duration of bleeding is 12 to 24 hours in many patients, offering a longer opportunity for intervention. Treatment varies widely, and optimal therapy has yet to be defined. An OVID search was conducted from January 1996 to January 2006, combining the terms warfarin or anticoagulation with intracranial hemorrhage or intracerebral hemorrhage. Seven experts on clinical stroke, neurologic intensive care, and hematology were provided with the available information and were asked to independently address 3 clinical scenarios about acute reversal and resumption of anticoagulation in the setting of warfarin-associated ICH. No randomized trials assessing clinical outcomes were found on management of warfarin-associated ICH. All experts agreed that anticoagulation should be urgently reversed, but how to achieve it varied from use of prothrombin complex concentrates only (3 experts) to recombinant factor VIIa only (2 experts) to recombinant factor VIIa along with fresh frozen plasma (1 expert) and prothrombin complex concentrates or fresh frozen plasma (1 expert). All experts favored resumption of warfarin therapy within 3 to 10 days of ICH in stable patients in whom subsequent anticoagulation is mandatory. No general agreement occurred regarding subsequent anticoagulation of patients with atrial fibrillation who survived warfarin-associated ICH. For warfarin-associated ICH, discontinuing warfarin therapy with administration of vitamin K does not reverse the hemostatic defect for many hours and is inadequate. Reasonable management based on expert opinion includes a wide range of additional measures to reverse anticoagulation in the absence of solid evidence.

Topics: Anticoagulants; Blood Coagulation Factors; Cerebral Hemorrhage; Factor VII; Factor VIIa; Humans; Hypertension; Iatrogenic Disease; Plasma; Recombinant Proteins; Warfarin

As many as one in four patients over age 40 will develop atrial fibrillation (AF), a significant risk factor for stroke. Although most clinicians are aware of the benefits of antithrombotic therapy, especially warfarin, for prevention of stroke, current guidelines for selection of antithrombotic therapy are confusing and inconsistently applied. The CHADS2 risk-stratification scheme, based on a clinical history of heart failure, hypertension, age >75, diabetes, or prior stroke, is a useful clinical tool to identify patients likely to benefit from warfarin, distinguishing these patients from patients at lower risk for whom aspirin is sufficient. Risk factors for intracerebral hemorrhage include anticoagulation intensity, hypertension, age, and previous stroke or cerebrovascular disease. Cerebral amyloid angiopathy and leukoaraiosis identified by high-resolution brain imaging are under investigation, but better schemes for stratifying bleeding risk are needed. In the future, new anticoagulants that are safer and easier to administer than warfarin will improve the benefit/risk burden for elderly patients with AF.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Drug Evaluation; Drug Therapy, Combination; Female; Fibrinolytic Agents; Geriatrics; Humans; Hypertension; Male; Risk Assessment; Stroke; Warfarin

This is a review of stroke mechanisms and management. The concept of stroke and transient ischemic attack and the recently proposed revision in definitions and controversies are discussed. We also discuss the use of antiplatelet and anticoagulant drugs for stroke due to carotid and cardiac disease.

Topics: Anticoagulants; Chronic Disease; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypercholesterolemia; Hypertension; Kidney Diseases; Platelet Aggregation Inhibitors; Risk Factors; Stroke; Warfarin

The aim of this article was to describe (i) the epidemiology and outcomes of stroke relating to diabetes; (ii) the pathophysiology of diabetes as a risk factor for stroke; (iii) the management of acute stroke in patients with diabetes; (iv) the evidence of primary and secondary prevention of stroke in patients with diabetes; and (v) the risk of new-onset diabetes using older antihypertensive agents. The combination of diabetes and stroke disease is a major cause of morbidity and mortality worldwide. Evidence from large clinical trials performed in patients with diabetes supports the need for aggressive and early intervention to target patients' cardiovascular (CV) risks in order to prevent the onset, recurrence and progression of acute stroke. Identification of at-risk patients with diabetes and metabolic syndrome has also allowed the delivery of early and effective intervention to reduce stroke risks, while active treatment during the acute phase of stroke will reduce long-term neurological and functional deficits. While the ongoing debate on the risk benefits of different antihypertensive, lipid-lowering and antiplatelet agents should not detract clinicians from pursuing aggressive CV risk reduction, the application of evidence-based medicine specifically in patients with diabetes will facilitate the use of appropriate agents to improve clinical outcomes. The overall management of patients with diabetes and acute stroke or at risk of secondary stroke should also include multifactorial intervention that not only targets patient's CV risk but also includes behavioural, lifestyle and, where appropriate, surgical intervention.

Topics: Anticoagulants; Carotid Stenosis; Diabetic Angiopathies; Dyslipidemias; Endarterectomy, Carotid; Humans; Hyperglycemia; Hypertension; Platelet Aggregation Inhibitors; Risk Factors; Smoking Cessation; Stroke; Warfarin

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Atrial Fibrillation; Brain Damage, Chronic; Case Management; Contraindications; Craniotomy; Decompression, Surgical; Diabetes Complications; Evidence-Based Medicine; Facial Neoplasms; Fibrin Tissue Adhesive; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Humans; Hypercholesterolemia; Hypertension; Infarction, Middle Cerebral Artery; International Normalized Ratio; Intracranial Embolism; Male; Melanoma; Middle Aged; Mohs Surgery; Paresis; Postoperative Complications; Preoperative Care; Prospective Studies; Retrospective Studies; Skin Neoplasms; Skin Transplantation; Thrombolytic Therapy; Warfarin

Although elevated systemic blood pressure (BP) results in high intravascular pressure, the main complications of hypertension are related to thrombosis rather than haemorrhage. It therefore seemed plausible that use of antithrombotic therapy may be useful in preventing thrombosis-related complications of elevated BP. The objectives were to conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with BP, to address the following hypotheses: (i) antiplatelet agents reduce total deaths and/or major thrombotic events when compared to placebo or other active treatment; and (ii) oral anticoagulants reduce total deaths and/or major thromboembolic events when compared to placebo or other active treatment. A systematic review of randomised studies in patients with elevated BP was performed. Studies were included if they were >3 months in duration and compared antithrombotic therapy with control or other active treatment. One meta-analysis of antiplatelet therapy for secondary prevention in patients with elevated BP reported an absolute reduction in vascular events of 4.1% as compared to placebo. Acetylsalicylic acid (ASA) did not reduce stroke or 'all cardiovascular events' compared to placebo in primary prevention patients with elevated BP and no prior cardiovascular disease. Based on one large trial, ASA taken for 5 years reduced myocardial infarction (ARR, 0.5%, NNT 200 for 5 years), increased major haemorrhage (ARI, 0.7%, NNT 154), and did not reduce all cause mortality or cardiovascular mortality. In two small trials, warfarin alone or in combination with ASA did not reduce stroke or coronary events. Glycoprotein IIb/IIIa inhibitors as well as ticlopidine and clopidogrel have not been sufficiently evaluated in patients with elevated BP. To conclude for primary prevention in patients with elevated BP, antiplatelet therapy with ASA cannot be recommended since the magnitude of benefit, a reduction in myocardial infarction, is negated by a harm of similar magnitude, an increase in major haemorrhage. For secondary prevention in patients with elevated BP, antiplatelet therapy is recommended because the magnitude of the absolute benefit is many times greater. Warfarin therapy alone or in combination with aspirin in patients with elevated BP cannot be recommended because of lack of demonstrated benefit. Further trials of antithrombotic therapy are required in patients with elevated BP.

Topics: Aspirin; Blood Pressure; Fibrinolytic Agents; Humans; Hypertension; Middle Aged; Thrombosis; Warfarin

Arteriosclerosis, characterized by remodeling and stiffening of large elastic arteries is the most significant manifestation of vascular aging. The increased stiffening is believed to originate from a gradual mechanical senescence of the elastic network, alterations in cross-linking of extracellular matrix components, fibrosis and calcification of elastic fibers (medial elastocalcinosis). The stiffening of large arteries reduces their capacitance and accelerates pulse wave velocity, thus contributing to a widening of pulse pressure and to the increased prevalence of isolated systolic hypertension with age. Current antihypertensive drugs were mainly designed to reduce peripheral resistance and are not adequate to alter the pathological process of vascular stiffening or even to selectively reduce systolic blood pressure in isolated systolic hypertension. This review puts forward the concept that elastocalcinosis is a valuable therapeutic target and presents evidence that this process can be prevented and reversed pharmacologically.

Topics: Aged; Aging; Antihypertensive Agents; Arteries; Arteriosclerosis; Calcinosis; Humans; Hypertension; Muscle, Smooth, Vascular; Osteoporosis; Systole; Vitamin K; Warfarin

Topics: Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Cerebral Infarction; Contraindications; Diabetes Complications; Humans; Hyperlipidemias; Hypertension; Risk Factors; Smoking; Thrombolytic Therapy; Warfarin

The most disabling consequence of atrial fibrillation (AF) is stroke. In the elderly, AF is the single most important cause of stroke. The risk of stroke is increased at least 6-fold in subjects with AF. Strokes in patients with AF are in general severe, associated with higher risk of fatality and prone to early and long-term recurrence. The cardiac origin of stroke can be strongly suspected by anamnesis, clinical examination and findings on neuroimaging. Paroxysmal AF is an important cause of brain embolism, that is often difficult to document. Risk factors for stroke in AF include: previous embolism (including previous transient ischaemic attack (TIA), or ischaemic stroke), age >65 years, structural cardiac disease, rheumatic or other significant valvular heart disease, valvular artificial prosthesis, hypertension, heart failure and significant left ventricular systolic dysfunction, diabetes and coronary disease. All AF patients with TIA or stroke have a formal indication for long-term anticoagulation. Only patients without risk factors or with contraindications to warfarin should be put on aspirin. Treating 1 000 patients with AF for 1 year with oral anticoagulants rather than aspirin would prevent 23 ischaemic strokes while causing 9 major bleedings. Despite its enormous preventive potential, oral anticoagulants are underused in AF, because treating physicians often have lack of knowledge about trials and guidelines, underestimate the benefits and overestimate the risks associated with continuous oral anticoagulation. The introduction of anticoagulants that do not need frequent control tests, such as ximelagatran, will increase the proportion of AF patients with risk factors for stroke who are anticoagulated. There is no evidence to support routine immediate anticoagulation in acute ischeamic stroke associated with AF.

Topics: Adult; Age Factors; Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Brain Ischemia; Comorbidity; Diagnostic Imaging; Fibrinolytic Agents; Humans; Hypertension; Intracranial Embolism; Middle Aged; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Risk Factors; Ultrasonography; Warfarin

Although elevated systemic blood pressure results in high intravascular pressure, the main complications, coronary heart disease (CHD), ischaemic strokes and peripheral vascular disease (PVD), are related to thrombosis rather than haemorrhage. Some complications related to elevated blood pressure, heart failure or atrial fibrillation, are themselves associated with stroke and thromboembolism. It therefore seemed plausible that use of antithrombotic therapy may be particularly useful in preventing thrombosis-related complications of elevated blood pressure.. To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with blood pressure, including those with elevations in both systolic and diastolic blood pressure, isolated elevations of either systolic or diastolic blood pressure, to address the following hypotheses: (i) antiplatelet agents reduce total deaths and/or major thrombotic events when compared to placebo or other active treatment; and (ii) oral anticoagulants reduce total deaths and/or major thromboembolic events when compared to placebo or other active treatment.. Reference lists of papers resulting from this search, electronic database searching (MEDLINE, EMBASE, DARE), and abstracts from national and international cardiovascular meetings were studied to identify unpublished studies. Relevant authors of these studies were contacted to obtain further data.. Randomised controlled trials (RCTs) in patients with elevated blood pressure were included if they were of at least 3 months in duration and compared antithrombotic therapy with control or other active treatment.. Data were independently collected and verified by two reviewers. Data from different trials were pooled where appropriate.. The ATC meta-analysis of antiplatelet therapy for secondary prevention in patients with elevated blood pressure reported an absolute reduction in vascular events of 4.1% as compared to placebo. Data on the patients with elevated blood pressure from the 29 individual trials included in this meta-analysis was requested but could not be obtained. Three additional trials met the inclusion criteria and are reported on here. Acetylsalicylic acid (ASA) did not reduce stroke or 'all cardiovascular events' compared to placebo in primary prevention patients with elevated blood pressure and no prior cardiovascular disease. Based on one large trial (HOT trial), ASA taken for 5 years reduced myocardial infarction (ARR, 0.5%, NNT 200 for 5 years), increased major haemorrhage (ARI, 0.7%, NNT 154), and did not reduce all cause mortality or cardiovascular mortality. There was no significant difference between ASA and clopidogrel for the composite endpoint of stroke, myocardial infarction or vascular death in one trial (CAPRIE 1996). In two small trials warfarin alone or in combination with ASA did not reduce stroke or coronary events.. For primary prevention in patients with elevated blood pressure, anti-platelet therapy with ASA cannot be recommended since the magnitude of benefit, a reduction in myocardial infarction, is negated by a harm of similar magnitude, an increase in major haemorrhage. For secondary prevention in patients with elevated blood pressure (ATC meta-analysis: APTC 1994) antiplatelet therapy is recommended because the magnitude of the absolute benefit is many times greater. Warfarin therapy alone or in combination with aspirin in patients with elevated blood pressure cannot be recommended because of lack of demonstrated benefit. Glycoprotein IIb/IIIa inhibitors as well as ticlopidine and clopidogrel have not been sufficiently evaluated in patients with elevated blood pressure. Further trials of antithrombotic therapy with complete documentation of all benefits and harms are required in patients with elevated blood pressure.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Clopidogrel; Humans; Hypertension; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Thromboembolism; Ticlopidine; Warfarin

Topics: Anticoagulants; Antipyrine; Arginine; Aspirin; Brain Edema; Edaravone; Fibrinolytic Agents; Free Radical Scavengers; Glycerol; Humans; Hyperlipidemias; Hypertension; Japan; Methacrylates; Pipecolic Acids; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk Factors; Stroke; Sulfonamides; Thrombolytic Therapy; Time Factors; Warfarin

To elucidate predisposing factors for enlargement of intracerebral hematoma (ICH) during warfarin therapy, we reviewed 47 patients on warfarin who developed acute ICH and determined relationships among ICH enlargement, INR reversal and clinical data. Among 36 patients treated to counteract the effects of warfarin within 24 h of onset, ICH increased in 10 patients (enlarged group), but remained unchanged in the remaining 26 (unchanged group), while ICH remained unchanged in another 11 patients in whom the effect of warfarin was reversed after 24 h. The international normalized ratio (INR) was counteracted immediately in 11 patients treated with prothrombin complex concentrate (PCC) but gradually in the other 36 treated by reducing the dose of warfarin, or by administering vitamin K or fresh frozen plasma. Multivariate analysis with a logistic regression model showed an INR value <2.0 at admission or for 24 h after immediate INR correction with PCC prevented ICH enlargement (OR 0.069, 95%CI 0.006-0.789, p = 0.031). An INR value of >2.0 within 24 h of ICH seems an important predisposing factor for ICH enlargement.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Cerebral Hemorrhage; Comorbidity; Diabetes Mellitus; Disease Progression; Female; Humans; Hypercholesterolemia; Hypertension; International Normalized Ratio; Liver Diseases; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Tomography, X-Ray Computed; Vitamin K; Warfarin

Stroke is a major cause of morbidity and mortality. Full assessment of stroke or transient ischaemic attack (TIA) patients is required to identify all risk factors and apply appropriate secondary preventative strategies. Antiplatelet therapies are effective in the secondary prevention of ischaemic stroke and can be justified despite adverse effects such as gastrointestinal haemorrhage. Aspirin (acetylsalicylic acid), aspirin plus dipyridamole, ticlopidine and clopidogrel are all of value but their adverse effect profiles vary significantly. Combinations of antiplatelet agents may offer additional benefit but not all combinations have been studied in stroke patients. Anticoagulation with agents such as warfarin is effective with coexisting atrial fibrillation and other conditions predisposing to cardioembolic stroke. Antihypertensive agents have been extensively studied in the primary prevention of stroke; however, relatively few trials of antihypertensive agents in the secondary prevention of stroke are available. The incidence of adverse effects of antihypertensive agents is relatively low and the benefit-risk profile would tend to favour their use in the secondary prevention of stroke. Recent studies of ACE inhibitors have identified an important role for these agents in the secondary prevention of stroke even in those who are normotensive and in those who have had a haemorrhagic stroke. The incidence of serious adverse effects with ACE inhibitors appears relatively low. Lipid-lowering agents may have a role to play in certain groups of patients with stroke. The incidence of adverse effects is relatively low with HMG-CoA reductase inhibitors. Cigarette smoking is an important risk factor for stroke and evidence is available that smoking cessation does reduce the individual's risk of stroke. Pharmacological agents are available to help smoking cessation. In patients with diabetes mellitus, intensive regimens with insulin and oral hypoglycaemic agents have so far not definitively been shown to reduce the incidence of macrovascular complications such as stroke. Tight glycaemic control has been shown to improve microvascular complications such as retinopathy, nephropathy and neuropathy and hence this is reason enough to advocate the use of these agents. Future developments in the treatment of diabetes may help. Secondary prevention of stroke has improved greatly over the past decade and hopefully will continue to improve. The use of pharmacological agents a

Topics: Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Antihypertensive Agents; Aspirin; Clinical Trials as Topic; Clopidogrel; Coumarins; Dipyridamole; Humans; Hypertension; Hypoglycemic Agents; Insulin; Platelet Aggregation Inhibitors; Risk Assessment; Risk Factors; Smoking Cessation; Stroke; Ticlopidine; Warfarin

Topics: Aspirin; Female; Humans; Hypertension; Male; Primary Prevention; Warfarin

In North America, atrial fibrillation is associated with at least 75 000 ischemic strokes each year. Most of these strokes occur in patients older than 75 years of age. The high incidence of stroke in very elderly persons reflects the increasing prevalence of atrial fibrillation that occurs with advanced age, the high incidence of stroke in elderly patients, and the failure of physicians to prescribe antithrombotic therapy in most of these patients. This failure is related to the increased risk for major hemorrhage with advanced age, obfuscating the decision to institute stroke prophylaxis with antithrombotic therapy. This case-based review describes the risk and benefits of prescribing antithrombotic therapy for a hypothetical 80-year-old man who has atrial fibrillation and hypertension, and it offers practical advice on managing warfarin therapy. After concluding that the benefits of warfarin outweigh its risks in this patient, we describe how to initiate warfarin therapy cautiously and how to monitor and dose the drug. We then review five recent randomized, controlled trials that document the increased risk for stroke when an international normalized ratio (INR) of less than 2.0 is targeted among patients with atrial fibrillation. Next, we make the case that cardioversion is not needed for this asymptomatic patient with chronic atrial fibrillation. Instead, we choose to leave the patient in atrial fibrillation and to control his ventricular rate with atenolol. Later, when the INR increases to 4.9, we advocate withholding one dose of warfarin and repeating the INR test. Finally, when the patient develops dental pain, we review the analgesic agents that are safe to take with warfarin and explain why warfarin therapy does not have to be interrupted during a subsequent dental extraction.

Topics: Aged; Aged, 80 and over; Analgesics; Anticoagulants; Antihypertensive Agents; Atenolol; Atrial Fibrillation; Dental Care; Drug Administration Schedule; Drug Monitoring; Humans; Hypertension; International Normalized Ratio; Risk Factors; Stroke; Surgical Procedures, Operative; Warfarin

Atrial fibrillation(AF) is a common arrhythmia that is an important independent risk factor for stroke. The overall risk of stroke in AF patients averages about 5%/y, but with wide variation depending on the presence of coexistent thromboembolic risk factors, which include increasing age, history of hypertension, previous stroke or transient ischemic attack(TIA), and diabetes. AF patients with prior stroke or TIA are at highest risk(about 12%/y). Adjusted-dose warfarin(target INR 2.0-3.0) is highly efficacious for preventing stroke in AF patients, and is safe for selected patients. Aspirin has a modest effect on reducing stroke. Warfarin is recommended for high-risk AF patients who can safely receive it. Aspirin may be indicated for those with a low stroke risk and for those who cannot receive warfarin.

Topics: Age Factors; Anticoagulants; Aspirin; Atrial Fibrillation; Clinical Trials as Topic; Diabetes Complications; Humans; Hypertension; Ischemic Attack, Transient; Platelet Aggregation Inhibitors; Risk Factors; Stroke; Thromboembolism; Warfarin

Topics: Aged; Aged, 80 and over; Anemia; Atrial Fibrillation; Cardiovascular Diseases; Family Practice; Female; Humans; Hypertension; Life Style; Male; Warfarin

Because of its prevalence in the population and its associated underlying diseases and morbidity, atrial fibrillation (AF) is an important and costly health problem. Advancing age, diabetes, heart failure, valvular disease, hypertension, and myocardial infarction predict the occurrence of AF within a population. The management of AF is complex and involves prevention of thromboembolic complications and treatment of arrhythmia-related symptoms. Stroke occurs in 4.5% of untreated patients with AF per year. Independent risk factors for stroke in nonrheumatic patients with AF are advanced age; a history of prior embolism, hypertension, or diabetes; and echocardiographic findings of left atrial enlargement and left ventricular dysfunction. Warfarin decreases stroke by two-thirds and death by one-third; aspirin is only about half as effective overall and is insufficient therapy for those with risk factors for stroke. Options for thromboembolic prophylaxis are use of warfarin for all in whom it is safe or, alternatively, warfarin for those with risk factors and aspirin for those without risk factors. One-half of the patients with AF are 75 years of age or older. The uniform applicability and relative safety of warfarin therapy in this age-group are controversial. Specific therapy for the arrhythmia should be dictated by the need to control symptoms. Symptomatic treatments include rate-control medications and strategies designed to terminate and prevent arrhythmia recurrence. Digoxin, beta-adrenergic blockers, verapamil, and diltiazem slow excessive ventricular rates in patients with AF and may favorably manage comorbid conditions. The efficacy of anti-arrhythmic medications is only 40 to 70% per year in preventing recurrences of AF, and these agents, except amiodarone, may increase the risk of sudden death in patients with certain types of organic heart disease and AF. The use of nonpharmacologic symptomatic therapies such as atrioventricular node modification or ablation with a rate-response pacemaker or surgical intervention is increasing.

Topics: Adrenergic beta-Antagonists; Adult; Age Factors; Aged; Anti-Arrhythmia Agents; Aspirin; Atrial Fibrillation; Catheter Ablation; Cerebrovascular Disorders; Diabetes Complications; Digoxin; Diltiazem; Embolism; Humans; Hypertension; Thromboembolism; Verapamil; 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

Several recent randomized clinical trials of anticoagulation in atrial fibrillation have demonstrated significant reduction in stroke rates with a small incidence of bleeding complications. The objective of this study was to determine whether the recommendations resulting from these trials have been implemented into routine practice, and if the anticoagulation control, therapeutic efficacy, and low complication rates achieved in the trials have been matched in community practice.. We analyzed the anticoagulation practices and outcomes obtained for patients in atrial fibrillation at a large staff model health maintenance organization (HMO). We reviewed the medical records of all patients in atrial fibrillation as of April 1990. We compared demographic characteristics and clinical risk factors between HMO patients and those in the clinical trials. We also compared anticoagulation monitoring, adequacy of anticoagulation control, and clinical outcomes at the HMO with those achieved in the clinical trials.. Of 238 HMO patients in atrial fibrillation, 198 were without contraindications and therefore eligible for anticoagulation. Of these, 168 were offered anticoagulation (84.8%) and 156 were receiving anticoagulation therapy (78.8% of those eligible). The HMO patients had a greater prevalence of comorbidities than those in the clinical trials. The routine monitoring interval at the HMO was estimated at between 36.3 and 40.9 days (compared with 21 to 28 days reported in the clinical trials). The prothrombin time ratios at the HMO were in the target range on 50% of days compared with 68% of days in the clinical trials. The annual stroke and major bleeding rates in the HMO patients (1.3% and 0.6%, respectively) were not significantly different from the rates in the clinical trials (1.3% and 1.1%, respectively). The annual minor bleeding rate of 13.6% at the HMO was greater than the 7.8% to 8.4% rates in the two trials with better anticoagulation control (Boston Area Anticoagulation Trial for Atrial Fibrillation and Stroke Prevention in Atrial Fibrillation Study) but was not significantly different than the rates of 12.7% and 13.7% of the two trials with poorer anticoagulation control (Canadian Atrial Fibrillation Anticoagulation Study and Stroke Prevention in Nonrheumatic Atrial Fibrillation Study).. Anticoagulation practices in this community setting appear to be good in that a large majority of patients were receiving anticoagulation therapy, and there were few major adverse outcomes. However, this study illustrates two common problems in attempting to apply the results of randomized clinical trials to routine practice: (1) differences between community patient populations and those on which the conclusions of clinical trials are based, and (2) less successful application of therapeutic interventions in settings other than that of a controlled clinical trial. The greater prevalence of comorbidities in the HMO patient population appears to convey a greater overall risk of thromboembolism and bleeding complications than in the clinical trials. In addition, the suboptimal anticoagulation control achieved at the HMO may increase the risks and decrease the potential benefits compared with those achieved in the clinical trials. Thus, the efficacy demonstrated in the clinical trials of anticoagulation in atrial fibrillation may not be directly translated into effectiveness in practice.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Cerebrovascular Disorders; Clinical Trials as Topic; Contraindications; Diabetes Mellitus; Female; Health Maintenance Organizations; Humans; Hypertension; Male; Practice Patterns, Physicians'; Prothrombin Time; Randomized Controlled Trials as Topic; Risk; Treatment Outcome; Warfarin

Topics: Aminophylline; Coumarins; Drug Therapy; Humans; Hypertension; Hypertension, Pulmonary; Lung; Nitroglycerin; Pulmonary Embolism; Pulmonary Heart Disease; Thromboembolism; Thrombosis; Warfarin

We determined associations of physiological abnormalities (systolic blood pressure, glucose, and body temperature) and warfarin use with outcomes in spontaneous intracerebral hemorrhage.. Post hoc analyses of INTERACT2 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial) comparing systolic blood pressure control (<140 versus <180 mm Hg) in 2839 hypertensive patients with intracerebral hemorrhage (onset <6 hours). Multivariable logistic regression defined associations of baseline scores assigned as 0 to 6 per 10 mm Hg systolic blood pressure increase (range, 150-220 mm Hg) and 0 or 1 for serum glucose (≤6.5 versus >6.5 mmol/L), body temperature (≤37.5 °C versus >37.5 °C), and warfarin use (no versus yes) and death or major disability (modified Rankin Scale scores 3-6 at 90 days).. Baseline score distribution was 0 (7.7%), 1 (15.6%), 2 (19.0%), 3 (19.1%), 4 (15.2%), 5 (11.6%), 6 (8.9%), and 7 (2.9%). After adjustment for baseline neurological severity and potential confounders, significant linear associations were evident for increasing (per point) score and death or major disability (odds ratio, 1.12 [95% CI, 1.07-1.17]), death (odds ratio, 1.15 [95% CI, 1.07-1.23]), and major disability (odds ratio, 1.10 [95% CI, 1.05-1.15]).. Combination of abnormal physiological parameters and warfarin use is associated with poor outcomes in intracerebral hemorrhage. Effects of their early control is under investigation in INTERACT3 (Intensive Care Bundle With Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial). Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00716079.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Glucose; Blood Pressure; Body Temperature; Cerebral Hemorrhage; Disability Evaluation; Double-Blind Method; Female; Humans; Hypertension; Male; Middle Aged; Prognosis; Treatment Outcome; Warfarin

Hypertension is a risk factor for both stroke and bleeding in patients with atrial fibrillation. Data are sparse regarding the interaction between blood pressure and the efficacy and safety of direct oral anticoagulants. In the ENGAGE AF-TIMI 48 trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48), 19,679 patients with atrial fibrillation and hypertension were categorized according to average systolic blood pressure (SBP) and diastolic blood pressure (DBP). The primary efficacy and safety end points were the time to the first stroke or systemic embolic event and the time to the first International Society of Thrombosis and Hemostasis major bleeding event, respectively. Risk was calculated using Cox proportional hazards models based on average SBP and DBP and adjusting for 18 clinical characteristics. The efficacy and safety of a higher dose edoxaban regimen (60/30 mg) versus warfarin were evaluated with stratification by average SBP and DBP. Stroke/systemic embolic event occurred significantly more frequently in patients with elevated average SBP (hazard ratio, 2.01; 95% CI, 1.50-2.70 for SBP ≥150 mm Hg relative to 130-139 mm Hg) or DBP (hazard ratio, 2.36; 95% CI, 1.76-3.16 for DBP ≥90 mm Hg relative to 75-<85 mm Hg). The higher dose edoxaban regimen reduced stroke/systemic embolic event across the full range of SBP (P

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Comorbidity; Cross-Over Studies; Dose-Response Relationship, Drug; Double-Blind Method; Drug Administration Schedule; Female; Humans; Hypertension; Logistic Models; Male; Patient Safety; Prognosis; Proportional Hazards Models; Pyridines; Risk Assessment; Severity of Illness Index; Stroke; Survival Analysis; Thiazoles; Treatment Outcome; Warfarin

To evaluate the association between use of antiplatelet or anticoagulant drugs and retinal or subretinal hemorrhage in participants with neovascular age-related macular degeneration (AMD) in the Comparison of AMD Treatments Trials (CATT).. Cohort study within CATT.. Participants in CATT with untreated active neovascular AMD (n = 1185).. Participants were interviewed for use of antiplatelet or anticoagulant drugs. Trained readers evaluated photographs for the presence and size of retinal or subretinal hemorrhage at baseline and years 1 and 2. Associations between use of antiplatelet or anticoagulant drugs and hemorrhage were evaluated among all participants and by baseline hypertension status using multivariate logistic regression models.. Odds ratio for association with antiplatelet or anticoagulant use.. Among 1165 participants with gradable photographs, 724 (62.1%) had retinal or subretinal hemorrhage at baseline; 84.4% of hemorrhages were 1 disc area (DA) or less, 8.1% were 1 to 2 DA, and 7.5% were more than 2 DA. At baseline, 608 participants (52.2%) used antiplatelet or anticoagulant drugs, including 514 participants (44.1%) using antiplatelets only, 77 (6.6%) using anticoagulants only, and 17 (1.5%) using both. Hemorrhage was present in 64.5% of antiplatelet or anticoagulant users and in 59.6% of nonusers (P = 0.09; adjusted odds ratio [OR], 1.18; 95% confidence interval, 0.91-1.51; P = 0.21). Neither presence nor size of baseline hemorrhage was associated with the type, dose, or duration of antiplatelet or anticoagulant use. Forty-four of 1078 participants (4.08%) had retinal or subretinal hemorrhage detected on 1- or 2-year photographs; these hemorrhages were not associated with antiplatelet or anticoagulant use at baseline (P = 0.28) or during follow-up (P = 0.64). Among participants with hypertension (n = 807), antiplatelet or anticoagulant use was associated with a higher rate of hemorrhage at baseline (66.8% vs. 56.4%; adjusted OR, 1.48; P = 0.01), but not size of retinal or subretinal hemorrhage (P = 0.41).. Most retinal or subretinal hemorrhages in eyes enrolled in CATT were less than 1 DA. Among all CATT participants, antiplatelet or anticoagulant use was not associated significantly with hemorrhage, but it was associated significantly with hemorrhage in participants with hypertension.

Topics: Aged; Aged, 80 and over; Angiogenesis Inhibitors; Anticoagulants; Aspirin; Bevacizumab; Cardiovascular Diseases; Clopidogrel; Female; Fluorescein Angiography; Humans; Hypertension; Intravitreal Injections; Male; Odds Ratio; Platelet Aggregation Inhibitors; Ranibizumab; Retinal Hemorrhage; Risk Factors; Ticlopidine; Tomography, Optical Coherence; Vascular Endothelial Growth Factor A; Warfarin; Wet Macular Degeneration

Hypertension is frequent in patients with atrial fibrillation (AF) and is an independent risk factor for stroke. The Randomized Evaluation of Long Term Anticoagulant TherapY (RE-LY) trial found dabigatran 110 mg (D110) and 150 mg twice daily (D150) noninferior or superior to warfarin for stroke reduction in patients with AF, with either a reduction (D110) or similar rates (D150) of major bleeding. Baseline characteristics and outcomes were compared in patients with and without hypertension. The quality of blood pressure control was also assessed. In RE-LY, 14,283 patients (78.9%) had hypertension. The mean blood pressure at baseline was 132.6 ± 17.6/77.7 ± 10.6 and 124.8 ± 16.7/74.6 ± 10.0 mm Hg for patients with and without hypertension, respectively. More patients with hypertension were diabetic (25.6% vs 14.8%, p <0.001), women (38.6% vs 28.3%, p <0.001), and had greater CHADS2 (2.3 vs 1.4, p <0.001) and CHA2DS2-VASc scores (3.8 vs 2.8, p <0.001). Mean blood pressure in all treatment arms in hypertensive patients was similar (130 ± 18/76 ± 11 mm Hg) during the trial. The efficacy and safety of D110 and D150 compared to warfarin were similar (p = nonsignificant) in hypertensive (stroke/systemic embolism rate of 1.47%, 1.20%, and 1.81% and major bleed rate of 2.89%, 3.70%, and 3.69% in the D110, D150, and W, respectively) and normotensive patients (stroke/systemic embolism rate of 1.79%, 0.78%, and 1.36% and major bleed rate of 2.84%, 2.37%, and 3.03% per year in the D110, D150, and W, respectively). Hypertensive patients had more major bleeds (3.39% vs 2.76%; p = 0.007). Intracranial bleeds were similar (0.47% vs 0.31%; p = 0.12). In conclusion, patients with hypertension in RE-LY were more likely female, diabetic, with a greater CHADS2 and CHA2DS2-VASc scores. Blood pressure control in RE-LY was excellent. The benefits of dabigatran over warfarin, including a substantial reduction of intracranial hemorrhage, were similar in both hypertensive and non-hypertensive patients.

Topics: Aged; Aged, 80 and over; Antithrombins; Atrial Fibrillation; Dabigatran; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Humans; Hypertension; Male; Middle Aged; Stroke; Treatment Outcome; Warfarin

The majority of the patients enrolled in the rivaroxaban vs. warfarin in Japanese patients with atrial fibrillation (J-ROCKET AF) trial had hypertension. In this subgroup analysis, we investigated differences in the safety and efficacy of rivaroxaban and warfarin in subjects with and without hypertension. The baseline blood pressure (BP) measurements of patients with hypertension in the rivaroxaban and warfarin groups were 130/77 mm Hg and 131/77 mm Hg, respectively, whereas those of patients without hypertension were 123/74 mm Hg and 124/73 mm Hg, respectively. The incidence rates of the principal safety outcomes in the rivaroxaban and warfarin groups were 18.39% per year and 16.81% per year, respectively, among patients with baseline hypertension (hazard ratio (HR): 1.10; 95% confidence interval (CI): 0.84-1.45) and 16.71% per year and 15.00% per year, respectively, among patients without hypertension at baseline (HR: 1.14; 95% CI: 0.66-1.97), indicating no significant interaction (P=0.933). The incidence rates of the primary efficacy endpoints in the rivaroxaban group and the warfarin group were 0.54% per year and 2.24% per year, respectively, in patients without baseline hypertension (HR: 0.25; 95% CI: 0.03-2.25), and 1.45% per year and 2.71% per year, respectively, in patients with baseline hypertension (HR: 0.54; 95% CI: 0.25-1.16), indicating no significant interaction (P=0.509). In conclusion, the safety and efficacy profile of rivaroxaban was similar to that of warfarin, independent of baseline hypertensive status.

Topics: Aged; Asian People; Atrial Fibrillation; Double-Blind Method; Factor Xa Inhibitors; Female; Fibrinolytic Agents; Humans; Hypertension; Japan; Male; Morpholines; Rivaroxaban; Thiophenes; Treatment Outcome; Warfarin

Ambrisentan is an oral, propanoic acid-based endothelin receptor antagonist often co-administered with warfarin to patients with pulmonary arterial hypertension. The aim of this study was to evaluate the potential for ambrisentan to affect warfarin pharmacokinetics and pharmacodynamics.. In this open-label cross-over study, 22 healthy subjects received a single dose of racemic warfarin 25 mg alone and after 8 days of ambrisentan 10 mg once daily. Assessments included exposure (AUC(0-last)) and maximum plasma concentration (C(max)) for R- and S-warfarin, and International Normalized Ratio maximum observed value (INR(max)) and area under the curve (INR(AUC(0-last))). The effects of warfarin on ambrisentan steady-state pharmacokinetics and the safety of ambrisentan/warfarin co-administration were assessed. Data are presented as geometric mean ratios.. Ambrisentan had no significant effects on the AUC(0-last) of R-warfarin [104.7; 90% confidence interval (CI) 101.7, 107.7) or S-warfarin (101.6; 90% CI 98.4, 105.0). Similarly, ambrisentan had no significant effects on the C(max) of R-warfarin (91.6; 90% CI 86.2, 97.4) or S-warfarin (89.9; 90% CI 84.8, 95.3). Consistent with these observations, little pharmacodynamic change was observed for INR(max) (85.3; 90% CI 82.4, 88.2) or INR(AUC(0-last)) (93.0; 90% CI 90.8, 95.3). In addition, co-administration of warfarin did not alter ambrisentan steady-state pharmacokinetics. Adverse events were infrequent, and there were no bleeding adverse events.. Multiple doses of ambrisentan had no clinically relevant effects on the pharmacokinetics and pharmacodynamics of a single dose of warfarin. Therefore, significant dose adjustments of either drug are unlikely to be required with co-administration.

Topics: Adolescent; Adult; Anticoagulants; Antihypertensive Agents; Area Under Curve; Cross-Over Studies; Drug Interactions; Drug Therapy, Combination; Female; Humans; Hypertension; Male; Middle Aged; Phenylpropionates; Pyridazines; Warfarin; Young Adult

To test the hypothesis that stroke and systemic embolic events (SEE) in the stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) III and V trials are different between paroxysmal and persistent atrial fibrillation (AF).. Data analysis from two cohorts of patients enrolled in the prospective SPORTIF III and V clinical trials (n = 7329); 836 subjects (11.4%) with paroxysmal AF [mean age 70.1 years (SD = 9.5)] were compared with 6493 subjects with persistent AF for this ancillary study.. The annual event rates for stroke/SEE are 1.73% for persistent AF and 0.93% for paroxysmal AF. In a multivariate analysis, after adjusting for stroke risk factors, gender and aspirin usage, the differences remained statistically significant with a higher hazard ratio (HR) for stroke/SEE in persistent AF [vs. paroxysmal AF, HR 1.87, 95% confidence interval (CI) 1.04-3.36; P = 0.037]. In 'high risk' patients (with >or=2 stroke risk factors) annual event rates for stroke/SEE were 2.08% for persistent AF and 1.27% for paroxysmal AF (adjusted HR = 1.68, 95% CI 0.91-3.1, P = 0.098). Elderly patients had annual event rates for stroke/SEE of 2.38% for persistent AF and 1.13% for paroxysmal AF (adjusted HR = 2.27, 95% CI 0.92-5.59, P = 0.075). Vitamin K antagonist (VKA)-naive paroxysmal AF patients had a 1.89%/year stroke/SEE rate, compared with 0.61% for previous VKA takers (HR = 0.33, 95% CI 0.11-1.01, P = 0.052).. In this large clinical trial cohort of anticoagulated AF patients, those with paroxysmal AF had stroke rates which were lower than for patients with persistent AF, although both groups had broadly similar stroke risk factors. Subjects with paroxysmal AF at 'high risk' had stroke/SEE rates that were not significantly different to persistent AF subjects.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Azetidines; Benzylamines; Cohort Studies; Female; Humans; Hypertension; Male; Middle Aged; Prospective Studies; Stroke; Warfarin

Atrial fibrillation and hypertension are two common conditions in the elderly, associated with significant morbidity and mortality. Little information is available regarding the epidemiology of hypertension in elderly patients with atrial fibrillation.. A secondary analysis of data from the Birmingham Atrial Fibrillation Treatment of the Aged study, a randomised controlled trial of thrombo-prophylaxis in atrial fibrillation in a primary care population. The study population comprised patients aged 75 and over with electrocardiogram (ECG) confirmed atrial fibrillation. Blood pressure was recorded in the general practice surgery on two occasions using standardised methods. History of hypertension was sought from the medical records and from asking the patient.. 3059 subjects had ECG confirmed atrial fibrillation. The prevalence of a history of hypertension in this group was 57.5%. The mean systolic blood pressure was 141 mmHg (standard deviation: 21 mmHg) in men and 144 mmHg (22 mmHg) in women. The mean diastolic blood pressure was 79 mmHg (12 mmHg) in men and 80 mmHg in women (12 mmHg). The mean systolic blood pressure was slightly lower than that of the general population aged 75 and over, but the mean diastolic blood pressure was significantly higher in patients in atrial fibrillation (by 8 mmHg). Among the patients with a diagnosis of hypertension, 86.5% were on blood pressure lowering medications.. Hypertension is more commonly diagnosed in older patients with atrial fibrillation than in the general population. The mean systolic blood pressure is slightly lower, but the mean diastolic blood pressure substantially higher in older patients in atrial fibrillation, compared to the general population.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Aspirin; Atrial Fibrillation; Blood Pressure; Cross-Sectional Studies; Female; Humans; Hypertension; Male; Prevalence; Stroke; Warfarin

To test the hypothesis that stroke and systemic embolic events (SEE) in the Stroke Prevention using an ORal Thrombin Inhibitor in atrial Fibrillation (SPORTIF) III and V trials were related to blood pressure, and that differences in event rates (stroke and SEE, bleeding) could also be related to the degree of hypertension.. A cross-sectional, longitudinal analysis was conducted, using data from the SPORTIF III and V trials. Results showed an increasing rate of stroke and SEE with increasing quartiles of systolic blood pressure (SBP) in AF patients. For the top quartile of SBP compared with the lowest quartile, the hazard ratio (HR) for stroke and SEE was 1.83 (95% confidence intervals [CI]: 1.22-2.74), whereas mortality was lower in the top quartile (HR 0.64; 95% CI: 0.49-0.83). In the combined SPORTIF III and V cohort, the event rate for stroke/SEE increased markedly at mean SBP of > 140 mmHg. There was no relationship between bleeding and quartiles of BP. The proportion of subjects with mean systolic BP > or = 140 mmHg was 35.8% (1220/3407) in SPORTIF III and 20.6% (807/3922) in SPORTIF V (P < 0.0001).. Hypertension contributes to increased stroke and SEE in AF. Event rates markedly increase at SBP levels of > or = 140 mmHg. The higher stroke rates observed in SPORTIF III compared with SPORTIF V may be related to the greater proportion of subjects with SBP > or = 140 mmHg during the trial.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Azetidines; Benzylamines; Cross-Sectional Studies; Double-Blind Method; Female; Hemorrhage; Humans; Hypertension; Longitudinal Studies; Male; Middle Aged; Risk Factors; Stroke; Thromboembolism; Warfarin

To describe factors associated with the development of stroke during long-term follow-up after acute myocardial infarction (AMI) in the LoWASA trial.. Patients who had been hospitalized for AMI were randomized within 42 days to receive either warfarin 1.25 mg plus aspirin 75 mg daily or aspirin 75 mg alone.. The study was performed according to the probe design, that is open treatment and blinded end-point evaluation.. The study was performed in 31 hospitals in Sweden. The mean follow-up time was 5.0 years with a range of 1.7-6.7 years.. In all, 3300 patients were randomized in the trial, of which 194 (5.9%) developed stroke (4.2% nonhaemorrhagic, 0.5% haemorrhagic and 1.3% uncertain. The following factors appeared as independent predictors for an increased risk of stroke: age, hazard ratio and 95% confidence interval (1.07; 1.05-1.08), a history of diabetes mellitus (2.4; 1.8-3.4), a history of stroke (2.3; 1.5-3.5), a history of hypertension (2.0; 1.5-2.7) and a history of smoking (1.5;1.1-2.0). Most of these factors were also predictors of a nonhaemorrhagic stroke whereas no predictor of haemorrhagic stroke was found.. Risk indicators for stroke long-term after AMI were increasing age, a history of either diabetes mellitus, stroke, hypertension or smoking.

Topics: Age Factors; Aged; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Female; Follow-Up Studies; Humans; Hypertension; Male; Myocardial Infarction; Proportional Hazards Models; Regression Analysis; Risk Factors; Smoking; Stroke; Time Factors; Warfarin

Warfarin decreases the activity of matrix Gla-protein and causes extensive arterial calcification leading to increased systolic blood pressure (SBP) and pulse pressure (PP) in rats. We performed post hoc analyses of the Stroke Prevention in Non-Rheumatic Atrial Fibrillation (SPINAF) trial, aiming to analyze the effects of warfarin on SBP and PP.. The SPINAF trial was a randomized, double-blind, placebo-controlled trial comparing warfarin and placebo in 525 subjects with nonrheumatic atrial fibrillation. After exclusions for inadequate follow-up, 284 subjects with average treatment lasting 23.7 months were available for analysis (144 given placebo and 140 warfarin).. Baseline SBP, diastolic blood pressure (DBP), mean arterial pressure (MAP), and PP were 132 +/- 18, 81 +/- 9, 98 +/- 11, and 50 +/- 16 mm Hg in the warfarin group, and 133 +/- 21, 80 +/- 13, 97 +/- 14, and 54 +/- 15 mm Hg in the placebo groups (all P values, NS). There was no statistically significant difference between the placebo and warfarin groups in any of the BP parameters at any time point. However, stratified analyses showed a significant increase in PP in warfarin-treated subjects with a history of hypertension (4.9 +/- 13.1 mm Hg v 0.2 +/- 11.9 mm Hg in the placebo group, P = 0.022), and those with baseline SBP > or =140 mm Hg (4.8 +/- 18.9 mm Hg v -3.4 +/- 11.2 mm Hg in the placebo group, P = .038). A similar trend was noted in diabetic subjects but it was not statistically significant.. Based on the study results, treatment with warfarin does not result in increased BP in men with atrial fibrillation. However, it is possible that subjects at higher baseline cardiovascular risk may be more susceptible to the chronic effects of warfarin on arterial hemodynamics.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Blood Pressure; Double-Blind Method; Follow-Up Studies; Humans; Hypertension; Male; Middle Aged; Systole; Warfarin

Topics: Age Factors; Aged; Anticoagulants; Cerebrovascular Disorders; Clinical Trials as Topic; Diabetes Complications; Dicumarol; Electrocardiography; Female; Heart Failure; Hemorrhage; Heparin; Humans; Hypertension; Male; Middle Aged; Myocardial Infarction; Phenindione; Placebos; Pulmonary Embolism; Recurrence; Sex Factors; Thrombophlebitis; Time Factors; Warfarin

Whether there are differences in direct oral anticoagulants efficacy and safety in patients with atrial fibrillation (AF) combined with hypertension is unclear. We therefore conducted a multicenter retrospective cohort study to assess the differences in the efficacy and safety of direct oral anticoagulants in patients with AF combined with hypertension. This multicenter retrospective cohort study was based on data from 15 centers in China and included 2086 patients with AF. We divided the patients into dabigatran and rivaroxaban groups according to their direct oral anticoagulants. Propensity score matching was used to balance the covariates between the groups. Due to our limited sample size, the number of cases of some clinical events with low incidence was small. During a mean follow-up period of 10 months, a total of 268 (12.9%) bleeding events occurred, including 27 (1.3%) major bleeding events and 241 (11.6%) minor bleeding events, and 45 (2.2%) thromboembolic events. In patients with AF combined with hypertension, rivaroxaban was associated with a higher major bleeding incidence than dabigatran (odds ratio [OR], 2.89 [95% confidence interval [CI, 1.22-6.87]; P = .012). In contrast, the risk of thromboembolism and minor bleeding was similar for rivaroxaban (OR, 0.55 [95%CI, 0.29-1.01]; P = .069) and dabigatran (OR, 0.82 [95%CI, 0.63-1.08]; P = .150). Based on the results of this study, in patients with AF and hypertension treated with direct oral anticoagulants, the incidence of thromboembolism and minor bleeding was not statistically different between dabigatran and rivaroxaban, but compared with rivaroxaban, dabigatran was associated with a lower risk of major bleeding.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Dabigatran; Hemorrhage; Humans; Hypertension; Retrospective Studies; Rivaroxaban; Stroke; Thromboembolism; Warfarin

Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Fibrinolytic Agents; Hemorrhage; Humans; Hypertension; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Retrospective Studies; Risk Factors; Stroke; Treatment Outcome; Warfarin

Maintenance drugs are used to treat chronic conditions. Several classes of maintenance drugs have attracted attention because of their potential to affect susceptibility to and severity of COVID-19.. Using claims data on 20% random sample of Part D Medicare enrollees from April to December 2020, we identified patients diagnosed with COVID-19. Using a nested case-control design, non-COVID-19 controls were identified by 1:5 matching on age, race, sex, dual-eligibility status, and geographical region. We identified usage of angiotensin-converting enzyme inhibitors (ACEI), angiotensin-receptor blockers (ARB), statins, warfarin, direct factor Xa inhibitors, P2Y12 inhibitors, famotidine and hydroxychloroquine based on Medicare prescription claims data. Using extended Cox regression models with time-varying propensity score adjustment we examined the independent effect of each study drug on contracting COVID-19. For severity of COVID-19, we performed extended Cox regressions on all COVID-19 patients, using COVID-19-related hospitalization and all-cause mortality as outcomes. Covariates included gender, age, race, geographic region, low-income indicator, and co-morbidities. To compensate for indication bias related to the use of hydroxychloroquine for the prophylaxis or treatment of COVID-19, we censored patients who only started on hydroxychloroquine in 2020.. Up to December 2020, our sample contained 374,229 Medicare patients over 65 who were diagnosed with COVID-19. Among the COVID-19 patients, 278,912 (74.6%) were on at least one study drug. The three most common study drugs among COVID-19 patients were statins 187,374 (50.1%), ACEI 97,843 (26.2%) and ARB 83,290 (22.3%). For all three outcomes (diagnosis, hospitalization and death), current users of ACEI, ARB, statins, warfarin, direct factor Xa inhibitors and P2Y12 inhibitors were associated with reduced risks, compared to never users. Famotidine did not show consistent significant effects. Hydroxychloroquine did not show significant effects after censoring of recent starters.. Maintenance use of ACEI, ARB, warfarin, statins, direct factor Xa inhibitors and P2Y12 inhibitors was associated with reduction in risk of acquiring COVID-19 and dying from it.

Topics: Aged; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; COVID-19 Drug Treatment; Factor Xa Inhibitors; Famotidine; Humans; Hydroxychloroquine; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypertension; Medicare; Retrospective Studies; United States; Warfarin

The aim of this study was to investigate risk factors of bleeding and mortality in patients with warfarin overdose (WOD). Totally, 783 patients were included, of which, 272 patients (34.7%) with an INR below 5,364 patients (46.5%) with an INR between 5-10, and 147 patients (18.8%) with an INR of 10 or above. Demographic, clinical, and laboratory findings of the patients were obtained from the Real Life Data Provision Center and Hospital Information Management System. Admittance in autumn (

Topics: Anticoagulants; Emergency Service, Hospital; Hemorrhage; Humans; Hypertension; International Normalized Ratio; Retrospective Studies; Risk Factors; Warfarin

To evaluate cardiovascular response in patients on warfarin and hypertensive patients not on warfarin during dental extraction.. This retrospective study included 53 patients who had undergone dental extraction while on warfarin (mean age 78.8 ± 6.3 years, 26 men) and 66 with hypertension who had undergone dental extraction but were not on warfarin (mean age 77.4 ± 6.8 years, 22 men). Vital signs were monitored in both groups during extraction.. The highest systolic blood pressure (SBP) values (mean 150.1 ± 21.1 mmHg) were observed in patients on warfarin before (9.0%) and after (10.3%) administration of local anesthesia (LA), during extraction (39.7%), and during (33.3%) and after (7.7%) suturing (n = 78; p < 0.01), and in hypertensive patients not receiving warfarin (160.6 ± 24.8 mmHg) before (19.2%) and after (27.3%) administration of LA, during extraction (29.3%), and during (18.2%) and after (6.1%) suturing (n = 99; p < 0.01). The highest SBP was linearly correlated with SBP before administration of LA in patients on warfarin (highest SBP = 0.9415 × SBP before LA + 23.243, R. The highest SBP was not distributed evenly between patients on warfarin and hypertensive patients not on warfarin during dental extraction and was strongly associated with SBP before LA regardless of anticoagulant status.. Thorough management of SBP is required in patients on warfarin to avoid thromboembolism and major hemorrhagic complications. Knowing the SBP value before dental treatment would help predict the risk of cardiovascular complications.

Topics: Aged; Aged, 80 and over; Blood Pressure; Humans; Hypertension; Male; Retrospective Studies; Tooth Extraction; Warfarin

Prevalence of atrial fibrillation (AF) increases with age, along with comorbidities and, thus, polypharmacy. Non-adherence is associated with polypharmacy. This study aimed to identify patients at risk for cardiovascular events according to their pharmacological treatment intensity and adherence. Patients (n = 18,113) with a mean age of 71.5 ± 8.7 years, at high cardiovascular risk were followed between December 2005 until December 2007 for a median time of 2 years. The association between polypharmacy and adherence and their impact on cardiovascular and bleeding events were explored. Adherence was defined as a study drug intake of ≥80%. Patients with more co-medications had a higher body mass index, higher prevalence of hypertension, coronary heart disease, heart failure, and diabetes mellitus (all p < 0.0001) compared to ≤4 or 5-8 co-medications, but no differences in history of stroke (p = 0.68) or transient ischemic attack (p = 0.065). Across all treatments, the adjusted hazard ratios (HRs) increased in patients with more co-medications (≥9 vs ≤4) for all-cause death (HR 1.30; 1.06-1.59), major bleeding (HR 1.65; 1.33-2.05), and all bleeding events (HR 1.44; 1.31-1.59). Yearly event rates were higher in non-adherent than adherent patients for stroke and systemic embolism (SSE) (3.14 vs 1.00), all-cause death (7.76 vs 2.66), major bleeding (6.21 vs 2.65), and all bleeding (28.71 vs 19.05; all p < 0.0001). After an event the patients were more likely to become non-adherent (adherence after SSE 30.3%, after major bleeding 33.4%, after all bleeding 66.7%; all p < 0.0001). The treatment effects were consistent to the overall group in the different polypharmacy groups. In conclusion, polypharmacy and non-adherence are risk indicators for increased adverse cardiovascular and bleeding events. Dabigatran is safe to use across the full spectrum of AF patients, independent of the number of co-medications and adherence. Patients with co-medications and comorbidities require special attention and encouragement to adhere to oral anticoagulation.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Body Mass Index; Coronary Disease; Dabigatran; Diabetes Mellitus; Embolism; Female; Heart Failure; Hemorrhage; Humans; Hypertension; Ischemic Attack, Transient; Male; Medication Adherence; Middle Aged; Polypharmacy; Proportional Hazards Models; Stroke; Warfarin

Topics: Administration, Oral; Antifibrinolytic Agents; Antithrombins; Atrial Fibrillation; Consensus; Delphi Technique; Diabetes Complications; Heart Failure; Humans; Hypertension; Kidney Failure, Chronic; Renal Dialysis; Renal Insufficiency, Chronic; Risk Factors; Stroke; Vascular Diseases; Warfarin

Quality of warfarin therapy in patients with a mechanical prosthetic heart valve (MPHV) has been barely investigated. We analysed determinants of low time in the therapeutic range (TiTR <60%) in 2111 patients with MPHVs from the nationwide PLECTRUM study by the Italian Federation of Anticoagulation Clinics. Overall, 48·5% of patients had a TiTR of < 60%. At logistic regression analysis, arterial hypertension (odds ratio [OR] 1·502, P < 0·001), diabetes (OR 1·732, P < 0·001), heart failure (OR 1·484, P = 0·004), mitral site (vs. aortic) (OR 1·399, P = 0·006), international normalised ratio (INR) ranges of 2·5-3·5 (OR 2·575, P < 0·001) and 3·0-4·0 (OR 8·215, P < 0·001) associated with TiTR < 60%. TiTR is substantially suboptimal in MPHV patients, particularly in higher INR ranges.

Topics: Adult; Age Distribution; Aged; Anticoagulants; Atrial Fibrillation; Diabetes Mellitus; Female; Heart Valve Prosthesis; Humans; Hypertension; International Normalized Ratio; Italy; Male; Middle Aged; Myocardial Ischemia; Peripheral Arterial Disease; Retrospective Studies; Smoking; Thrombophilia; Treatment Outcome; Warfarin

Topics: Adult; Anticoagulants; Basal Ganglia Hemorrhage; Betacoronavirus; Brain; Cerebral Angiography; Cerebral Hemorrhage; Comorbidity; Computed Tomography Angiography; Coronavirus Infections; COVID-19; Diabetes Mellitus, Type 2; Endothelium, Vascular; Female; Frontal Lobe; Heparin, Low-Molecular-Weight; Humans; Hypertension; Magnetic Resonance Imaging; Male; Middle Aged; Myocardial Ischemia; Pandemics; Pneumonia, Viral; Pulmonary Embolism; Retrospective Studies; Risk Factors; SARS-CoV-2; Severity of Illness Index; Tomography, X-Ray Computed; Venous Thrombosis; Warfarin

A 42-year-old woman was referred from a primary care centre for severe hypertension, stage 3A chronic kidney disease and proteinuria. This was associated with a significant obstetric history of pre-eclampsia during her previous two pregnancies. Secondary hypertension was suspected and autoimmune workup was positive for anticardiolipin IgG and lupus anticoagulant. A renal biopsy showed evidence of chronic thrombotic microangiopathy, with electron microscopy features suggestive of fibrillar glomerulonephritis. The diagnosis of antiphospholipid syndrome with antiphospholipid-associated nephropathy was made. She was started on anticoagulation with warfarin, and her hypertension was controlled with lisinopril and amlodipine with subsequent improvement in proteinuria. She remains on regular follow-up to monitor for possible development of malignancy or connective tissue disease.

Topics: Adult; Amlodipine; Anticoagulants; Antihypertensive Agents; Antiphospholipid Syndrome; Diagnosis, Differential; Drug Therapy, Combination; Female; Humans; Hypertension; Kidney Diseases; Lisinopril; Thrombotic Microangiopathies; Warfarin

This study aimed to investigate the effectiveness of monotherapy acetylsalicylic acid (ASA) and warfarin for stroke prevention in low-risk atrial fibrillation (AF) by using a population- -based cohort study in Taiwan.. A newly diagnosed low-risk AF patient cohort were identified by using National Health Insurance Research Database (NHIRD) in Taiwan in 2008. The study cohort was observed with a follow-up of 2 years to examine the onset of ischemic stroke (IS) (to 2010). The longitudinal data were analyzed by using generalized estimation equations (GEE).. A total of 8,065 newly-diagnosed low-risk AF patients were identified in 2008. 7.4% were prescribed with ASA and 4.6% were prescribed with warfarin. The GEE results showed that low-risk AF patients with hypertension who received warfarin were associated with a statistically significant 58.4% reduction of IS risk (OR = 0.416, p = 0.024, 95% CI 0.194-0.891). Additionally, low-risk AF patients with hyperlipidemia who received warfarin were associated with a 69.3% reduction of IS risk (OR = 0.307, p = 0.044, 95% CI 0.097-0.969).. Warfarin is suggested to be prescribed in preventing IS for low-stroke-risk AF patients with hypertension and hyperlipidemia.

Topics: Adult; Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Brain Ischemia; Comparative Effectiveness Research; Databases, Factual; Female; Humans; Hyperlipidemias; Hypertension; Incidence; Male; Middle Aged; Risk Assessment; Risk Factors; Stroke; Taiwan; Time Factors; Treatment Outcome; Warfarin; Young Adult

The use and range of indications for anticoagulation therapy are steadily growing. The objective of this study was to develop a scoring model to predict the occurrence of significant bleeding in patients taking warfarin with a supra-therapeutic international normalized ratio.. Data were collected from the medical records of patients taking warfarin with an international normalized ratio > 3.5. The characteristics of bleeding episodes and the need for transfusion of blood products were recorded. Regression models were constructed to predict the occurrence of significant bleeding (requiring a transfusion of more than 2 units of packed red blood cells, intrapericardial or intracranial hemorrhage). The predictive values of previously published scores (ATRIA: anemia, hypertension, severe renal disease, age ≥ 75 years, or prior bleeding history; and ORBIT: old, reduced hemoglobin, bleeding history, kidney insufficiency or antiplatelet treatment) were compared with our New Bleeding Score (NBLDSCOR); the areas under the curve for the receiver-operating characteristic plots were compared using a non-parametric DeLong test.. Significant bleeding was reported in 87 out of 389 admitted patients. With an area under the curve of 0.736 ± 0.032, NBLDSCOR was the best predictor of significant bleeding in this population. Neither ATRIA nor ORBIT was a good predictor of significant bleeding, where the area under the curve for the receiver-operating characteristic plot for ATRIA was 0.654 ± 0.034 and for ORBIT was 0.604 ± 0.033. The predictive power of NBLDSCOR was superior to ATRIA and ORBIT (p < 0.001), while there was no meaningful difference in the predictive powers of ATRIA and ORBIT.. The NBLDSCOR including age, negative Rhesus factor, low hemoglobin, renal impairment, and concomitant peptic ulcer and disseminated cancer is a good predictor of significant bleeding in this patient population.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anemia; Anticoagulants; Cross-Sectional Studies; Female; Hemorrhage; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Retrospective Studies; Risk Assessment; Warfarin

Vitamin K antagonist (VKA) reversal in patients with acute major bleeding and coagulopathy is an example of an urgent intervention in the emergency department. Intravenous (IV) prothrombin complex concentrate (PCC) may reverse VKA-induced coagulopathy in <30 min. In patients lacking IV access, effective PCC administration becomes problematic. No previous case reports have documented PCC infusion via intraosseous (IO) or alternative routes in this setting.. A 74-year-old man presented to the emergency department (ED) after a head injury, with sudden onset of left-sided facial droop, weakness, hypertension, and dizziness. Initial vital signs include blood pressure of 221/102 mm Hg, a heart rate of 75 beats/min, and oxygen saturation of 96% on room air. Warfarin 3 mg once daily was among his medications. His international normalized ratio (INR) was 3.9 with a computed tomography scan showing intraparenchymal hemorrhage in the right temporal lobe. Multiple attempts for IV access at various sites were unsuccessful. Therefore, IO access was established. Because of his prolonged prothrombin time, elevated INR, and intraparenchymal hemorrhage, the decision was made to use 4-factor PCC to reverse the supratherapeutic INR. The INR normalized as an emergent right parietal hematoma evacuation was performed. After an inpatient course, the patient was eventually discharged. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VKAs, like warfarin, are commonly prescribed medications. When life-threatening hemorrhage is present, rapid reversal of a VKA-induced coagulopathy may be a life-saving therapy. In the event that IV access has not been established, we have demonstrated that IO access is a viable alternative route for PCC administration.

Topics: Aged; Anticoagulants; Blood Coagulation Factors; Dizziness; Hemorrhage; Humans; Hypertension; Infusions, Intraosseous; Male; Muscle Weakness; Time Factors; Warfarin

Temporary transvenous pacemaker implantation is an important and critical procedure for emergency physicians. Traditionally, temporary pacemakers are inserted by electrocardiography (ECG) guidance in the emergency department because fluoroscopy at the bedside in an unstable patient can be limited by time and equipment availability. However, in the presence of atrial septal defect, ventricular septal defect, and patent foramen ovale, the pacemaker lead can be implanted inadvertently into the left ventricle or directly into the coronary sinus instead of right ventricle. Regular pacemaker rhythm can be achieved despite inadvertent implantation of the pacemaker lead into the left ventricle, leading to ignorance of the possibility of lead malposition.. A 65-year-old female patient with hemodynamic instability and complete atrioventricular block underwent temporary pacemaker implantation via right jugular vein with ECG guidance at the emergency department. Approximately 12 h after implantation, it was noticed that the ECG revealed right bundle branch block (RBBB)-type paced QRS complexes. Diagnostic workup revealed that the lead was inadvertently located in the left ventricular apex. This case illustrates the importance of careful scrutiny of the 12-lead ECG and imaging clues in identifying lead malposition in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because inadvertent left ventricle endocardial pacing carries a high risk for systemic embolization, it is important to determine whether an RBBB pattern induced by ventricular pacing is the result of a malpositioned lead or uncomplicated transvenous right ventricular pacing.

Topics: Aged; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Cardiac Pacing, Artificial; Diagnosis, Differential; Electrocardiography; Electrodes, Implanted; Emergency Service, Hospital; Female; Heart Ventricles; Humans; Hypertension; Metoprolol; Syncope; Warfarin

Clinical variables including hypertension could be linked with major bleeding events and death beyond vitamin K antagonist (warfarin) or direct oral anti-coagulants (DOACs) treatment strategy.. Subgroup analysis of major bleeding (primary endpoint) associated with clinical variables, site of bleeding, ongoing antithrombotics, reversal treatment or blood transfusion, outcomes (secondary endpoints) was performed in patients with bleeding events submitted to hard 5:1 propensity-score matching for hypertension.. Enrolled patients were 2,792 (mean age, 65.6 ± 19.9 years) during 2-year survey including 166,000 visits, of 200,000 inhabitants catchment area; 8,239 patients received warfarin and 3,797 DOACs. Hypertension account for 1,077 (39%) patients; major bleeding for 474 (17%); death for 29 (1%), and 72 (3%) on 1-month and 1-year, respectively. Hypertension, age, glucose, cancer, ischemic vascular disease, and CHA2D2VASc score were more likely to link with major bleeding. On multivariate analysis, only age (odds ratio [OR], 1.02; P < 0.001), CHA2DS2VASc score ≥ 2 (OR, 2.14; P = 0.001), and glucose (OR, 1.01; P = 0.005) were predictors of major bleeding. Kaplan-Meier analysis demonstrated patients with hypertension as compared with patients without showed 60% versus 20% death on 1-month (P < 0.001). Warfarin compared with DOACs was more likely to present with major bleeding (0.7% versus 0.2%; OR, 2.8; P = 0.005). Receiver operator characteristics analysis showed high value (0.61) of age and glucose over creatinine and systolic arterial pressure (P = NS).. Four in 10 patients with major bleeding showed hypertension; of these 8 in 10 will die within 1 month. Warfarin compared with DOACs was more likely to present with major bleeding.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Blood Glucose; Blood Transfusion; Cardiovascular Diseases; Creatinine; Dabigatran; Emergency Service, Hospital; Epistaxis; Female; Gastrointestinal Hemorrhage; Hematuria; Hemoptysis; Hemorrhage; Humans; Hypertension; Intracranial Hemorrhages; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Prognosis; Propensity Score; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Severity of Illness Index; Sex Factors; Thiazoles; Warfarin

Atrial fibrillation (AF) and dementia are predominant among the elderly; patients with AF have an increased dementia risk. We aimed to study if prescribed antihypertensive drugs and cardiovascular pharmacotherapies are associated with a lower relative risk of dementia.. All included patients were ≥45 years and diagnosed with AF in primary care; 12,096 (6580 men and 5516 women) in Sweden. We excluded patients with a dementia diagnosis before onset of AF. Cox regression was used (hazard ratios, HRs, and 95% confidence interval, CI) with adjustments for sex, age, socioeconomic factors and co-morbidities.. Incident dementia occurred in 750 patients (6.2%) during an average of 5.6 years of follow-up (a total of 69,214 person-years). Patients prescribed thiazides HR 0.81 (95% CI 0.66-0.99) and warfarin HR 0.78 (95% CI 0.66-0.92) had a lower risk of dementia than patients without these drugs. The use of 1-4 of the different antihypertensive drug classes (thiazides, beta blocker, vessel active calcium channel blockers or renin angiotensin aldosterone (RAAS) blockers) were associated with a reduction of incident dementia; HR 0.80 (95% CI 0.64-1.00) for one to two drugs, and HR 0.63 (95% CI 0.46-0.84) for three or four drugs, versus having no prescribed antihypertensive drugs. The combination of a RAAS-blocker and a thiazide was significant, HR 0.70 (95% CI 0.53-0.92), versus not having that particular combination prescribed, while RAAS-blockers or thiazides separately were not significant.. Prescribed antihypertensive drugs, including thiazide/RAAS-blocker combination therapy and use of warfarin, were associated with a decreased incidence of dementia.

Topics: Aged; Aged, 80 and over; Antihypertensive Agents; Atrial Fibrillation; Cardiovascular Agents; Dementia; Female; Follow-Up Studies; Humans; Hypertension; Incidence; Male; Middle Aged; Risk Factors; Sweden; Thiazides; Warfarin

Background According to drug interaction databases, torsemide may potentiate the effects of warfarin. Evidence for this drug-drug interaction, however, is conflicting and the clinical significance is unknown. Objective The aim of this study is to evaluate the impact of torsemide initiation on warfarin dosage requirements. Setting This study was conducted at the Veterans Affairs Healthcare System in San Diego, California. Method A retrospective cohort study was conducted using Veterans Affairs data from patients who were converted from bumetanide to torsemide between March 2014 and July 2014. Patients were also prescribed and taking warfarin during the observation period. Warfarin dosage requirements were evaluated to determine if any changes occurred within the first 3 months of starting torsemide. Main outcome measure The primary outcome was the average weekly warfarin dose before and after torsemide initiation. Results Eighteen patients met study inclusion criteria. The weekly warfarin dose before and after initiation of torsemide was not significantly different (34 ± 15 and 34 ± 13 mg, p > 0.05). Of those eighteen patients, only two experienced elevations in INR that required a decrease in warfarin dosage after torsemide initiation. Between those two patients, dosage reductions ranged from 5.3 to 18%. Conclusion These results indicated that most patients did not require any warfarin dosage adjustments after torsemide was initiated. The potential for interaction, however, still exists. While empiric warfarin dosage adjustments are not recommended when initiating torsemide, increased monitoring is warranted to minimize the risk of adverse effects.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Cohort Studies; Drug Dosage Calculations; Drug Interactions; Female; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Retrospective Studies; Sulfonamides; Torsemide; Warfarin

Several studies have suggested a link exists between L-thyroxine and the coagulation system, and, according to some drug interaction studies, L-thyroxine can potentiate the effect of warfarin. This study sought to assess whether thyroid hormone therapy could impact the risk of bleeding in patients receiving vitamin K antagonists (VKAs).. We conducted a monocentric, retrospective study on prospectively collected data from consecutive patients enrolled in the Registry of patient with AntiThrombotic agents admitted to an Emergency Department (RATED) database, and compared the hemorrhage rates (both major and nonmajor) of patients receiving treatment with and without L-thyroxine. Propensity score matching analysis was performed to reduce the differences between patients receiving L-thyroxine and those not receiving L-thyroxine in order to reassess bleeding outcomes in patients receiving VKAs.. From January 2014 to June 2015, 1454 patients receiving VKAs were recruited into the RATED database. Overall, 187 patients (12.8%) received L-thyroxine. Patients receiving L-thyroxine were more likely to be female than those not receiving L-thyroxine (78.1 vs. 55%) and more likely to exhibit hypertension (65.5 vs. 55.7%; p = 0.015), but less likely to have history of myocardial infarction (9.6 vs. 16.6%; p = 0.022) or higher creatinine levels (96.1 vs. 112.1 μmol/L; p = 0.04). After propensity score matching, bleeding outcomes were not significantly different between patients receiving L-thyroxine and those not receiving L-thyroxine.. Our study revealed no evidence that L-thyroxine could increase bleeding risk in patients receiving VKAs. However, physicians must be aware that patients with thyroid disease receiving VKA therapy could have other drug interactions, particularly with amiodarone therapy. CLINICALTRIALS.. NCT02706080.

Topics: Aged; Aged, 80 and over; Anticoagulants; Female; Fibrinolytic Agents; Hemorrhage; Humans; Hypertension; Male; Middle Aged; Myocardial Infarction; Retrospective Studies; Thyroxine; Vitamin K; Warfarin

Atrial fibrillation (AF) is a major risk factor for ischemic stroke and associated with a 5-fold higher risk of stroke. In this retrospective cohort study, the incidence of and risk factors for ischemic stroke in patients with AF were identified. All patients (≥30 years old) without previous stroke who were diagnosed with AF in 2007-2013 were selected from the National Health Insurance Service-National Sample Cohort. To identify factors that influenced ischemic stroke risk, Cox proportional hazard regression analysis was conducted. During a mean follow-up duration of 3.2 years, 1022 (9.6%) patients were diagnosed with ischemic stroke. The overall incidence rate of ischemic stroke was 30.8/1000 person-years. Of all the ischemic stroke that occurred during the follow-up period, 61.0% occurred within 1-year after AF diagnosis. Of the patients with CHA2DS2-VASc score of ≥2, only 13.6% were receiving warfarin therapy within 30 days after AF diagnosis. Relative to no antithrombotic therapy, warfarin treatment for >90 days before the index event (ischemic stroke in stroke patients and death/study end in non-stroke patients) associated with decreased ischemic stroke risk (Hazard Ratio = 0.41, 95%confidence intervals = 0.32-0.53). Heart failure, hypertension, and diabetes mellitus associated with greater ischemic stroke risk. AF patients in Korea had a higher ischemic stroke incidence rate than patients in other countries and ischemic stroke commonly occurred at early phase after AF diagnosis. Long-term (>90 days) continuous warfarin treatment may be beneficial for AF patients. However, warfarin treatment rates were very low. To prevent stroke, programs that actively detect AF and provide anticoagulation therapy are needed.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Diabetes Complications; Female; Follow-Up Studies; Heart Failure; Humans; Hypertension; Incidence; Male; Middle Aged; Multivariate Analysis; Proportional Hazards Models; Retrospective Studies; Risk Factors; Stroke; Warfarin

Warfarin reduces stroke risk in atrial fibrillation (AF) patients. The quality of warfarin control, measured by time in therapeutic range (TTR), impacts outcome and adverse events. One tool evaluating risk of adverse events and potential warfarin control would simplify risk-benefit assessment of warfarin. Recently, HASBLED was demonstrated effective for this purpose, but this was in well-controlled patients with deep vein thrombosis. HASBLED as a predictor of warfarin control has not been validated in other populations including differing indications, warfarin control levels and ethnicities. The aim of this study was to determine whether HASBLED can predict warfarin control in patients with AF in Australia and Singapore. Retrospective data were collected for patients receiving warfarin between January and June 2014 in Australia and Singapore. Patient data were used to calculate HASBLED at the start and end of the study period. TTR was calculated for each patient, and mean TTR used for analysis to stratified HASBLED scores. Of the 4370 patients, there were 3199 in Australia and 1171 in Singapore with mean TTRs of 82% and 58%, respectively. At the start of the study, a HASBLED score ≥3 predicted significantly lower TTR in Singapore, whilst at the end of the study, this score identified patients with poor control in both Australia and Singapore. A HASBLED score ≥3 in patients treated with warfarin can differentiate significantly lower TTRs in Australian and Singapore patients with AF. HASBLED may assess bleed risk and warfarin control, identifying patients at high risk of poor warfarin outcome requiring additional INR monitoring or alternative anticoagulation.

Topics: Aged; Aged, 80 and over; Algorithms; Anticoagulants; Asian People; Atrial Fibrillation; Australia; Female; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Retrospective Studies; Risk Factors; Singapore; Stroke; Treatment Failure; Warfarin; White People

New oral anticoagulants for the prevention of stroke and systemic embolism in patients with atrial fibrillation have recently been introduced. In this translational study, we explored the risk of long-term anticoagulation on intracerebral hemorrhage under sustained severe arterial hypertension. We initiated anticoagulation with warfarin or apixaban in spontaneously hypertensive rats prone to develop severe hypertension and subsequent intracerebral bleeding complications. A non-anticoagulated group served as control. During an 11-week-study period, blood pressure, anticoagulation parameters, and clinical status were determined regularly. The incidence of histopathologically proven intracerebral hemorrhage was defined as the primary endpoint. Both warfarin and apixaban anticoagulation was fairly stable during the study period, and all rats developed severe hypertension. Intracerebral hemorrhage was determined in 29% (4/14) of warfarin rats and in 10% (1/10) of apixaban rats. Controls did not show cerebral bleeding complications (chi-square not significant). Mortality rate at study termination was 33% (2/6) in controls, 43% (6/14) in the warfarin group, and 60% (6/10) in the apixaban group. Animals died from extracerebral complications in most cases. Our study describes an experimental intracerebral hemorrhage model in the context of sustained hypertension and long-term anticoagulation. Extracerebral bleeding complications occurred more often in warfarin-treated animals compared with apixaban and control rats.

Topics: Animals; Anticoagulants; Cerebral Hemorrhage; Hemorrhage; Hypertension; Pyrazoles; Pyridones; Rats; Time Factors; Warfarin

This study aimed at identifying the determinants and prognostic significance of a sedimentation level (fluid-blood level) in the hematoma among patients with acute intracerebral hemorrhage (ICH) who participated in the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2).. Post-hoc analysis of the INTERACT2 dataset, a randomized controlled trial of patients with acute ICH with elevated systolic blood pressure (SBP), randomly assigned to intensive (target SBP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Patients with a sedimentation level at baseline assessment on CT, and modified Rankin Scale score at 90-day, were included in these analyses. Factors associated with a sedimentation level and its significance in relation to 90-day clinical outcomes were assessed in univariable and multivariable logistic regression models.. Of 2,065 participants, 19 (1%) had sedimentation level on baseline CT, which was independently associated with warfarin use (p = 0.006) and lobar ICH (p = 0.025). Sedimentation level was also associated with death or major disability at 90-day in both crude (84 vs. 53%; p = 0.014) and multivariable analyses adjusted for age, gender, Chinese region, warfarin use, baseline National Institutes of Health Stroke Scale score, onset to CT time, volume and location of ICH, intraventricular extension, and randomized intensive BP lowering (OR 3.94, 95% CI 1.01-15.37; p = 0.049).. The presence of hematoma sedimentation level on baseline CT is associated with warfarin use and lobar location of ICH, and predicts a worse outcome. Although uncommon, sedimentation level is an easily detectable prognostic factor in acute ICH.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Cerebral Hemorrhage; Disease Management; Female; Hematoma; Humans; Hypertension; Logistic Models; Male; Middle Aged; Multivariate Analysis; Prognosis; Risk Factors; Tomography, X-Ray Computed; Warfarin

A 34-year-old woman who had been using oral contraceptives for 10 years developed hypertensive crisis with papilloedema after an upper respiratory infection. Laboratory data showed hyperreninemic hyperaldosteronism and elevated levels of fibrinogen, fibrin, and fibrinogen degradation products. Echocardiography demonstrated two masses (18 mm) in the left ventricle. On the fourth hospital day, cerebral infarction, renal infarction, and upper mesenteric artery occlusion suddenly occurred despite the blood pressure being well-controlled using anti-hypertensive drugs. Echocardiography revealed the disappearance of the left ventricular masses, which suggested left ventricular thrombi. Cessation of the contraceptives and administration of heparin, warfarin, and anti-platelets drugs improved her general condition.

Topics: Adult; Antihypertensive Agents; Blood Pressure; Contraceptives, Oral; Echocardiography; Female; Fibrin Fibrinogen Degradation Products; Fibrinogen; Heart Ventricles; Heparin; Humans; Hypertension; Respiratory Tract Infections; Thrombosis; Treatment Outcome; Warfarin

To investigate the impact on outcomes of changing treatment guideline recommendations by comparing the proportion of patients with atrial fibrillation (AF) recommended oral anticoagulants (OACs) under the 2011 and 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines.. We used the "National Health Insurance Research Database" in Taiwan, which included 354,649 patients with AF from January 1, 1996 through December 31, 2011. Patients with a CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score of 2 or more and a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex category) score of 2 or more were considered to have a definitive indication for receiving OACs according to the 2011 and 2014 ACC/AHA guidelines, respectively.. The percentages of patients with AF recommended OACs increased from 69.3% (n=245,598) under the 2011 guideline to 86.7% (n=307,640) under the new 2014 guidelines, an increment of 17.5% (95% CI, 17.4-17.6). Most women with AF (94.1%) and patients older than 65 years (97.2%) would receive OACs on the basis of the 2014 guidelines. Among patients previously not being recommended OACs in older guidelines, OAC use under the new guidelines was associated with a lower risk of adverse outcomes (ischemic stroke or intracranial hemorrhage or bleeding requiring blood transfusion or mortality) with an adjusted hazard ratio of 0.89 (95% CI, 0.85-0.94).. In this nationwide cohort study, use of the 2014 guidelines led more patients with AF to receive OACs for stroke prevention, and this increased OAC use was associated with better outcomes. Better efforts to implement guidelines would lead to improved outcomes for patients with AF.

Topics: Administration, Oral; Age Distribution; Aged; Anticoagulants; Atrial Fibrillation; Comorbidity; Diabetes Mellitus; Female; Heart Failure; Humans; Hypertension; Insurance Claim Review; Intracranial Hemorrhages; Male; Outcome and Process Assessment, Health Care; Practice Guidelines as Topic; Risk Assessment; Sex Distribution; Stroke; Taiwan; Vascular Diseases; Warfarin

Intracerebral hemorrhage is a well-known complication resulting from warfarin use; however, warfarin-associated intraspinal hematoma is very rare. Warfarin-associated intraspinal hematoma may exhibit delayed progression, and patients may present with atypical symptoms, occasionally resulting in delayed diagnosis. We report the case of a 65-year-old man who visited our emergency department (ED) with acute urinary retention. He had been previously diagnosed with non-valvular atrial fibrillation, arterial hypertension, and benign prostatic hyperplasia, and he used warfarin for the prevention of systemic embolism. The patient was initially diagnosed with worsening of the prostatic hyperplasia. After 2 days, he revisited the ED with painless paraparesis. Magnetic resonance imaging of the thoracic spine revealed an intraspinal hematoma at Th7-8, and blood coagulation tests indicated a prothrombin time-international normalized ratio of 3.33. Despite attempts to reverse the effects of warfarin with vitamin K administration, the paraparesis progressed to paraplegia, necessitating urgent surgical removal of the hematoma. Partial recovery of motor function was evident after surgery. From the present case, we learned that intraspinal hematoma should be included in the differential diagnosis of patients using warfarin who present with acute urinary retention. Although there are no evidence-based treatment guidelines for warfarin-associated intraspinal hematoma, surgical treatment may be warranted for those who exhibit neurological deterioration.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Delayed Diagnosis; Diagnosis, Differential; Disease Progression; Hematoma, Epidural, Spinal; Humans; Hypertension; International Normalized Ratio; Male; Paraparesis; Prostatic Hyperplasia; Prothrombin Time; Recovery of Function; Urinary Retention; Warfarin

In this report, we present an interesting case of a patient with Rumpel-Leede phenomenon, a rare occurrence that can result in significant delays in medical treatment. This phenomenon is characterized by the presence of a petechial rash that results from acute dermal capillary rupture. In our patient, it occurred secondary to raised pressure in the dermal vessels caused by repeated inflation of a sphygmomanometer cuff. Contributory factors in Rumpel-Leede phenomenon include prevalent conditions such as diabetes mellitus, hypertension, thrombocytopenia, chronic steroid use, antiplatelets, and anticoagulants.. A 58-year-old Russian woman with diabetes and hypertension presented to our hospital with a non-ST elevation myocardial infarction, and she subsequently developed a petechial rash on her distal upper limbs. A vasculitic screen was performed, with normal results.. Given the timing and distribution of the rash, it was felt that this was an example of Rumpel-Leede phenomenon in a susceptible individual. This is an important diagnosis to be aware of in patients with vascular risk factors presenting for acute medical care who subsequently develop a petechial rash.

Topics: Anticoagulants; Atrial Fibrillation; Blood Pressure Determination; Diabetes Mellitus, Type 2; Female; Humans; Hypertension; Middle Aged; Myocardial Infarction; Purpura; Risk Factors; Warfarin

The new oral anticoagulants (NOACs) are used for the prevention of thromboembolic complications in patients with non-valvular atrial fibrillation (AF) and those at risk of deep venous thrombosis. Their rapid onset of action and predictable pharmacokinetic and pharmacodynamic profiles make them the optimal alternative to warfarin in the treatment of these two categories of patients. Unfortunately, however, NOACs cannot be used in patients with valvular AF or valvular cardiac prostheses. Although mechanical valves are effectively a contraindication to NOAC use due to several pathophysiological mechanisms that promote the use of warfarin rather than NOACs, few data exist regarding the use of such new pharmacological compounds on patients with cardiac biological valves or those who have undergone mitral repair or tubular aortic graft implantation.. Our case series involved 27 patients [mean age 70 ± 10 years; mean CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, Stroke/transient ischemic attack (doubled), Vascular disease, Age 65-74 years, Sex category): 6 ± 1.4; and mean HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratios, Elderly, Drugs or alcohol): 4 ± 1] with AF and biological prostheses, repaired mitral valves, or tubular aortic graft who were treated with the factor Xa inhibitor rivaroxaban due to inefficacy or adverse effects of warfarin.. The mean left ventricular ejection fraction was 48 ± 9 %, the left atrial diameter was 46.5 ± 7 mm, and the estimated glomerular filtration rate was 45 ± 21 mL/min/1.73 m(2). The mean duration of treatment was 15 ± 2 months. No relevant complications or recurrent thromboembolic events occurred. Three patients had recurrent nose bleeding and two had hematuria that led to reduction of the rivaroxaban dose by the treating physician to 15 mg once a day after 4 months of therapy. No further bleeding episode was recorded after escalating the dose.. Rivaroxaban is a valuable treatment option for patients with biological prostheses, repaired mitral valves, or a tubular aortic graft in order to prevent thromboembolic complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Female; Fibrinolytic Agents; Heart Failure; Hemorrhage; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Rivaroxaban; Stroke; Thromboembolism; Warfarin

We conducted a retrospective analysis examining the association between systolic blood pressure (SBP) or hypertension bracket and stroke risk in patients with atrial fibrillation (AF).. The study included 14,256 anticoagulated patients in the ROCKET AF trial. Cox proportional hazards models were used to compare the risk of adverse outcomes by European Society of Cardiology hypertension bracket and screening SBP.. In total, 90.5% of patients had hypertension (55.8% controlled, 34.6% uncontrolled). The adjusted risk of stroke or systemic embolism (SE) increased significantly for every 10-mm Hg increase in screening SBP (hazard ratio [HR] 1.07, 95% CI 1.02-1.13). There was a trend toward an increased adjusted risk of stroke or SE in patients with controlled (HR 1.22, 95% CI 0.89-1.66) and uncontrolled hypertension (HR 1.42, 95% CI 1.03-1.95) (P = .06). In contrast, the adjusted risk of major bleeding was similar between hypertensive brackets and did not vary significantly by screening SBP. The benefit of rivaroxaban versus warfarin in preventing stroke or SE was consistent among patients regardless of SBP (P interaction = .69).. In a trial of anticoagulated patients with AF, increasing screening SBP was independently associated with stroke and SE, and one-third of patients had uncontrolled hypertension. The relative effectiveness and safety of rivaroxaban versus warfarin were consistent across all levels of screening SBP. A single SBP may be an important factor in reducing the overall risk of stroke and SE in anticoagulated patients with AF.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Blood Pressure; Embolism; Female; Hemorrhage; Humans; Hypertension; Male; Middle Aged; Proportional Hazards Models; Randomized Controlled Trials as Topic; Retrospective Studies; Risk; Rivaroxaban; Stroke; Warfarin

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

Although controversial, several prior studies have suggested that oral anticoagulants (OACs) are underused in the US atrial fibrillation (AF) population. Appropriate use of OACs is essential because they significantly reduce the risk of stroke in those with AF. In the >2 million Americans with AF, OACs are recommended when the risk of stroke is moderate or high but not when the risk of stroke is low. To quantify trends and guideline adherence, we evaluated OAC use (either warfarin or dabigatran) in a 10-year period in patients with new AF in the Veterans Health Administration.. New AF was defined as at least 2 clinical encounters documenting AF within 120 days of each other and no previous AF diagnosis (N = 297,611). Congestive Heart Failure, Hypertension, Age > 75, Diabetes, and Stroke (CHADS2) scores were determined using age and diagnoses of hypertension, diabetes, heart failure, and stroke or transient ischemic attack during the 12 months before AF diagnosis. Receipt of an OAC within 90 days of a new diagnosis of AF was evaluated using VA pharmacy data.. Overall, initiation of an OAC fell from 51.3% in 2002 to 43.1% in 2011. For patients with CHADS2 score of 0, 1, 2, 3, 4, and 5-6, the proportions of patients prescribed an OAC showed a relative decrease of 26%, 23%, 14%, 12%, 9%, and 13%, respectively (P < .001). Clopidogrel use was stable at 10% of the AF population.. Among US veterans with new AF and additional risk factors for stroke, only about half receive OAC, and the proportion is declining.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antithrombins; Atrial Fibrillation; Clopidogrel; Dabigatran; Diabetes Mellitus; Female; Guideline Adherence; Heart Failure; Humans; Hypertension; Ischemic Attack, Transient; Male; Middle Aged; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk; Risk Assessment; Stroke; Ticlopidine; United States; United States Department of Veterans Affairs; Warfarin

The aim of this case report is to discuss the issue of nutritional therapy in patients taking warfarin. Patients are often prescribed vitamin K free diets without nutritional counseling, leading to possible health consequences.. A 52-year-old woman with obesity and hypertension was prescribed a low calorie diet by her family doctor in an effort to promote weight loss. After a pulmonary embolism, she was placed on anticoagulant therapy and on hospital discharge she was prescribed a vitamin K free diet to avoid interactions. Given poor control of her anticoagulant therapy, she was referred to our Nutritional Unit outpatients' service.. This case illustrates the importance of a thorough medical nutrition assessment in the management of patients with obesity and the need for a change in the dietary approach of nutritional therapy in the management of vitamin K anticoagulant therapy. In patients taking warfarin, evidence suggest that the aim of nutritional therapy should be to keep dietary intake of vitamin K constant.

Topics: Anticoagulants; Caloric Restriction; Female; Humans; Hypertension; Middle Aged; Nutrition Assessment; Obesity; Pulmonary Embolism; Vitamin K; Warfarin; Weight Loss

Sustained growth in the arrhythmia population at Stanford Health Care led to an independent nurse practitioner-run outpatient direct current cardioversion (DCCV) program in 2012. DCCVs performed by a medical doctor, a nurse practitioner under supervision, or nurse practitioners from 2009 to 2014 were compared for safety and efficacy. A retrospective review of the electronic medical records system (Epic) was performed on biodemographic data, cardiovascular risk factors, medication history, procedural data, and DCCV outcomes. A total of 869 DCCVs were performed on 557 outpatients. Subjects were largely men with an average age of 65 years; 1/3 were obese; most had atrial fibrillation; and majority of subjects were on warfarin. The success rate of the DCCVs was 93.4% (812 of 869) with no differences among the groups. There were no short-term complications: stroke, myocardial infarction, or death. The length of stay was shortest in the NP group compared to the other groups (p <0.001). In conclusion, the success rate of DCCV in all groups was extremely high, and there were no complications in any of the DCCV groups.

Topics: Aged; Aged, 80 and over; Ambulatory Care; Anticoagulants; Atrial Fibrillation; Cardiomyopathies; Comorbidity; Diabetes Mellitus, Type 2; Electric Countershock; Female; Humans; Hypertension; Length of Stay; Male; Middle Aged; Nurse Practitioners; Obesity; Patient Safety; Physicians; Practice Patterns, Nurses'; Retrospective Studies; Stroke; Treatment Outcome; Warfarin

Retinal vein occlusion (RVO) and retinal artery occlusion (RAO) cause significant visual impairment. The role of thrombophilia and cardiovascular testing is uncertain, and optimal treatment strategies have not been determined. We reviewed medical records of 39 patients with RVO and RAO (23 women and 16 men). Thrombophilia and cardiovascular evaluations were performed and outcomes were reviewed. In all, 24 (61.5%) patients had at least 1 thrombophilia. Elevated factor VIII levels were found in RVO (n = 5) but not in RAO. There are no other significant differences in thrombophilias in RVO compared to those in RAO. Most patients had hypertension(41.2% RAO and 55% RVO) and hyperlipidemia (35.5% RAO and 81.8% RVO). In all, 4 women were using oral contraceptives, 2 were pregnant or postpartum. Follow-up data was available for 28 patients (13 RAO, 15 RVO). Nineteen were treated with aspirin, four with warfarin, and one with low molecular weight heparin. Eight patients reported improvement in vision at time of follow-up (5 RAO, 3 RVO). Multiple risk factors are associated with RVO and RAO, and a complete assessment should include thrombophilia and cardiovascular studies.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Female; Humans; Hyperlipidemias; Hypertension; Male; Middle Aged; Postpartum Period; Pregnancy; Pregnancy Complications; Retinal Vein Occlusion; Retrospective Studies; Risk Factors; Thrombophilia; Warfarin

To compare the methods of office blood pressure (BP) measurement and ambulatory blood pressure monitoring (ABPM) to ensure optimal BP control in hypertensive anticoagulated patients.. Seventy-eight patients who were receiving antihypertensive drugs and warfarin in a dose-adjusted approach to achieve therapeutic international normalized ratio because of the association of atrial fibrillation were enrolled in the study. Twenty-four hour ABPM was applied to all patients. For the assessment of optimal BP control, office BP measurements were compared with ABPM recordings. All patients were divided into 'good control' and 'poor control' groups with a cut-off level of 140 mmHg systolic blood pressure (SBP). The groups of patients with 'good control' and 'poor control' were further subdivided into four groups according to the cardiovascular outcome on the basis of ABPM reference threshold levels: 'true good control' or 'seemingly good control' and 'true poor control' or 'seemingly poor control' (white coat effect). Positive and negative predictive values of the office BP measurement method versus ABPM were estimated.. According to office measurements, 56.9% of all cases were in the 'good control' group and 43.1% were in the 'poor control' group. When we reclassified patients according to daytime and night-time mean SBP, we realized that they were in 'true good control', 'seemingly good control', 'true poor control', and 'seemingly poor control' groups with ratios of 25.5, 31.4, 21.6, and 21.6% on the basis of daytime systolic mean values and 19.6, 37.3, 35.3, and 7.8% on the basis of night-time systolic mean values, respectively. When we considered ABPM as a reference method, sensitivity, specificity, and positive and negative predictive values of office SBP measurements were 40.74, 54.17, 50.00, and 44.83% for daytime SBP mean values and 48.65, 71.43, 81.82, and 34.48% for night-time SBP mean values, respectively.. Poor control of SBP in patients with anticoagulant therapy may result in fatal events such as intracranial bleeding; thus, they are still under significant risk, although they are considered to have controlled BP with office measurements. ABPM is an essential method for accurate BP control in contrast to office BP measurement in anticoagulated patients.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Blood Pressure; Blood Pressure Monitoring, Ambulatory; False Positive Reactions; Female; Humans; Hypertension; Male; Middle Aged; Predictive Value of Tests; Sensitivity and Specificity; Warfarin

The difference between left atrial (LA) and systemic coagulation activity in paroxysmal atrial fibrillation (PAF) is unclear.. We enrolled 100 patients with PAF who underwent AF ablation. Warfarin was stopped 1 day before the procedure. LA volume index and LA emptying fraction were measured by 64-slice multidetector computed tomography. Immediately after transseptal puncture, blood samples were simultaneously collected from the LA and systemic circulation (SC). In addition, to evaluate the effect of warfarin on D-dimer levels we recruited an additional 27 PAF patients on continuous warfarin. Even in patients with low CHADS2 scores (mean 0.59 ± 0.68) and during sinus rhythm, the prevalence of positive LA-D-dimer (≥ 0.5 µg/ml) was greater than that of SC-D-dimer (23% vs. 10%, P<0.01). The LA-D-dimer-positive patients had a larger mean LA volume index and reduced LA emptying fraction than the LA-D-dimer-negative patients. Multiple logistic regression analysis revealed that LA volume index was independently correlated with positive LA-D-dimer (odds ratio 2.245, 95% confidence interval 1.194-4.626, P=0.0112). The prevalence of positive LA-D-dimer was significantly lower in patients taking continuous warfarin, than in those on discontinuous warfarin (3.7% vs. 23%, P=0.025).. An enlarged LA volume index was associated with high LA coagulation status in patients with paroxysmal AF. Adequate warfarin control during AF catheter ablation may reduce the prevalence of positive LA-D-dimer.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Blood Coagulation; Cardiovascular Agents; Catheter Ablation; Combined Modality Therapy; Comorbidity; Diabetes Mellitus; Female; Fibrin Fibrinogen Degradation Products; Heart Atria; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Multidetector Computed Tomography; Predictive Value of Tests; Prognosis; Proportional Hazards Models; Prospective Studies; Prothrombin Time; Severity of Illness Index; Stroke; Thrombophilia; Thrombosis; Ultrasonography; Warfarin

Anticoagulation therapy with warfarin is recommended for stroke prevention in patients with atrial fibrillation (AF) or atrial flutter (AFL) whose risks for stroke are high. However, previous studies suggest that warfarin is markedly underused. This study aims to investigate the incidence and risk factors of warfarin underutilization in patients with high risk of stroke in Korea.. This was a cross-sectional study using the data of 2009 from National Patients Sample compiled by the Health Insurance Review and Assessment Service. Patients with high risk of thromboembolism were identified with congestive heart failure, hypertension, age ≥75 years, diabetes, and prior stroke (CHADS2) score ≥2. High-risk patients of bleeding were excluded using Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) score >4. Warfarin and antithrombotic therapy underutilization were defined and estimated in high-risk patients. Any demographic and clinical factors associated with warfarin and antithrombotic therapy underutilization were explored using a logistic regression model.. Of the national patient sample, 15,885 patients were identified with AF or AFL. Among them, a total of 8475 patients who had an admission history, CHADS2 ≥2, and ATRIA score ≤4 were included in the analysis. From the study sample, warfarin underutilization and antithrombotic therapy underutilization were estimated to be 64.0% and 20.4%, respectively. Predictors of warfarin underutilization include female sex, age ≥80 years, lower CHADS2 score, and insurance type (Medical Aid program).. A high portion of AF/AFL patients with CHADS2 score ≥2 were undertreated with warfarin. As ischemic stroke is one of the leading causes of death in Korea, a more aggressive approach to prevent stroke in patients with AF/AFL is required.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Atrial Flutter; Cross-Sectional Studies; Diabetes Complications; Female; Health Status Indicators; Heart Failure; Hospitalization; Humans; Hypertension; Incidence; Logistic Models; Male; Middle Aged; Republic of Korea; Risk Factors; Stroke; Thromboembolism; Warfarin

Acetylsalicylic acid (ASA) and warfarin are used to prevent ischemic cerebrovascular events. They have serious complications including intracranial hemorrhages (ICHs). Warfarin-related intracerebral hemorrhage (ich) incidence is .2%-5% in population that accounts for 10%-12% of all ichs. In this article, we investigated the profile of ASA and warfarin-related spontaneous ICHs in comparison with ICHs without any drug use (WADU) with their clinical, radiological, and biochemical properties.. In all, 486 patients aged 18-101 years with spontaneous ICHs were included. Patients constituted 4 separate groups: users of warfarin, ASA, ASA + warfarin, and WADU. Clinical, neurological, etiological, and radiological data of these patients were compared.. There were 32 patients in warfarin, 58 patients in ASA, and 7 in warfarin + ASA group. Most of the patients were in no drug group (389 patients). The most frequent type of hemorrhage was supratentorial intraparenchymal hemorrhage. The most common accompanying disease was hypertension. The number of female patients was statistically significant in the warfarin group. Glasgow Coma Scale (GCS), accompanying diseases, opening of the hematoma to the ventricle, localization of the hemorrhage, age of the patient, and activated partial thromboplastin time level are all related to the outcome of patients. Warfarin users had worst mortality rate.. Use of warfarin, low GCS score, opening to ventricle, older age, accompanying diabetes, and/or hypertension were worse prognostic factors. It is possible that patients with these unfavorable prognostic factors cannot survive.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Blood Coagulation; Comorbidity; Diabetes Mellitus; Female; Fibrinolytic Agents; Glasgow Coma Scale; Humans; Hypertension; Intracranial Hemorrhages; Male; Middle Aged; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Turkey; Warfarin; Young Adult

Topics: Anticoagulants; Antihypertensive Agents; Contusions; Female; Humans; Hypertension; Medication Errors; Perindopril; Warfarin

To investigate the clinical features and current therapy of atrial fibrillation (AF) of inpatients in Urumqi, China.. The clinical data of inpatients diagnosed with AF from January, 2008 to December, 2012, in 12 hospitals in Urumqi were retrospectively analyzed.. Totally 1 310 AF inpatients were enrolled in this study with the age of (64.8 ± 3.3) years old and a men to women ratio of 1.39. Most patients were in age groups of 61-70 years (26.5%) and 71-80 years (27.6%). More patients with paroxysmal AF were at cardiac function class I-II (75.2%), while more patients with persistent AF were at cardiac function class III-IV (31.0%) (both P values < 0.05). The most common co-morbidities of AF were hypertension (49.2%), coronary heart disease (38.5%), diabetes mellitus (20.1%). Compared with patients of chronic AF, the patients of paroxysmal AF had higher success rates in amiodarone conversation and sinus rhythm maintenance after ablation (44.8% vs 29.9%, 87.5% vs 68.9%, P values < 0.05). Among the 1 310 inpatients, 992 patients (75.7%) received antithrombotic therapy. There were statistically significant differences in CHA2DS2 score and incidence rate of cerebral infarction among patients receiving aspirin, warfarin or rivaroxaban/other anticoagulation drugs [2(1, 3) vs 3(2, 4) vs 3(2, 5) and 6.3% vs 23.8% vs 30.2%, both P values < 0.05].. Our results of AF inpatients' age, gender, related disease distribution, AF types, incidence of stoke, therapeutic and epidemiological features are in accordance with the domestic and abroad reports.

Topics: Aged; Amiodarone; Anti-Arrhythmia Agents; Anticoagulants; Aspirin; Atrial Fibrillation; China; Comorbidity; Diabetes Mellitus; Factor Xa Inhibitors; Female; Fibrinolytic Agents; Humans; Hypertension; Incidence; Inpatients; Male; Morpholines; Retrospective Studies; Rivaroxaban; Stroke; Thiophenes; Treatment Outcome; Warfarin

The burden of cardiovascular disease is expected to escalate in developing countries. However, studies and guidelines concerning atrial fibrillation (AF) are restricted to the developed world.. To assess the treatment modalities of AF in South Africa.. A cross-sectional, observational, multicentre, national registry of the treatment of 302 patients with AF was conducted from February 2010 to March 2011. Specific drug use for rate or rhythm control, as well as drug use for stroke prevention, was surveyed. Events during the 12 months prior to the survey were also characterised, including non-drug treatments, resource utilisation and complications.. The single most prevalent clinical characteristic was hypertension (65.9%). Rhythm control was being pursued in 109 patients (36.1%) with class Ic and class III antiarrhythmic agents, while rate control, mainly with beta-blockers, was pursued in the remainder of the patients. Concomitant use of other cardiovascular drugs was high, and 75.2% of patients were on warfarin for stroke prevention. There was a high burden of AF-related morbidity during the preceding year, with 32.5% reporting a history of heart failure, 8.3% a stroke and 5.3% a transient ischaemic attack. Therapeutic success, as defined by either the presence of sinus rhythm or rate-controlled AF, was achieved in 86.8% as judged clinically by the treating physician, but in only 70.2% according to the electrocardiogram criterion of heart rate ≤80 bpm.. There were no striking differences from previously reported registries worldwide. The lack of application of strict rate control criteria is highlighted.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Aged, 80 and over; Anti-Arrhythmia Agents; Atrial Fibrillation; Cost of Illness; Cross-Sectional Studies; Electrocardiography; Female; Humans; Hypertension; Male; Middle Aged; Prospective Studies; Registries; South Africa; Stroke; Warfarin; Young Adult

We herein present the first reported case of severe proptosis caused by ocular and periocular hemorrhages in a continuous ambulatory peritoneal dilaysis patient without previous history of trauma. The bleeding tendency caused by uremia and the use of warfarin during uncontrolled high blood pressure were most likely responsible for her ocular and periocular hemorrhages. Appropriate control of blood pressure and adequate self-care education are important for the prevention and treatment of any bleeding complications in uremic patients receiving both maintenance anticoagulation therapy and peritoneal dialysis.

Topics: Adult; Exophthalmos; Eye; Female; Hemorrhage; Humans; Hypertension; Peritoneal Dialysis, Continuous Ambulatory; Uremia; Warfarin

To study the clinical presentation of the first episode of atrial fibrillation (AF), treatment tactics and its compliance with current recommendations, features of the further clinical course and prognosis in patients with AF we performed a retrospective study on data of Polyclinic No 1 of the General Management Department of the President of RF . We analyzed data from 58 patients (36 men, 22 women) from January 2009 to September 2011 inclusive. The first episode of AF was recorded in the age from 48 to 90 years (in 39.7% of patients - aged 80 to 90 years old), mostly had paroxysmal character (84.5%), in 82.1% of cases was accompanied by marked clinical symptoms: sense of disruption of the heart (50%), feeling short of breath (28.6%), weakness (17.9%). In 87% of cases clinical symptomatology required calls for medical emergencies. In 42.9% of cases uncontrolled hypertension was possible predisposing factor for developing AF. Paroxysmal AF moved to constant in 38.8% of patients during the period from 1 year to 18 years. Due to the high risk of thromboembolic complications (2 to 5 on a scale of CHADS2), after the detection AF warfarin was shown to 96.6% of patients, because of the high risk of bleeding in practice was appointed only 37.9%. Complications of therapy in the form of bleeding were 9.1%. Tactics of rhythm control by antiarrhythmic drugs I and III classes has remained in 36.7% of patients with paroxysmal AF. -adrenoblockers were constantly taken by 63.3% of the patients using antiarrhythmic drugs I and III classes for relief of arrhythmia during her recurrence (the strategy of "pill in pocket").

Topics: Aged; Aged, 80 and over; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Episode of Care; Female; Hemorrhage; Humans; Hypertension; Male; Middle Aged; Prognosis; Retrospective Studies; Secondary Prevention; Warfarin

Cerebral microbleeds (CMBs) are known to be indicative of bleeding-prone microangiopathy. Little is known about the significance of CMBs in anticoagulated patients. We determined the frequency of new CMBs in ischemic stroke patients who had been receiving warfarin treatment for 2 years.. A total of 204 ischemic stroke patients on warfarin therapy for 2 years underwent a repeat MRI. We compared demographic features, vascular risk factors, and radiological findings of patients with and without new CMBs.. New CMBs on gradient-echo MRI were found in 29 of 204 patients (10%). Of 35 patients who had CMBs in the original study, 9 developed new CMBs after 2 years (26%), compared with 20 of the 169 patients (12%) who did not have CMBs at baseline (p=0.03). Patients with new CMBs were older than patients without CMBs (p=0.04), and the frequency of leukoaraiosis was significantly higher (p=0.02). The mean duration of warfarin treatment was not significantly different between the patients with and without new CMBs (p=0.28).. This longitudinal study suggested that the presence of CMBs at baseline increased the frequency of new CMBs in patients on warfarin therapy.

Topics: Aged; Anticoagulants; Brain Ischemia; Cerebral Hemorrhage; Female; Follow-Up Studies; Humans; Hypertension; International Normalized Ratio; Leukoaraiosis; Longitudinal Studies; Magnetic Resonance Imaging; Male; Middle Aged; Risk Factors; Stroke; Warfarin

Although atrial fibrillation (AF) is one of the most common rhythm disorders observed in clinical practice, a multicenter epidemiological study has not been conducted in our country. This study aimed to assess our clinical approach to AF based upon the records of the first multicenter prospective Atrial Fibrillation in Turkey: Epidemiologic Registry (AFTER) study.. Taking into consideration the distribution of the population in our country, 2242 consecutive patients with at least one AF attack determined by electrocardiographic examination in 17 different tertiary health care centers were included in the study. Inpatients and patients that were admitted to emergency departments were excluded from the study. Epidemiological data of the patients and the treatment administered were assessed.. The mean age of the patients was determined as 66.8 ± 12.3 years with female patients representing 60% of the study population. While the most common AF type in the Turkish population was non-valvular AF (78%), persistent/permanent AF was determined in 81% of all patients. Hypertension (%67) was the most common co-morbidity in patients with AF. While a stroke or transient ischemic attack or history of systemic thromboembolism was detected in 15.3% of the patients, bleeding history was recorded in 11.2%. Also, 50% of the patients were on warfarin treatment and 53% were on aspirin treatment at the time of the study. The effective INR level was detected in 41.3% of the patients. The most frequent cause of not receiving anticoagulant therapy was physician neglect.. These results demonstrate the necessity for improved quality of physician care of patients with AF, especially with regards to antithrombotic therapy.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Atrial Fibrillation; Electrocardiography; Female; Hemorrhage; Humans; Hypertension; Ischemic Attack, Transient; Male; Middle Aged; Platelet Aggregation Inhibitors; Prospective Studies; Risk Factors; Stroke; Thromboembolism; Turkey; Warfarin; Young Adult

This study determined the association between co-morbidities, including heart failure (HF) and time in therapeutic range (TTR), in patients with nonvalvular atrial fibrillation. Longitudinal patient-level anticoagulation management records collected from 2006 to 2010 were analyzed. Adult patients with nonvalvular atrial fibrillation who used warfarin for a 12-month period with no gap of >60 days between visits were identified. TTR <55% was defined as "lower" TTR. CHADS₂ score of ≥2 was defined as "higher" CHADS₂. Logistic regression analyses were conducted to determine the association between co-morbidities and TTR. A total of 23,425 patients met the study criteria. The mean age ± SD was 74.8 ± 9.7 years, with 84.8% aged ≥65 years. The most common co-morbidities were hypertension (41.7%), diabetes (24.1%), HF (11.7%), and previous stroke (11.1%). The mean TTR ± SD was 67.3 ± 14.4%, with 18.6% of patients in the lower TTR range. In multivariate analyses using age, gender, hypertension, diabetes, stroke, and region as covariates, HF (adjusted odds ratio [OR] 1.41, 95% confidence interval [CI] 1.28 to 1.56; p <0.001), diabetes (OR 1.28, 95% CI 1.19 to 1.38; p <0.001), and previous stroke (OR 1.15, 95% CI 1.04 to 1.27; p <0.001) were associated with lower TTR. In a second set of multivariate analyses using gender and region as covariates, a higher CHADS₂ score was associated with lower TTR (OR 1.11, 95% CI 1.04 to 1.18; p <0.001). In conclusion, HF was associated with the greatest likelihood of a lower TTR, followed by diabetes, then stroke. Anticoagulation control may be more challenging for patients with these conditions.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Comorbidity; Decision Support Techniques; Diabetes Complications; Female; Heart Failure; Humans; Hypertension; International Normalized Ratio; Logistic Models; Longitudinal Studies; Male; Middle Aged; Risk Factors; Software; Stroke; Time Factors; Warfarin

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Dabigatran; Diabetes Complications; Female; Hemorrhage; Humans; Hypertension; Male; Middle Aged; Morpholines; Pyrazoles; Pyridones; Randomized Controlled Trials as Topic; Rivaroxaban; Secondary Prevention; Stroke; Thiophenes; Warfarin

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. This study aims to update the knowledge about AF and associated stroke risk and benefits of anticoagulation.. We extracted data from the hospital, specialized outpatient, and primary healthcare and drug registries in a Swedish region with 1.56 million residents. We identified all individuals who had received an AF diagnosis during the previous 5 years; all stroke events during 2010; and patients with AF aged ≥50 years who had received warfarin during 2009.. AF had been diagnosed in 38 446 subjects who were alive at the beginning of 2010 (prevalence of 3.2% in the adult [≥20 years] population); ≈46% received warfarin therapy. In 2010, there were 4565 ischemic stroke events and 861 intracranial hemorrhages. AF had been diagnosed in 38% of ischemic events (≥50% among those aged ≥80 years) and in 23% of intracranial hemorrhages. An AF diagnosis was often lacking in hospital discharge records after stroke events. Warfarin therapy was associated with an odds ratio of 0.50 (confidence interval, 0.43-0.57) for ischemic stroke and, despite an increased risk of intracranial hemorrhage, an odds ratio of 0.57 (confidence interval, 0.50-0.64) for the overall risk for stroke.. AF is more common than present guidelines suggest. The attributable risk of AF for ischemic stroke increases with age and is close to that of hypertension in individuals aged ≥80 years. Because a majority of patients with AF with increased risk for stroke had not received anticoagulation therapy, there is a large potential for improvement.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Cohort Studies; Female; Humans; Hypertension; Male; Middle Aged; Odds Ratio; Prevalence; Registries; Regression Analysis; Risk Factors; Stroke; Sweden; Warfarin

To prevent major hemorrhage during anticoagulation, it is quite important to manage controllable risk factors such as hypertension, diabetes mellitus, smoking habit, and too much alcohol intake. It is also important to avoid dual antithrombotic therapy as long as possible, which increases severe bleeding events. For patients with major bleeding during anticoagulation, we should stop oral medication, stop bleeding by mechanical compression or surgical interventions, and maintain circulation blood volume and blood pressure by appropriate intravenous drip infusion. When intracranial hemorrhage happens, adequate treatment to suppress blood pressure should be provided. Administration of prothrombin complex concentrate (PCC) and vitamin K is effective for urgent reversal of anticoagulation by warfarin. The PCC may be also useful for that by novel oral anticoagulants.

Topics: Administration, Oral; Alcohol Drinking; Anticoagulants; Benzimidazoles; beta-Alanine; Cerebral Hemorrhage; Dabigatran; Diabetes Mellitus; Drug Therapy, Combination; Factor IX; Fibrinolytic Agents; Hemorrhage; Humans; Hypertension; Risk Assessment; Risk Factors; Smoking; Vitamin K; Warfarin

Topics: Adult; Anticoagulants; Antihypertensive Agents; Contusions; Female; Humans; Hypertension; Medication Errors; Perindopril; Warfarin

The Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society jointly recommend indefinite warfarin anticoagulation in patients with CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke) score of at least 2 who have undergone ablation for atrial fibrillation. This study determined the impact of CHADS2 score on risk of late stroke or transient ischemic attack after the performance of a surgical Cox maze procedure.. A retrospective review of 433 patients who underwent a Cox maze procedure at our institution was conducted. Three months after surgery, warfarin was discontinued regardless of CHADS2 score if the patient showed no evidence of atrial fibrillation, was off antiarrhythmic medications, and had no other indication for anticoagulation. A follow-up questionnaire was used to determine whether any neurologic event had occurred since surgery.. Follow-up was obtained for 90% of the study group (389/433) at a mean of 6.6 ± 5.0 years. Among these patients, 32% (125/389) had a CHADS2 score of at least 2, of whom only 40% (51/125) remained on long-term warfarin after surgery. Six patients had late neurologic events (annualized risk of 0.2%). Neither CHADS2 score nor warfarin anticoagulation was significantly associated with the occurrence of late neurologic events. Among the individual CHADS2 criteria, both diabetes mellitus and previous stroke or transient ischemic attack were predictive of late neurologic events.. The risk of stroke or transient ischemic attack in patients after a surgical Cox maze procedure was low and not associated with CHADS2 score or warfarin use. Given the known risks of warfarin, we recommend discontinuation of anticoagulation 3 months after the procedure if the patient has no evidence of atrial fibrillation, has discontinued antiarrhythmic medications, and is without any other indication for systemic anticoagulation.

Topics: Age Factors; Aged; Anticoagulants; Atrial Fibrillation; Cardiac Surgical Procedures; Diabetes Complications; Heart Failure; Humans; Hypertension; Ischemic Attack, Transient; Patient Acuity; Postoperative Complications; Retrospective Studies; Risk Factors; Stroke; Thromboembolism; Time Factors; Warfarin

Topics: Administration, Oral; Adult; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Cytochrome P-450 CYP2C9; Exons; Female; Genetic Predisposition to Disease; Genetic Testing; Genotype; Haplotypes; Hemorrhage; Humans; Hypertension; Mixed Function Oxygenases; Morpholines; Mutation; Poland; Rivaroxaban; Thiophenes; Vitamin K; Vitamin K Epoxide Reductases; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Heart Rate; Humans; Hypertension; Warfarin

Hyperthyroidism is a questionable risk factor for thromboembolism among patients with atrial fibrillation..   To correlate clinical risk factors for thromboembolism from a group of patients with atrial fibrillation related to hyperthyroidism with transoesophageal echocardiography (TOE) markers of a thrombogenic milieu..   Clinical risk factors for thromboembolism, thyroid hormonal status, time since diagnosis of hyperthyroidism and TOE markers of a thrombogenic milieu were assessed in consecutive patients with atrial fibrillation related to hyperthyroidism. The following TOE parameters were assessed to define the presence of thrombogenic milieu: dense spontaneous echo contrast, thrombi or left atrial appendage blood flow velocities <0·20 m/s. Clinical risk factors for thromboembolism were based on CHADS(2) (Cardiac failure, Hypertension, Age, Diabetes and Stroke) classification..   This study included 31 consecutive patients aged between 18 and 65 years with atrial fibrillation related to hyperthyroidism scheduled for TOE..   Thrombogenic milieu was present in 14 of 31 (45·2%) patients. The thyroid status could not predict the presence of a thrombogenic milieu. Despite low CHADS(2) score of 0/1, 6 of 13 (46·1%) patients had a thrombogenic milieu, whereas 10 of 18 (55·6%) patients with score ≥2 had none. The probability of having a thrombogenic milieu did not correlate with the number of clinical risk factors..   Among patients younger than 65 years of age with atrial fibrillation related to hyperthyroidism, there is no association between clinical risk factors with TOE markers of a thrombogenic milieu. TOE adds useful information that may affect antithrombotic therapy guided by clinical risk classification.

Topics: Adult; Anticoagulants; Atrial Fibrillation; Diabetes Complications; Echocardiography, Transesophageal; Female; Heart Failure; Humans; Hypertension; Hyperthyroidism; Male; Middle Aged; Risk Assessment; Risk Factors; Stroke; Thromboembolism; Warfarin

Hypertension is the most important modifiable risk factor for intracerebral hemorrhage (ICH), but blood pressure (BP) management during the acute phase of ICH is still controversial. Approximately one-fourth of ICHs occur during treatment with warfarin or aspirin.. This study was designed to determine the effect of admission BP on the early prognosis of ICH patients by dividing them into three groups (warfarin, aspirin, and no drugs).. Three hundred and sixty-nine patients with supratentorial ICH were divided into three groups according to medication. Each group was evaluated in terms of prognosis and the risk for mortality based on the modified Rankin Scale (mRS) score at discharge (good prognosis: mRS ≤ 3; poor prognosis: mRS > 3). The effect of admission BP on prognosis was evaluated for each group.. The in-hospital mortality rate was 72% for ICH patients treated with warfarin, 41.6% for ICH patients treated with aspirin, and 35% for ICH patients treated with no drugs. Admission mean arterial blood pressure (MABP) values were higher in patients with poor prognosis compared with patients with good prognosis for the aspirin (P = .002) and no-drug (P = .001) groups, but not in the warfarin (P = .067) group.. A high MABP at admission was found to be an independent predictor of poor prognosis for ICH patients treated with aspirin or with no drugs, but not for ICH patients treated with warfarin.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Aspirin; Blood Pressure; Cerebral Hemorrhage; Female; Fibrinolytic Agents; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Prognosis; Risk Factors; Warfarin

Medication nonadherence is a barrier to successfully managing hypertension, but little is known about the contribution that immediate discontinuations have on antihypertensive (AHT) nonadherence. The purpose of this study was to determine the proportion of new AHT users who discontinue after a single dispensation, and to examine potential predictors of these discontinuations.. This retrospective cohort study utilizing linked administrative data from Saskatchewan, Canada. Subjects were ≥40 years of age and received a new AHT between 1994-2002. The primary end point was the proportion of subjects who discontinued their AHT after the first dispensation (first-fill discontinuation). The proportion of nonadherence attributed to first-fill discontinuations was then calculated. Multivariate regression identified factors associated with first-fill discontinuations.. 52,039 subjects were included in the analyses. Mean age was 59.4 (s.d. 12.5) years, and 42% were male. Overall, 25,812/52,039 (50%) subjects were nonadherent at 1 year; first-fill discontinuations accounted for 39.1% (10,081/25,812) of this nonadherence. Approximately 20% (10,081/52,039) of all subjects discontinued all AHT therapy after the first fill. A higher chronic disease score (adjusted odds ratio (OR) 1.09, 95% confidence interval (CI) 1.08-1.11) and antidepressant medication usage during the observation year (adjusted OR 1.17, 95% CI 1.09-1.26) was associated with increased risk for first-fill discontinuations. Older age, starting AHT therapy after 1994, frequent physician visits, or use of a statin, acetylsalicylic acid, warfarin or antihyperglycemic during the observation year was associated with a lower risk for first-fill discontinuations.. A substantial proportion of nonadherence to AHT medications is due to discontinuations after only a single dispensation.

Topics: Age Factors; Aged; Antidepressive Agents; Antihypertensive Agents; Aspirin; Chronic Disease; Depression; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypertension; Hypoglycemic Agents; Male; Medication Adherence; Middle Aged; Retrospective Studies; Saskatchewan; Warfarin

Only 50% of patients who would benefit from warfarin therapy for atrial fibrillation (AF) receive treatment because of clinical concerns regarding chronic anti-coagulation. Percutaneous strategies to treat AF, including pulmonary vein isolation with a curative intent or atrioventricular nodal ablation and implantation of a permanent pacemaker for palliative rate control, have not eliminated the need to manage thromboembolic risk. With the development of a percutaneous left atrial appendage (LAA) occlusion device (the WATCHMAN percutaneous left atrial appendage occluder - Atritech Inc., Plymouth, MN, USA) for thromboembolic protection in non-valvular AF a significant therapeutic option for select patients may be available. We present the first case performed in Australia (24 November 2009) and explore this new methodology.

Topics: Aged; Anticoagulants; Aspirin; Atrial Appendage; Atrial Fibrillation; Cardiac Catheterization; Female; Humans; Hypertension; Ischemic Attack, Transient; Patient Preference; Risk; Risk Assessment; Septal Occluder Device; Thromboembolism; Tomography, X-Ray Computed; Ultrasonography; Warfarin

The Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke (CHADS(2)) score is used to predict the need for oral anticoagulation for stroke prophylaxis in patients with atrial fibrillation. The Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category (CHA(2)DS(2)-VASc) schema has been proposed as an improvement. Our objective is to determine how adoption of the CHA(2)DS(2)-VASc score alters anticoagulation recommendations.. Between 2004 and 2008, 1664 patients were seen at the University of Virginia Atrial Fibrillation Center. We calculated the CHADS(2) and CHA(2)DS(2)-VASc scores for each patient. The 2006 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines for atrial fibrillation management were used to determine anticoagulation recommendations based on the CHADS(2) score, and the 2010 European Society of Cardiology guidelines were used to determine anticoagulation recommendations based on the CHA(2)DS(2)-VASc score.. The average age was 62±13 years, and 34% were women. Average CHADS(2) and CHA(2)DS(2)-VASc scores were 1.1±1.1 and 1.8±1.5, respectively (P<.0001). The CHADS(2) score classified 33% as requiring oral anticoagulation. The CHA(2)DS(2)-VASc score classified 53% as requiring oral anticoagulation. For women, 31% had a CHADS(2) score ≥ 2, but 81% had a CHA(2)DS(2)-VASc score ≥ 2 (P = .0001). Also, 32% of women with a CHADS(2) score of zero had a CHA(2)DS(2)-VASc score ≥ 2. For men, 25% had a CHADS(2) score ≥ 2, but 39% had a CHA(2)DS(2)-VASc score ≥ 2 (P<.0001).. Compared with the CHADS(2) score, the CHA(2)DS(2)-VASc score more clearly defines anticoagulation recommendations. Many patients, particularly older women, are redistributed from the low- to high-risk categories.

Topics: Administration, Oral; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Comorbidity; Diabetes Complications; Drug Administration Schedule; Europe; Female; Heart Failure; Hemorrhage; Humans; Hypertension; Male; Middle Aged; Practice Guidelines as Topic; Predictive Value of Tests; Primary Prevention; Propensity Score; Risk Assessment; Risk Factors; Secondary Prevention; Sex Factors; Societies, Medical; Stroke; United States; Warfarin

The decision to prescribe oral anticoagulant therapy in patients with atrial fibrillation is based on an assessment of the competing risks of ischemic stroke and major bleeding, of which intracerebral hemorrhage (ICH) is the most important type. We sought to determine the comparative importance of risk factors for ischemic stroke and ICH in patients with acute stroke and atrial fibrillation with particular emphasis on risk factors common to both stroke types.. Consecutive patients with acute ischemic stroke or ICH and atrial fibrillation included in the Registry of the Canadian Stroke Network constituted the cohort. Multivariable logistic regression analysis was used to determine the association between baseline risk factors and presentation with ICH versus ischemic stroke. Risk factors included: (1) those previously reported to be risk factors for both ischemic stroke and major bleeding (particularly ICH) ("shared" risk factors, including age, alcohol, hypertension, diabetes mellitus, renal impairment, prior stroke/transient ischemic attack and preadmission dementia); and (2) other risk factors associated with either stroke subtype alone.. A total of 3197 patients presented with atrial fibrillation and acute stroke, of which 12.2% presented with ICH. Of the "shared" risk factors, age (OR, 1.19; 95% CI, 1.06-1.34 per decade) and prior stroke/transient ischemic attack (OR, 1.45; 95% CI, 1.12-1.87) were more associated with ischemic stroke than ICH, whereas a history of hypertension (OR, 0.89; 95% CI, 0.68-1.17), diabetes mellitus (OR 1.23; 95% CI, 0.92-1.64), renal impairment (OR, 1.28; 95% CI, 0.95-1.71), and alcohol intake were not more strongly associated with either stroke subtype.. Of the risk factors known to be associated with both ischemic stroke and ICH in patients with atrial fibrillation, we found that none had a stronger association with ICH. Older age was more strongly associated with ischemic stroke than ICH.

Topics: Age Factors; Aged; Alcohol Drinking; Anticoagulants; Atrial Fibrillation; Brain Ischemia; Canada; Cerebral Hemorrhage; Data Interpretation, Statistical; Dementia; Diabetes Mellitus; Female; Humans; Hypertension; Kidney Diseases; Male; Middle Aged; Platelet Aggregation Inhibitors; Prospective Studies; Recurrence; Registries; Risk Assessment; Risk Factors; Stroke; Warfarin

Evidence-based guidelines should in most cases be followed also in the treatment of elderly. Older people are often suboptimally treated with the recommended drugs.. To describe how well general practitioners adhere to current guidelines in the treatment of elderly with cardiovascular disease and evaluate local education as a tool for improvement.. Data was collected from the medical records of patients aged ≥ 65, who visited a primary health care center in Sweden 2006 and had one or more of the following diagnoses: hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation, or prior stroke. Local education was organized and included feed-back to the patient's doctor and discussion about regional guidelines. Repeated measurements were performed in 2008.. The adherence to guidelines was low. Approximately one-third of the patients with hypertension reached target blood pressure, stroke patients more often. More patients with heart failure were treated with angiotensin converting enzyme inhibitor than in other European countries, but still only 60%. Half of the patients with chronic atrial fibrillation were treated with Warfarin, although more than two-thirds had a CHADS(2) score indicating the need. Educational efforts appeared to increase the adherence and hence should be encouraged.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Blood Pressure; Cardiovascular Diseases; Chronic Disease; Evidence-Based Practice; General Practice; General Practitioners; Guideline Adherence; Heart Failure; Humans; Hypertension; Patient Compliance; Stroke; Warfarin

Atrial fibrillation (AF) is associated with an increased long-term risk of stroke, heart failure, and mortality. Previous studies have demonstrated the suboptimal use of anticoagulation therapy in patients with AF.. A retrospective survey of patients (N = 1,113) fitted with dual-chamber pacemakers found 71 patients (age 69 ± 35, mean ± standard deviation) with atrial tachycardia and AF (defined as >5 minutes per day). Their medical records and anticoagulation status were investigated and used to stratify each patient for stroke risk with the Birmingham 2009 schema (CHA(2)DS(2)-VASc) and assessed to determine the rate of appropriate thromboembolism (TE) prophylaxis prescription.. The most common overall concomitant risk factor for stroke was hypertension (54%), followed by age ≥75 (51%), being female and previous stroke/transient ischemic attack/TE (39%). The average CHA(2)DS(2)-VASc score was 3.7 ± 1.6. Fifty-six percent of the patients were not receiving appropriate anticoagulation therapy.. This study demonstrates an underutilization of the oral anticoagulant warfarin in patients with known AF and that the clinicians may not be regarding current stroke risk factors when adopting a thromboprophylaxis strategy.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Female; Heart Rate; Humans; Hypertension; Incidence; Male; Middle Aged; Pacemaker, Artificial; Retrospective Studies; Risk; Sex Factors; Stroke; Tachycardia; Thromboembolism; Wales; Warfarin

64-multidetector CT angiography (MDCTA) can identify plaques and assess different plaque components (lipid, fibrous tissue and calcifications). The first patient was a 75-year-old-man with atrial fibrillation (AF). Axial 64-MDCTA image of a coronary artery atherosclerotic plaque was obtained, which included the plaque on the outer vessel wall. The authors measured the five points of CT values around the vague center of the plaque with almost equal interval, which was shown in figure 1. Max was 80 Hounsfield unit (HU), and min was 28 HU. After 3 months warfarin therapy (1.5 mg id), max increased to 100 HU, and min increased to 69 HU. The second patient was a 74-year-old-male with hypertension and AF. Max was 61 HU, and min was 37 HU. After 3 months warfarin therapy (2.5 mg id), max increased to 70 HU, and min increased to 50 HU. Warfarin increased CT values of the artherosclerotic plaques in two patients with AF.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Coronary Angiography; Coronary Artery Disease; Coronary Vessels; Humans; Hypertension; Image Processing, Computer-Assisted; Male; Plaque, Atherosclerotic; Tomography, X-Ray Computed; Warfarin

Older patients with atrial fibrillation (AF) and coronary artery disease (CAD) face high risk of stroke and bleeding with antithrombotic therapy. Balancing safe and effective use of aspirin, clopidogrel, and warfarin in this population is important.. From the Duke Databank for Cardiovascular Disease, we identified patients with AF ≥65 years old with angiographically confirmed CAD from 2000 to 2010. Antithrombotic use was described across age and Congestive heart failure, Hypertension, Age >75 years, Diabetes, prior Stroke/transient ischemic attack (CHADS(2)) stroke risk and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) bleeding scores. Death and the composite of death, myocardial infarction, and stroke by antithrombotic strategy were reported.. Of 2,122 patients ≥65 years old with AF and CAD, 477 (22.5%) were ≥80 years old; 1,133 (53.4%) had acute coronary syndromes. Overall rates of aspirin, clopidogrel, and warfarin use were 83.4%, 34.6%, and 38.9%, respectively. Compared with patients 65 to 79 years old, more patients ≥80 years old were at high stroke risk (CHADS(2) ≥2, 84.7% vs 57.8%) and high bleeding risk (ATRIA 5-10, 55.8% vs 23.3%). Warfarin use in both age groups increased with higher CHADS(2) scores and decreased with higher ATRIA scores. Of patients ≥80 years old with CHADS(2) ≥2, 150 (38.2%) received warfarin. Antithrombotic strategy was not associated with improved 1-year adjusted outcomes.. Among older patients with AF and CAD, overall warfarin use was low. Patients ≥80 years old at highest stroke risk received warfarin in similar proportions to the overall cohort. Further investigation into optimizing antithrombotic strategies in this population is warranted.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Atrial Fibrillation; Clopidogrel; Coronary Artery Disease; Diabetes Complications; Female; Fibrinolytic Agents; Heart Failure; Humans; Hypertension; Male; Risk Assessment; Stroke; Ticlopidine; Treatment Outcome; Warfarin

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

Topics: Angiotensin II Type 1 Receptor Blockers; Anticoagulants; Aspirin; Atrial Fibrillation; Biphenyl Compounds; Cerebral Hemorrhage; Clopidogrel; Evidence-Based Medicine; Follow-Up Studies; Humans; Hypertension; Irbesartan; Platelet Aggregation Inhibitors; Stroke; Tetrazoles; Ticlopidine; Treatment Outcome; Warfarin

Almost 50% of patients with congestive heart failure (HF) have preserved ejection fraction (PEF). Data on the effect of HF-PEF on atrial fibrillation outcomes are lacking. We assessed the prognostic significance of HF-PEF in an atrial fibrillation population compared to a systolic heart failure (SHF) population. A post hoc analysis of the National Heart, Lung, and Blood Institute-limited access data set of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial was carried out. The patients with a history of congestive HF and a preserved ejection fraction (EF >50%) were classified as having HF-PEF (n = 320). The patients with congestive HF and a qualitatively depressed EF (EF <50%) were classified as having SHF (n = 402). Cox proportional hazards analysis was performed. The mean follow-up duration was 1,181 ± 534 days/patient. The patients with HF-PEF had lower all-cause mortality (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.46 to 0.85, p = 0.003) and cardiovascular mortality (HR 0.56, 95% CI 0.38 to 0.84, p = 0.006), with a possible decreased arrhythmic end point (HR 0.39, 95% CI 0.16 to 1.006, p = 0.052) than did the patients with SHF. No differences were observed for ischemic stroke (HR 1.08, 95% CI 0.48 to 2.39, p = 0.86), rehospitalization (HR 0.89, 95% CI 0.75 to 1.07, p = 0.24), or progression to New York Heart Association class III-IV (odds ratio 0.80, 95% CI 0.42 to 1.54, p = 0.522). In conclusion, although patients with HF-PEF have better mortality outcomes than those with SHF, the morbidity appears to be similar.

Topics: Age Factors; Aged; Anticoagulants; Atrial Fibrillation; Disease Progression; Female; Heart Failure; Humans; Hypertension; Male; Patient Readmission; Prognosis; Proportional Hazards Models; Randomized Controlled Trials as Topic; Sex Factors; Stroke; Stroke Volume; United States; Warfarin

Ms TS is a 66-year-old woman who receives warfarin for prevention of systemic embolization in the setting of hypertension, diabetes, and atrial fibrillation. She had a transient ischemic attack about 4 years ago when she was receiving aspirin. Her INR control was excellent; however, over the past few months it has become erratic, and her average dose required to maintain an INR of 2.0 to 3.0 appears to have decreased. She has had back pain over this same period and has been taking acetaminophen at doses at large as 650 mg four times daily, with her dose varying based on her symptoms. You recall a potential interaction and wonder if (1) her acetaminophen use is contributing to her loss of INR control, and (2) does this interaction place her at increased risk of warfarin-related complications?

Topics: Acetaminophen; Aged; Analgesics, Non-Narcotic; Anticoagulants; Atrial Fibrillation; Back Pain; Biotransformation; Diabetes Complications; Drug Interactions; Drug Monitoring; Embolism; Female; Humans; Hypertension; International Normalized Ratio; Vitamin K; Warfarin

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

Carotid dissection has rarely been described in pregnancy. We report a 24-year-old woman who developed an acute stroke 14 days postpartum after a complicated pregnancy. Her left internal carotid artery was found to be occluded, presumably secondary to a carotid dissection. Her neurologic symptoms resolved and she was treated with short-term warfarin therapy and blood pressure control.

Topics: Anticoagulants; Antihypertensive Agents; Blood Coagulation Disorders; Brain; Carotid Artery, Internal; Carotid Artery, Internal, Dissection; Female; Humans; Hypertension; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Pre-Eclampsia; Pregnancy; Stroke; Warfarin; Young Adult

Chronic hypertension and anticoagulation are important risk factors for the development of intracerebral hemorrhage (ICH). Spontaneous ICH occurring in the Emergency Department (ED) following a normal unenhanced computed tomography (CT) scan of the brain and an acute blood pressure (BP) surge is exceedingly rare and has, to our knowledge, never been reported in the literature.. Single case observation in a suburban tertiary care medical center.. A neurologically intact 72-year-old man whose BP and neurologic status were monitored during an ED evaluation suddenly became unresponsive following an acute BP surge. A CT of the brain shortly before the episode was normal; following the episode, a repeat CT demonstrated a large right ganglionic ICH.. We present a rare case of an elderly man on warfarin who developed a spontaneous ICH during an ED evaluation following an acute BP surge. We propose that the ICH occurred as a result of the BP surge and was contributed to by warfarin anticoagulation.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Blood Pressure; Brain; Cerebral Hemorrhage; Emergency Service, Hospital; Humans; Hypertension; Male; Tomography, X-Ray Computed; Warfarin

Topics: Aged; Anticoagulants; Atherosclerosis; Cystitis; Diagnosis, Differential; Embolism, Cholesterol; Female; Foreign-Body Reaction; Gastrointestinal Hemorrhage; Granuloma; Hematuria; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypertension; Ischemic Attack, Transient; Risk Factors; Syndrome; Tuberculosis, Urogenital; Urinary Bladder Neoplasms; Warfarin

Oral anticoagulant therapy has been shown to decrease the risk for vascular complications in patients with atrial fibrillation (AF). We evaluated the frequency of oral anticoagulant use in patients with AF, whether oral anticoagulant use was associated with effective INR values, and the reasons for not including an anticoagulant in the treatment.. The study included 426 consecutive patients (256 women, 170 men; mean age 66+/-11 years) who presented with a diagnosis of AF between October 2007 and November 2008. The patients were inquired about whether they were using warfarin and/or aspirin and the reasons for not taking an oral anticoagulant. The INR levels were measured in those receiving warfarin.. Permanent AF was present in 72.8%, and paroxysmal AF was present in 27.2%. Patients = or >75 years of age accounted for 32.4%. The risk for stroke was high in 69.3%, moderate in 21.8%, and low in 8.9%, hypertension being the most frequent risk factor (66.7%). Inquiry about medications showed that 107 patients (25.1%) were taking aspirin and warfarin, 21 patients (4.9%) and 237 patients (55.6%) were taking warfarin and aspirin alone, respectively, while 61 patients (14.3%) used none. The incidence of oral anticoagulant use was 30.1%, being significantly low in patients = or >75 years of age (p=0.0001), and having hypertension (p=0.023) or coronary artery disease (p=0.004). Effective INR values recommended by the guidelines were attained in 47.7% (n=61) of patients receiving warfarin. Sex, age, clinical risk factors, and socioeconomic parameters were not associated with achievement of target INR values. The most frequent reason for not starting anticoagulant treatment was the low tendency of physicians to prescribe the drug (74.3%), followed by the presence of contraindications (9.8%).. The most important factor for inadequate oral anticoagulant use especially in patients having a high risk for stroke is the low incidence of prescription of the drug by the physicians, suggesting low influence of the guidelines on the clinical practice.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Female; Humans; Hypertension; International Normalized Ratio; Male; Middle Aged; Practice Guidelines as Topic; Risk Factors; Stroke; Warfarin

The effect of atorvastatin on warfarin-induced aortic medial calcification and systolic blood pressure (SBP) of rats induced by warfarin was studied. Thirty healthy and adult rats were randomly divided into Warfarin group (n=10), Atorvastatin group (n=10) and normal control group (n=10). Caudal arterial pressure of rats was measured once a week, and 4 weeks later, aorta was obtained. Elastic fiber, collagen fiber and calcium accumulation in tunica media of cells were measured by Von Kossa staining. The results showed that warfarin treatment led to elevation of systolic blood pressure and aortic medial calcification. The chronic treatment also increased collagen, but decreased elastin in the aorta. However, the atorvastatin treatment had adverse effects. It was concluded that treatment with atorvastatin presented evidence of blood pressure lowing and calcification reducing. These data demonstrate that atorvastatin protected aortic media from warfarin-induced calcification and elevation of systolic blood pressure.

Topics: Animals; Aortic Diseases; Atorvastatin; Blood Pressure; Calcinosis; Heptanoic Acids; Hypertension; Male; Pyrroles; Random Allocation; Rats; Rats, Wistar; Warfarin

We hereby describe a 42-year-old lady who developed vertebral artery dissection following a head injury. The clinical features and management of the condition are discussed.

Topics: Adult; Amlodipine; Anticoagulants; Antihypertensive Agents; Aspirin; Craniocerebral Trauma; Female; Hemianopsia; Humans; Hypertension; Magnetic Resonance Angiography; Stroke; Tomography, X-Ray Computed; Vertebral Artery Dissection; Warfarin

Platelet microparticles (PMPs), are procoagulant membrane vesicles that are derived from activated platelets, the levels of which are elevated in patients with hypertension, coronary artery disease (CAD), diabetes, and stroke, all of which are conditions that lead to (and are associated with) atrial fibrillation (AF). We hypothesized the following: (1) PMP levels are elevated in patients with AF compared to levels in both healthy control subjects (ie, patients without cardiovascular diseases who are in sinus rhythm) and disease control subjects (ie, patients with hypertension, CAD, diabetes or stroke, but who are in sinus rhythm); (2) PMP levels correlate with levels of soluble P-selectin (sP-selectin) [a marker of platelet activation]; and (3) PMP levels are related to the underlying factors in patients with AF that contribute to the overall risk of stroke secondary to AF.. We performed a case-control study of 70 AF patients, 46 disease control subjects and 33 healthy control subjects. Peripheral venous levels of PMP and sP-selectin were analyzed by flow cytometry and enzyme-linked immunosorbent assay, respectively.. Both AF patients and disease control subjects had significantly higher levels of PMPs (p < 0.001) and sP-selectin (p = 0.001) compared to healthy control subjects, but there was no difference between AF patients and disease control subjects. There was no difference in PMP levels between patients with paroxysmal and permanent AF (p = 0.581), and between those receiving therapy with aspirin and warfarin (p = 0.779). No significant correlation was observed between PMP and sP-selectin levels (p = 0.463), and the clinical characteristics that contribute to increased stroke risk in patients with AF. On stepwise multiple regression analysis in the combined cohort of AF patients plus disease control subjects, the presence/absence of AF was not an independent determinant of PMP and sP-selectin levels.. There is evidence of platelet activation (ie, high PMP and sP-selectin levels) in AF patients, but this is likely to be due to underlying cardiovascular diseases rather than the arrhythmia per se.

Topics: Aged; Aspirin; Atrial Fibrillation; Blood Coagulation Factors; Blood Platelets; Cardiovascular Diseases; Case-Control Studies; Cell Membrane; Cerebral Infarction; Coronary Disease; Diabetes Mellitus, Type 2; Enzyme-Linked Immunosorbent Assay; Female; Fibrinolytic Agents; Flow Cytometry; Humans; Hypertension; Male; Middle Aged; Multivariate Analysis; P-Selectin; Particle Size; Platelet Activation; Reference Values; Risk Factors; Statistics as Topic; Warfarin

Warfarin causes extensive vascular calcification leading to increased systolic blood pressure and pulse pressure in rats, may be associated with increased valvular and coronary calcifications in man, and possibly worsens hypertension in high-risk patients, particularly in those with diabetes mellitus or uncontrolled hypertension. The authors evaluated blood pressure and intensity of antihypertensive therapy over 36 months in a cohort of 58 patients with diabetes and hypertension on warfarin and 58 control subjects with diabetes and hypertension not on warfarin. The results demonstrate that warfarin therapy at conventional doses does not increase systolic blood pressure or pulse pressure in patients with diabetes and hypertension.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Blood Pressure; Controlled Clinical Trials as Topic; Diabetes Mellitus; Dose-Response Relationship, Drug; Follow-Up Studies; Humans; Hypertension; Longitudinal Studies; Male; Regression Analysis; Research Design; Treatment Outcome; Warfarin

The aim of this population-based cohort study was to examine the changes in the regular use of cardiovascular medication among the elderly aged 75 years or more in Finland in 1998 and 2003.. The study population (n = 700) was a random sample of all persons aged 75 years or more living in Kuopio, in eastern Finland. Of them, 601 persons participated in 1998. The surviving persons (n = 339) were re-examined in 2003. Of them 85% (n = 289) were home-dwelling and 15% (n = 50) lived in institutional care. Data on their use of medication and their physical and mental health was collected from interviews conducted by trained nurses.. From 1998 to 2003 regular use of one or more cardiovascular medicine increased from 80% to 87% among all the survivors (n = 339, P < 0.001). The mean number of regularly used cardiovascular medicines increased from 2.1 (95% CI 1.9-2.3) to 2.7 (95% CI 2.5-2.9, P < 0.001) during the follow-up period. The most commonly used cardiovascular medicines were beta-blocking agents. The proportion of users of beta-blocking agents was in 1998 45% and in 2003 51%. The proportion of users of diuretics increased from 27% to 40% (P < 0.001), users of cardiac therapy from 35% to 43% (P < 0.001), users of ACE inhibitors and AT 1 receptor antagonists from 20% to 30% (P < 0.001) and users of lipid modifying agents from 7% to 12%.. The use of cardiovascular medicines was common among elderly persons. The proportion of users increased with age and over time. A large proportion of elderly persons would need medication monitoring focusing on cardiovascular medication.

Topics: Adrenergic beta-Antagonists; Age Factors; Aged; Aged, 80 and over; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Cohort Studies; Digoxin; Diuretics; Drug Utilization; Finland; Homebound Persons; Humans; Hypertension; Institutionalization; Nitrates; Survivors; Time Factors; Warfarin

This study was designed to study racial/ethnic differences in the risk for intracranial hemorrhage (ICH) and the effect of warfarin on ICH risk among patients with atrial fibrillation (AF).. Nonwhites are at greater risk for ICH than whites in the general population. Whether this applies to patients with AF and whether warfarin therapy is associated with comparable risk of ICH in nonwhites are unknown.. We retrospectively identified a multiethnic stroke-free cohort hospitalized with nonrheumatic AF. Warfarin use and anticoagulation intensity were assessed by searching pharmacy and laboratory records. Crude ICH event rates were calculated by Poisson regression. Cox proportional hazard models were constructed to assess the independent effect of race/ethnicity on ICH after adjusting for age, gender, hypertension, diabetes, heart failure, and warfarin exposure.. Between 1995 and 2000, we identified 18,867 qualifying AF hospitalizations (78.5% white, 8% black, 9.5% Hispanic, and 3.9% Asian) and 173 qualifying ICH events over 3.3 years follow-up. Achieved anticoagulation intensity was lower among blacks but not different between the other groups. Warfarin was associated with increased ICH risk in all races, but the magnitude of risk was greater among nonwhites. There were no gender differences. The hazard ratio for ICH with whites as referent was 4.06 for Asians (95% confidence interval [CI] 2.47 to 6.65), 2.06 for Hispanics (95% CI 1.31 to 3.24), and 2.04 (95% CI 1.25 to 3.35) for blacks.. Nonwhites with AF were at greater risk for warfarin-related ICH. Blacks, Hispanics, and Asians were at successively greater ICH risk than whites.

Topics: Age Distribution; Aged; Aged, 80 and over; Asian People; Atrial Fibrillation; Black People; California; Cohort Studies; Comorbidity; Ethnicity; Female; Follow-Up Studies; Hispanic or Latino; Humans; Hypertension; International Normalized Ratio; Intracranial Hemorrhages; Male; Middle Aged; Prevalence; Racial Groups; Retrospective Studies; Risk Factors; Sex Distribution; Stroke; Warfarin; White People

To report a case in which the anticoagulation effect of warfarin appeared to have been potentiated by chitosan, probably due to interference with the absorption of vitamin K.. An 83-year-old male with hypertensive cardiovascular disease, type 2 diabetes mellitus, and chronic atrial fibrillation complicated by left atrial thrombus formation was maintained on warfarin 2.5 mg/day. Marked elevation of the international normalized ratio (INR) was noticed after self-medication with chitosan 1200 mg twice daily. He denied taking any other drugs, natural substances, herbal medicines, and nutritional supplements, and stated that he had not changed his dietary habits. After parenteral administration of vitamin K and discontinuation of chitosan, the INR returned to within the target range. However, the patient took chitosan again, and the INR increased to well above the target range. Following strong medical advice, the patient stopped taking chitosan, and the INR remained stable thereafter.. Chitosan is a positively charged polymer that binds to the negatively charged lipids and bile acids in the gastrointestinal tract. It can affect the absorption of vitamins A, D, E, and K. Therefore, the anticoagulation effect of warfarin may be potentiated by chitosan through this mechanism. Use of the Naranjo probability scale revealed that the adverse effect was probably due to chitosan.. The interaction between warfarin and chitosan has not previously been reported. Healthcare professionals should be aware of this potential interaction.

Topics: Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Chitosan; Chronic Disease; Diabetes Mellitus, Type 2; Drug Synergism; Humans; Hypertension; International Normalized Ratio; Male; Self Medication; Thrombosis; Vitamin K; Vitamins; Warfarin

To study the recurrence of ischemic stroke in patient with nonvalvular atrial fibrillation (NVAF) and to determine the recurrence related factors of ischemic stroke in patients with NVAF.. The clinical data of 386 NVAF patients with ischemic stroke treated in our hospital from January 1992 to February 2002 were included in this study. The basic clinical information of each patient was recorded. Analysis of recurrence and recurrence related factors of ischemic stroke in patients with NVAF was conducted.. Overall the 10-year recurrence rate of ischemic stroke in patients with NVAF was 34%. Hypertension, diabetes mellitus, transient ischemic attack (TIA), hyperlipemia and mural thrombus in left atrium were significantly correlated with the recurrence rate by univariate Cox proportional hazards regression analysis; but aspirin therapy, warfarin therapy and hypertension control were protective factors for the recurrence of ischemic stroke in patients with NVAF. Multivariate Cox proportional hazards regression analysis revealed that hypertension, TIA and mural thrombus in left atrium were independent recurrence related factors for ischemic stroke in patients with NVAF; but aspirin therapy and warfarin therapy were protective factors for the recurrence.. Hypertension, TIA and mural thrombus in left atrium were independent recurrence related factors for ischemic stroke in patient with NVAF; but aspirin therapy and warfarin therapy were protective factors for the recurrence.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Atrial Fibrillation; Cohort Studies; Female; Follow-Up Studies; Humans; Hypertension; Ischemic Attack, Transient; Male; Middle Aged; Multivariate Analysis; Recurrence; Regression Analysis; Retrospective Studies; Risk Factors; 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

We have demonstrated a point prevalence of 26% renal artery stenosis in patients with antiphospholipid syndrome (APS) and uncontrolled hypertension. We describe the effect of anticoagulation on blood pressure control and renal function.. We studied 23 patients retrospectively with renal artery stenosis (RAS). Fourteen received oral anticoagulation for more than 1 yr (target International Normalized Ratio (INR) of 3.0-4.5). Five patients had primary APS. Patients were divided into two groups based on their INR (< 3.0 and > or = 3.0). Nine patients had repeat magnetic resonance angiography (MRA) or an angiogram of the renal arteries after 2 yr.. Only 8/14 patients managed to maintain their INR > or = 3.0 (median INR 3.1, range 2.8-3.7) while six had a INR < 3.0 (median INR 1.9, range 1.2-2.4). Patients with a median INR < 3.0 had poorly controlled blood pressure and there was significant deterioration in mean serum creatinine values (Wilcoxon's test, P < 0.03). Nine patients underwent follow-up renal artery imaging. Three of nine patients with an INR < 3.0 (median INR 1.9) had re-stenosis and a fourth developed bilateral renal artery stenosis. Five patients with INR > or = 3.0 (median INR 3.1) did not show re-stenosis of the renal arteries; their renal function was stable and blood pressure was well controlled. One other patient with secondary APS (mixed connective tissue disorder) with INR > 3.0 showed recanalization of the stenosed renal artery.. Anticoagulation with INR maintained > or = 3.0 helped to control the blood pressure and prevent the progression of renal disease.

Topics: Anticoagulants; Antihypertensive Agents; Antiphospholipid Syndrome; Blood Pressure; Creatinine; Female; Humans; Hypertension; Magnetic Resonance Angiography; Male; Radiography; Renal Artery; Renal Artery Obstruction; Retrospective Studies; Treatment Outcome; Warfarin

Topics: Age Factors; Aged; Aged, 80 and over; Atrial Fibrillation; Cardiovascular Diseases; Clinical Trials as Topic; Comorbidity; Female; Humans; Hypertension; Incidence; Male; Quality of Life; Risk Factors; Stroke; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Atrial Fibrillation; Cystitis; Fruit; Herb-Drug Interactions; Humans; Hypertension; International Normalized Ratio; Male; Medical History Taking; Medication Errors; Phytotherapy; Plant Preparations; Vaccinium macrocarpon; Warfarin

To describe the clinical practice in antithrombotic therapy to prevent stroke in older patients with atrial fibrillation (AF).. Cross-sectional study.. Ourense's area with 95,840 inhabitants over 65 years.. Patients over 65 with non rheumatic AF, chronic or paroxistic; 411 cases, 69.6% older than 75 year.. Demographic characteristics, personal history, stroke risk, diagnostic characteristics of AF, antithrombotic treatment, and its adequacy.. Only 33% high risk patients received oral anticoagulation (OCA) with warfarin at diagnosis. Some features were found to be significant independent risk factors for OCA: age (older than 75 vs 65-74 years; odds ratio =0.32; 95% confidence interval, 0.18-0.59), and prior stroke (odds ratio =2.02; 95% confidence interval, 1.16-3.55).. Warfarin prophylactic is insufficiently prescribed, especially in older than 75 years (with high baseline risk of stroke and no counter-indications). There was inadequate prescription in 73.4% cases.

Topics: Administration, Oral; Age Factors; Aged; Anticoagulants; Atrial Fibrillation; Confidence Intervals; Cross-Over Studies; Data Interpretation, Statistical; Drug Prescriptions; Humans; Hypertension; Odds Ratio; Risk Factors; Stroke; Warfarin

Previous studies provide conflicting results about whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation (AF). We examined data from a large contemporary cohort of AF patients to address this question.. We prospectively studied 13,559 adults with AF and recorded data on patients' clinical characteristics and the occurrence of incident hospitalizations for ischemic stroke, peripheral embolism, and major hemorrhagic events through searching validated computerized databases and medical record review. We compared event rates by patient sex using multivariable log-linear regression, adjusting for clinical risk factors for stroke, and stratifying by warfarin use. We identified 394 ischemic stroke and peripheral embolic events during 15,494 person-years of follow-up off warfarin. After multivariable analysis, women had higher annual rates of thromboembolism off warfarin than did men (3.5% versus 1.8%; adjusted rate ratio [RR], 1.6; 95% CI, 1.3 to 1.9). There was no significant difference by sex in 30-day mortality after thromboembolism (23% for both). Warfarin use was associated with significantly lower adjusted thromboembolism rates for both women and men (RR, 0.4; 95% CI, 0.3 to 0.5; and RR, 0.6; 95% CI, 0.5 to 0.8, respectively), with similar annual rates of major hemorrhage (1.0% and 1.1%, respectively).. Women are at higher risk than men for AF-related thromboembolism off warfarin. Warfarin therapy appears be as effective in women, if not more so, than in men, with similar rates of major hemorrhage. Female sex is an independent risk factor for thromboembolism and should influence the decision to use anticoagulant therapy in persons with AF.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Cohort Studies; Female; Humans; Hypertension; Male; Middle Aged; Risk Factors; Sex Characteristics; Stroke; Thromboembolism; Warfarin

A 19-year-old woman, 8 days postpartum, presented to the Emergency Department (ED) with a chief complaint of headache, decreased vision, and agitation. Past medical history was unremarkable. Physical examination was remarkable only for dry mucous membranes, decreased visual acuity, and trace pedal edema bilaterally. While in the ED, the patient experienced a generalized tonic-clonic seizure. Computed tomography (CT) scan of the head was suspicious for venous infarction. Magnetic resonance imaging (MRI) and MR venography revealed sagittal sinus and left transverse sinus thrombosis. The risk factors, clinical presentation, diagnostic evaluation, and management of cerebral venous thrombosis are reviewed.

Topics: Adult; Anticoagulants; Cerebral Angiography; Female; Headache; Humans; Hypertension; Phenytoin; Puerperal Disorders; Risk Factors; Seizures; Sinus Thrombosis, Intracranial; Tomography, X-Ray Computed; Warfarin

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Aorta, Thoracic; Arteriosclerosis; Cardiac Catheterization; Embolism, Cholesterol; Humans; Hypertension; Lower Extremity; Male; Middle Aged; Myocardial Infarction; Peripheral Vascular Diseases; Stents; Syndrome; Ultrasonography; Warfarin

Topics: Aged; Aged, 80 and over; Anticoagulants; Arterial Occlusive Diseases; Carotid Artery Diseases; Coronary Angiography; Coronary Artery Bypass; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Female; Fibrinolytic Agents; Heart Septal Defects, Atrial; Heparin; Humans; Hypertension; Intraoperative Complications; Intraoperative Period; Popliteal Vein; Subclavian Artery; Thrombolytic Therapy; Tissue Plasminogen Activator; Warfarin

Topics: Adult; Anticoagulants; Antihypertensive Agents; Cilostazol; Drug Therapy, Combination; Femoral Artery; Fibrinolytic Agents; Humans; Hypertension; Intermittent Claudication; Leg; Male; Pain; Physical Exertion; Ramipril; Tetrazoles; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Aspirin; Fibrinolytic Agents; Humans; Hypertension; Secondary Prevention; Stroke; Warfarin

Warfarin increases mortality of intracerebral hemorrhage (ICH). The authors investigated whether this effect reflects increased baseline ICH volume at presentation or increased ICH expansion.. Subjects were drawn from an ongoing prospective cohort study of ICH outcome. The effect of warfarin on baseline ICH volume was studied in 183 consecutive cases of supratentorial ICH age > or = 18 years admitted to the emergency department over a 5-year period. Baseline ICH volume was determined using computerized volumetric analysis. The effect of warfarin on ICH expansion (increase in volume > or = 33% of baseline) was analyzed in 70 consecutive cases in whom ICH volumes were measured on all subsequent CT scans up to 7 days after admission. Multivariable analysis was used to determine warfarin's influence on baseline ICH, ICH expansion, and whether warfarin's effect on ICH mortality was dependent on baseline volume or subsequent expansion.. There was no effect of warfarin on initial volume. Predictors of larger baseline volume were hyperglycemia (p < 0.0001) and lobar hemorrhage (p < 0.0001). Warfarin patients were at increased risk of death, even when controlling for ICH volume at presentation. Warfarin was the sole predictor of expansion (OR 6.2, 95% CI 1.7 to 22.9) and expansion in warfarin patients was detected later in the hospital course compared with non-warfarin patients (p < 0.001). ICH expansion showed a trend toward increased mortality (OR 3.5, 95% CI 0.7 to 8.9, p = 0.14) and reduced the marginal effect of warfarin on ICH mortality.. Warfarin did not increase ICH volume at presentation but did raise the risk of in-hospital hematoma expansion. This expansion appears to mediate part of warfarin's effect on ICH mortality.

Topics: Adult; Aged; Anticoagulants; Apolipoproteins E; Cerebral Hemorrhage; Cohort Studies; Disease Progression; Female; Genotype; Hematoma; Hospital Mortality; Humans; Hyperglycemia; Hypertension; Life Tables; Male; Middle Aged; Platelet Aggregation Inhibitors; Prospective Studies; Radiography; Risk; Treatment Outcome; Warfarin

Paroxysmal atrial fibrillation (PAF) can be eliminated with continuous circular lesions (CCLs) around the pulmonary veins (PVs), but it is unclear whether all PVs are completely isolated.. Forty-one patients with symptomatic PAF underwent 3D mapping, and all PV ostia were marked on the 3D map based on venography. Irrigated radiofrequency energy was applied at a distance from the PV ostia guided by 2 Lasso catheters placed within the ipsilateral superior and inferior PVs. The mean radiofrequency duration was 1550+/-511 seconds for left-sided PVs and 1512+/-506 seconds for right-sided PVs. After isolation, automatic activity was observed in the right-sided PVs in 87.8% and in the left-sided PVs in 80.5%. During the procedure, a spontaneous or induced PV tachycardia (PVT) with a cycle length of 189+/-29 ms was observed in 19 patients. During a mean follow-up of 6 months, atrial tachyarrhythmias recurred in 10 patients. Nine patients underwent a repeat procedure. Conduction gaps in the left CCL in 9 patients and in the right CCL in 2 patients were closed during the second procedure. A spontaneous PVT with a cycle length of 212+/-44 ms was demonstrated in 7 of 9 patients, even though no PVT had been observed in 6 of these 7 patients during the first procedure. No AF recurred in 39 patients after PV isolation during follow-up.. Automatic activity and fast tachycardia within the PVs could reflect an arrhythmogenic substrate in patients with PAF, which could be eliminated by isolating all PVs with CCLs guided by 3D mapping and the double-Lasso technique in the majority of patients.

Topics: Adenosine; Aged; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiac Catheterization; Catheter Ablation; Combined Modality Therapy; Coronary Disease; Electrocardiography; Female; Follow-Up Studies; Heart Conduction System; Humans; Hypertension; Male; Middle Aged; Phlebography; Postoperative Complications; Prospective Studies; Pulmonary Veins; Recurrence; Tachycardia; Treatment Outcome; Warfarin

Isolated systolic hypertension is the predominant form of hypertension in the elderly population. Reduction of arterial compliance appears to contribute to the elevation of pulse pressure (PP) and among potential mechanisms, gradual vascular calcification, fragmentation of elastic lamellae, and augmentation of rigid component like collagen could contribute to increase aortic stiffening. Few experimental models of the disease are currently available.. To induce large artery calcification, rats were treated with warfarin and vitamin K(1) (WK) for 4 and 8 weeks, to inhibit the maturation of matrix Gla protein. The impact of chronic PP elevation was determined on large artery and cardiac remodeling and on aortic endothelial function.. The WK treatment led to aortic medial calcification and a proportional elevation of PP, attributable mainly to a selective elevation of systolic blood pressure. The chronic treatment also increased collagen, whereas elastin decreased in the aorta. Pulse wave velocity, an index of aortic stiffening, increased in rats treated with WK. However, indices of left ventricular and aortic hypertrophy and remodeling remained normal. In addition, the WK treatment did not modify the vasoconstriction to norepinephrine and endothelin-1, and the vasodilatory response to acetylcholine and sodium nitroprusside.. Chronic treatment with WK represents a new model of isolated systolic hypertension with several characteristics of the human disease. The relative ease to induce calcification in this model may help to foster more fundamental research, which is lacking in this type of hypertension.

Topics: Animals; Anticoagulants; Antifibrinolytic Agents; Aorta; Calcinosis; Calcium; Collagen; Disease Models, Animal; Drug Administration Schedule; Elastin; Hemodynamics; Hypertension; Male; Rats; Rats, Wistar; Renin; Systole; Vascular Diseases; Vasomotor System; Vitamin K 1; Warfarin

To describe the course, management, and prognosis of massive spontaneous choroidal hemorrhage.. The presenting visual acuity, ocular findings, duration to surgical intervention, and outcomes of five patients were retrospectively reviewed.. Five eyes from four patients (median age, 80 years; range, 66-85 years) were studied. The patients were observed from 4 to 72 months (median, 33 months). Three patients were on anticoagulation therapy with warfarin; one patient had bilateral involvement with no history of anticoagulation therapy. Three patients were hypertensive, and three of the four had been diagnosed with age-related macular degeneration. Four eyes underwent choroidal drainage procedures, and one was observed. In all patients whose choroids were drained, the final vision was no light perception.. Massive spontaneous choroidal hemorrhage may be associated with hypertension, systemic anticoagulation, advanced age, and age-related macular degeneration. Final visual acuities are generally poor.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Choroid Hemorrhage; Female; Humans; Hypertension; Longitudinal Studies; Macular Degeneration; Male; Outcome Assessment, Health Care; Prognosis; Retrospective Studies; Visual Acuity; Warfarin

To determine vascular risk factor (VRF) profiles in transient ischemic attack (TIA) and ischemic stroke.. We studied 239 patients with TIA and 1,473 ischemic stroke patients included in a prospective stroke registry over a 10-year period.. Main VRF were: hypertension, hyperlipidemia, diabetes mellitus and atrial fibrillation. In the multivariate analysis, prior ischemic stroke (OR=1.65; 95% CI, 1.07-2.56), atrial fibrillation (OR=1.60; 95% CI, 1.14-2.26) and current use of warfarin treatment (OR=0.34; 95% CI, 0.13-0.94) were the only independent risk factors associated with ischemic stroke.. Different potentially modifiable vascular risk factor profiles were identified in ischemic stroke versus TIA. This suggests that there are pathogenic differences between TIA and ischemic strokes.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Brain; Cerebral Infarction; Diabetes Complications; Female; Humans; Hyperlipidemias; Hypertension; Ischemic Attack, Transient; Male; Multivariate Analysis; Predictive Value of Tests; Risk Factors; Surveys and Questionnaires; Warfarin

We report the case o a 40-year-old male patient with "primary antiphospholipid syndrome" who developed ischemic cerebral infarctions and renal microangiopathy with infarction. A review of the literature on renal involvement in the primary antiphospholipid syndrome disclosed the differences from the antiphospholipid syndrome in the systemic lupus erythematosus. We describe the evolution of the patient at eight years, and we emphasize the importance of the treatment with warfarin. Also, we review the pathophysiology of severe secondary arterial hypertension.

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Arterioles; Brain Ischemia; Cerebral Infarction; Dysarthria; Fibrosis; Humans; Hypertension; Infarction; Kidney; Magnetic Resonance Imaging; Male; Smoking; Thrombophilia; Warfarin

Isolated spontaneous renal artery dissection is a rare condition that can result in renal parenchymal loss and severe hypertension. Although several risk factors have been identified in association with renal artery dissection, the natural history is not well defined. The rarity and nonspecific presentation of the disease often lead to diagnostic delay. That, coupled with the anatomic limitations imposed by dissection into small branch arteries, frequently precludes successful revascularization. Over a 12-month period, four cases of spontaneous renal artery dissection (SRAD) were treated at a single institution. The patients (ages 44-58 years) presented with acute onset of abdominal/flank pain, fever, and hematuria. Diagnostic work-up included an abdominal CT scan revealing segmental renal infarction. Angiographic evaluation was diagnostic for renal artery dissection in all cases. In one case there was evidence of fibromuscular dysplasia (FMD), and in a second there was acute dissection superimposed upon atherosclerotic disease. Diagnosis was made within 12-72 hr of the onset of symptoms. All patients were managed expectantly with anticoagulation. Two patients were known to have a history of hypertension prior to admission. All four patients have required antihypertensive treatment following dissection, but the condition has been easily controlled. Renal function has remained stable in all cases. None of the four cases required exploration. Two of the four patients underwent repeat angiographic evaluation for recurrent symptoms of pain. In the case of the patient with FMD, a new dissection was seen in the contralateral renal artery, and in the second, repeat angiogram revealed proximal remodeling of the dissected artery. Management strategies for SRAD include surgical revascularization, endovascular intervention, and observation with or without anticoagulation. The available literature does not demonstrate a clear benefit of treatment with any of these modalities. In the short term, the combination of anticoagulation and expectant management appears to produce satisfactory outcomes for this difficult problem.

Topics: Adult; Anticoagulants; Antihypertensive Agents; Aortic Dissection; Female; Flank Pain; Heparin; Humans; Hypertension; Male; Middle Aged; Renal Artery; Tomography, X-Ray Computed; Warfarin

To study the demographic and clinical characteristics of patients with antiphospholipid syndrome (APS) with serious haemorrhagic complications of anticoagulant treatment in an attempt to establish risk factors for bleeding.. Patients with APS who were attending our lupus unit and who presented with severe bleeding while receiving oral anticoagulation were studied retrospectively. Severe bleeding was defined by the need for admission to hospital. Demographic data, clinical features, concomitant diseases and drugs, warfarin doses, duration of anticoagulation, and International Normalised Ratios (INR) at the time of bleeding were collected.. Fifteen patients were included in the study (12 with systemic lupus erythematosus (SLE) plus APS and 3 with primary APS). The median age was 41.7 (range 27-66) and the median duration of the disease was 12.9 years (range 3-22). Duration of anticoagulation was between 10 days and 17 years. The INR at the time of bleeding was under 3 in 4 patients, between 3 and 4 in 5 patients and above 4 in 6 patients. There were 4 episodes of subdural haematoma, 4 episodes of renal haematoma (two after renal biopsy), 2 episodes of ovarian haemorrhage, 2 episodes of rectal haemorrhage, 1 episode of menorrhagia, 1 episode of haemarthrosis, and 1 episode of spinal haematoma. Concomitant drugs were aspirin in 9 patients, antibiotics in 2 patients, and azathioprine in 3 patients. In 6 patients hypertension was present as a concomitant disease. There were no deaths due to bleeding. Anticoagulant treatment was restarted in all patients and 3 of them had a new episode of bleeding.. No relation was established between age, duration of oral anticoagulant treatment, and bleeding. Concomitant drugs, mainly aspirin, and high blood pressure were present at the time of bleeding in a large number of patients.

Topics: Adult; Aged; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Antiphospholipid Syndrome; Aspirin; Female; Hemarthrosis; Hematoma; Hematoma, Subdural; Hemorrhage; Humans; Hypertension; Kidney Diseases; Male; Menorrhagia; Middle Aged; Ovarian Diseases; Recurrence; Risk Factors; 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: Adult; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Atrial Fibrillation; Comorbidity; Diabetes Complications; Double-Blind Method; Fibrinolytic Agents; Heart Valve Diseases; Hemorrhage; Humans; Hypertension; Ischemic Attack, Transient; Isoindoles; Middle Aged; Phenylbutyrates; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Risk Factors; Stroke; Thromboembolism; Warfarin

Previous studies have documented sex differences in the management and outcome of patients with cardiovascular disease. However, little data exist on whether similar sex differences exist in stroke patients. We conducted a study to determine whether sex differences exist in patients with acute stroke admitted to Ontario hospitals.. Using linked administrative databases, we performed a population-based cohort study. The databases contained information on all 44 832 patients discharged from acute-care hospitals in Ontario between April 1993 and March 1996 with a most responsible diagnosis of acute stroke. The main outcomes measured consisted of sex differences in comorbidities, the use of rehabilitative services, the use of antiplatelet therapy and anticoagulants (in elderly stroke survivors aged > or =65 years only), discharge destination, and mortality.. Male stroke patients were more likely than female stroke patients to have a history of ischemic heart disease (18.1% versus 15.3%, respectively; P<0.001) and diabetes mellitus (20.1% versus 18. 7%, respectively; P<0.001), whereas female patients were more likely than male patients to have hypertension (33.8% versus 30.0%, respectively; P<0.001) and atrial fibrillation (12.9% versus 10.2%, respectively; P<0.001). There were no sex differences in the usage of in-hospital rehabilitative services. The overall 90-day postdischarge use of aspirin and ticlopidine was similar in stroke survivors aged 65 to 84 years. However, among stroke survivors aged > or =85 years, men were more likely than women to receive aspirin (36. 0% versus 30.7%, respectively; P<0.001) and ticlopidine (9.2% versus 6.8%, respectively; P=0.007). Use of warfarin was similar for the two sexes. Men were more likely than women to be discharged home (50. 6% versus 40.9%, respectively; P<0.001) and less likely to be discharged to chronic care facilities (16.8% versus 25.2%, respectively; P<0.001). The risk of death 1 year after stroke was somewhat lower in women than men (adjusted odds ratio 0.939, 95% CI 0.899 to 0.980; P=0.004). The mortality differences were greatest among elderly stroke patients.. Elderly men are more likely than elderly women to receive aspirin and ticlopidine and equally like to receive warfarin after a stroke. Despite these differences, elderly women have a better 1-year survival after a stroke.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Atrial Fibrillation; Cohort Studies; Comorbidity; Diabetes Mellitus; Female; Humans; Hypertension; Male; Myocardial Ischemia; Ontario; Platelet Aggregation Inhibitors; Retrospective Studies; Sex Characteristics; Stroke; Stroke Rehabilitation; Survival Rate; Ticlopidine; Treatment Outcome; Warfarin

We conducted this study to evaluate whether there is an association between preoperative drug therapy and in-hospital mortality in patients undergoing coronary artery graft surgery. We collected data on 1593 consecutive patients undergoing coronary artery surgery. The relative risk of in-hospital mortality was determined by logistic regression with in-hospital mortality as the dependent variable, and independent variables that included known risk factors and preoperative cardioactive or antithrombotic drug treatment, i.e., age; left ventricular function; left main coronary artery disease; urgent priority; gender; previous cardiac surgery; concurrent cardiovascular surgery; chronic lung disease; creatinine concentration; hemoglobin concentration; diabetes; hypertension; cerebrovascular disease; recent myocardial infarction; prior vascular surgery; number of arteries bypassed; and regular daily treatment with beta-blockers, aspirin within 5 days, calcium antagonists, angiotensin converting enzyme (ACE) inhibitors, digoxin, or warfarin. In-hospital mortality was 3.3%. The relative risk of in-hospital mortality (with 95% confidence intervals of the relative risk) associated with the following drug treatments was: nitrates 3.8 (1.5-9.6), beta-blockers 0.4 (0.2-0.8), aspirin within 5 days 1.0 (0.5-1.9), calcium antagonists 1.1 (0.6-2.1), ACE inhibitors 0.8 (0.4-1.5), digoxin 0.7 (0.2-1.8), and warfarin 0.3 (0.1-1.6). We conclude that in-hospital mortality is positively associated with preoperative nitrate therapy and negatively associated with beta-adrenergic blocker therapy. A significant association between in-hospital mortality and the preoperative use of calcium antagonists, ACE inhibitors, aspirin, digoxin, and warfarin was not confirmed.. We examined the association between common drug treatments for ischemic heart disease and short-term survival after cardiac surgery using a statistical method to adjust for patients' preoperative medical condition. Death after surgery was more likely after nitrate therapy and less likely after beta-blocker therapy.

Topics: Adrenergic beta-Antagonists; Age Factors; Aged; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Aspirin; Cardiotonic Agents; Cerebrovascular Disorders; Chronic Disease; Coronary Artery Bypass; Coronary Disease; Creatinine; Diabetes Complications; Digoxin; Female; Fibrinolytic Agents; Forecasting; Hemoglobins; Hospital Mortality; Humans; Hypertension; Logistic Models; Lung Diseases; Male; Middle Aged; Myocardial Infarction; Nitrates; Reoperation; Risk Factors; Sex Factors; Survival Rate; Ventricular Function, Left; Warfarin

A multicenter, retrospective study was undertaken to survey the prevalence of thromboembolism complicated with atrial fibrillation and the efficacy of treatment in both elderly and younger patients. The primary prevention group consisted of 1,810 patients without prior cerebral thromboembolism, and was divided into the elderly patient group (> or = 65 years old, 588 patients) and younger patient group (< 65 years old, 1,222 patients). The elderly group had higher prevalences of chronic atrial fibrillation (65.3% vs 56.4%, p < 0.001) and ischemic heart disease and hypertension (16.8% vs 9.3% and 34.2% vs 24.4%, respectively, p < 0.001) and lower prevalence of treatment with warfarin (9.2% vs 20.1%, p < 0.001). Elderly patients with mitral valve disease and hypertension had lower prevalence of treatment with warfarin as compared with younger patients (p < 0.001). This was also true for the secondary prevention group of 147 patients with prior history of cerebral infarction (p < 0.001). During the mean follow-up period of 4.6 years, patients with underlying cardiac diseases had a higher risk of thromboembolism compared with those without cardiac diseases for both the elderly (12.1% vs 6.1%, p < 0.05) and younger (7.5% vs 3.6%, p < 0.02) groups. Treatment with antiplatelets or warfarin could reduce the risk of thromboembolism in the elderly group (p < 0.1) and the younger group (p < 0.001). The risk of major hemorrhagic complication, i.e., gastrointestinal tract or intracranial hemorrhage, was quite low in patients receiving antithrombotic drugs. The present study indicates that the attitude toward the use of warfarin for prevention of thromboembolism is conservative and the risk of thromboembolism is higher in elderly patients with atrial fibrillation in Japan. Our attitude to the use of antithrombotic drugs in elderly patients with atrial fibrillation needs to be modified.

Topics: Aged; Atrial Fibrillation; Chronic Disease; Female; Hemorrhage; Humans; Hypertension; Japan; Male; Middle Aged; Myocardial Ischemia; Platelet Aggregation Inhibitors; Prevalence; Retrospective Studies; Thromboembolism; Warfarin

The natural statins should be used as first line agents in the prevention of stroke. The effects of the synthetic statins on the prevention of coronary events and stroke have not been reported at this time. The National Stroke Association's Stroke Prevention Advisory Board has prepared a consensus statement on risk reducing intervention. The Board identified hypertension, MI, atrial fibrillation, hyperlipidemia and asymptomatic carotid artery stenosis (60% to 99% occlusion) as proven stroke risk factors. The Board's recommendations for the prevention of a first stroke are: 1. Hypertension should be treated with lifestyle, pharmacologic and multidisciplinary management strategies. 2. Aspirin post MI and warfarin (international normalized ratio, 2 to 3) for patients with atrial fibrillation, left ventricular thrombus or significant left ventricular dysfunction. Statin agents should be used post MI. 3. Atrial fibrillation patients age 75 or older should be treated with warfarin. Younger patients 65 to 75 with atrial fibrillation and risk factors should be treated with warfarin [corrected]. Younger patients 65 to 75 with atrial fibrillation without risk factors should be treated with warfarin or aspirin [corrected]. 4. Patients with hyperlipidemia and coronary artery disease should be on statin agents. 5. Carotid endarterectomy is recommended for asymptomatic carotid stenosis (60% to 99%) when surgical morbidity and mortality are less than 3%. 6. Adherence to a low-fat diet, smoking avoidance, mild alcohol use, and physical activity should follow published guidelines.

Topics: Aged; Aspirin; Diabetes Complications; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypertension; Life Style; Middle Aged; Platelet Aggregation Inhibitors; Risk Factors; Stroke; Warfarin

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Cerebrovascular Disorders; Cohort Studies; Dose-Response Relationship, Drug; Family Practice; Female; Humans; Hypertension; Male; Platelet Aggregation Inhibitors; Prospective Studies; Risk; Treatment Outcome; Warfarin

Atherosclerotic lesions of the aortic arch are potential sources of arterial embolism. Mobile thrombi in the aortic arch in young patients without diffuse atherosclerosis have been reported recently, but such cases remain exceptional. We describe a series of young patients with unexplained arterial embolism in whom transesophageal echocardiography detected mobile aortic arch thromboses.. Transesophageal echocardiography files collected between 1991 and 1995 in French academic cardiology centers were reviewed to identify patients who fulfilled the following criteria: (1) an arterial embolic event in the preceding weeks; (2) a mobile pedunculated aortic arch thrombosis, defined as an echogenic mass protruding into the lumen of the aorta and inserted on the aortic arch; and (3) absence of obvious diffuse aortic atherosclerosis or of aortic debris on transesophageal echocardiography. Twenty-three cases were identified from 27 855 examinations. Thromboses were located on the horizontal aorta (n = 4), near the ostium of the left subclavian artery (n = 5), or on the concavity of the posterior segment of the aortic arch (in the isthmus) (n = 14). The insertion site was a small atherosclerotic plaque in 21 patients. The remaining aortic wall always appeared normal or mildly atherosclerotic. The mean age of the patients was 45 +/- 8.4 years (range, 26 to 61 years). All patients were treated with intravenous heparin after the diagnosis of aortic arch thrombosis, and surgical removal of the thrombosis was performed in 10 patients in whom histological examination confirmed an atherosclerotic process at the site of insertion of the thrombosis. The prognosis was mainly influenced by embolic events.. Thromboses of the aortic arch appear to be a variant form of aortic atherosclerotic disease associated with arterial embolism in young patients.

Topics: Adult; Aorta, Thoracic; Arteriosclerosis; Aspirin; Blood Coagulation Tests; Diabetes Complications; Echocardiography, Transesophageal; Female; Follow-Up Studies; Humans; Hypercholesterolemia; Hypertension; Male; Middle Aged; Recurrence; Retrospective Studies; Risk Factors; Smoking; Thrombectomy; Thrombosis; Warfarin

Topics: Adult; Aged; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Antihypertensive Agents; Aspirin; Electrocoagulation; Epistaxis; Female; Humans; Hypertension; Male; Middle Aged; Retrospective Studies; Tampons, Surgical; Warfarin

The annual incidence of ischemic stroke among patients with chronic non-valvular atrial fibrillation is about 4.5 percent. In five controlled trials, oral anticoagulant therapy with warfarin reduced the annual incidence of stroke by 68 percent to 1.4 percent. The effect of aspirin has not been unequivocally determined. Aspirin reduced the annual risk of stroke by 18 percent (n.s.) in one trial, and by 44 percent in another, though the two trials differed both in mean age of the patients and in aspirin doses. Direct comparison of warfarin and aspirin revealed no difference in efficacy. Advanced age, previous stroke or transient ischemic attack (TIA), hypertension and diabetes were all found to be risk factors for stroke in patients with atrial fibrillation. In patients under 65 years of age without risk factors, the annual risk of stroke was 1 percent. After TIA or minor stroke, warfarin reduced the annual risk of a second stroke from 12 percent to 4 percent. Aspirin had no such effect. The annual incidence of major bleeding episodes was 0.2-2.0 percent in the warfarin-treated subgroup, 0.2-1.5 percent in the aspirin subgroup and 0-1.6 percent in the placebo subgroup. Based on findings in the above mentioned trials, warfarin (INR 2.0-3.0) is recommended for stroke prevention in patients over 60 years of age with non-valvular atrial fibrillation. Trials are under way to ascertain whether conventional warfarin treatment can be replaced by less complicated and safer treatments in patients with chronic atrial fibrillation.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Cerebrovascular Disorders; Controlled Clinical Trials as Topic; Diabetes Complications; Female; Humans; Hypertension; Ischemic Attack, Transient; Male; Middle Aged; Platelet Aggregation Inhibitors; Risk Factors; Warfarin

We sought to determine the frequency of spontaneous cerebrovascular events in adult patients with cyanotic congenital heart disease and to evaluate any contributing factors.. Cerebrovascular events are a serious complication of cyanotic congenital heart disease in infants and children but are said to be uncommon in adults.. Between 1988 and 1995, 162 patients with cyanotic congenital heart disease (mean age 37 years, range 19 to 70) were retrospectively evaluated for any well documented cerebrovascular events that occurred at > or = 18 years of age. Events related to procedures, endocarditis or brain abscess were excluded.. Twenty-two patients (13.6%) had 29 cerebrovascular events (1/100 patient-years). There was no significant difference between those with and without a cerebrovascular event in terms of age, smoking history, degree of erythrocytosis, ejection fraction or use of aspirin or warfarin (Coumadin). Patients who had a cerebrovascular event had a significantly increased tendency to develop hypertension, atrial fibrillation, microcytosis (mean corpuscular volume < 82) and history of phlebotomy (p < 0.05). Even when patients with hypertension or atrial fibrillation were excluded, there was an increased risk of cerebrovascular events associated with microcytosis (p < 0.01).. Adults with cyanotic congenital heart disease are at risk of having cerebrovascular events. This risk is increased in the presence of hypertension, atrial fibrillation, history of phlebotomy and microcytosis, the latter condition having the strongest significance (p < 0.005). This finding leads us to endorse a more conservative approach toward phlebotomy and a more aggressive approach toward treating microcytosis in adults with cyanotic congenital heart disease.

Topics: Adult; Aged; Anemia, Iron-Deficiency; Anticoagulants; Aspirin; Atrial Fibrillation; Cerebrovascular Disorders; Female; Heart Defects, Congenital; Humans; Hypertension; Ischemic Attack, Transient; Male; Middle Aged; Platelet Aggregation Inhibitors; Retrospective Studies; Risk Factors; Smoking; Warfarin

Topics: Aged; Aspirin; Atrial Fibrillation; Cerebrovascular Disorders; Dementia, Vascular; Humans; Hypertension; Ischemic Attack, Transient; Risk Factors; Warfarin

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

Episodic cerebro or retinovascular ischemic events without apparent cause occur in patients with cancer. We report a patient in remission from lymphoma whose multiple episodes of presumed ocular ischemia occurred in the setting of a circulating lupus anticoagulant. Symptoms resolved following therapy with Warfarin.

Topics: Antineoplastic Combined Chemotherapy Protocols; Bleomycin; Brain; Cyclophosphamide; Dexamethasone; Doxorubicin; Humans; Hypertension; Ischemic Attack, Transient; Lupus Coagulation Inhibitor; Lymphoma, Large B-Cell, Diffuse; Magnetic Resonance Imaging; Male; Middle Aged; Remission Induction; Scotoma; Vincristine; Vision, Monocular; Warfarin

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

Topics: Adult; Compartment Syndromes; Humans; Hypertension; Male; Renal Veins; Thigh; Thrombosis; Warfarin; Wounds, Nonpenetrating

We investigated incidence, age distribution in relation to etiology, and localization of spontaneous intracerebral hematoma in 100 consecutive cases. Incidence in the total population of the Giessen area was estimated to be greater than 11/100,000 inhabitants/yr and increased with age. There was a trend toward higher incidence in males. Overall mortality was 27%, 22% of 58 patients aged less than 70 years and 33% of 42 patients aged greater than or equal to 70 years. Hypertensive putaminal hematoma showed the highest mortality rate (42%, 10 of 24 cases). Chronic alcoholism and anticoagulant medication influenced the mortality rate unfavourably. We found the following localizations and etiologies to have a specific relation with age: 1) lobar hematomas from vascular malformations, group aged less than 40 years; 2) hypertensive putaminal hematomas and hypertensive thalamic hematomas, group aged 40-69 years; and 3) lobar hematomas, group aged greater than or equal to 70 years. Alcoholism was an additional factor in 38% of the 13 middle-aged men with hypertensive putaminal hematomas. Fourteen cases of spontaneous intracerebral hematoma were possibly due to cerebral amyloid angiopathy. Six of these 14 patients had recurrent lobar hematomas, but only three of the six could be histologically investigated. In these three cases, cerebral amyloid angiopathy was proven.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Alcoholism; Cerebral Hemorrhage; Female; Germany; Hematoma; Humans; Hypertension; Incidence; Male; Middle Aged; Sex Characteristics; Warfarin

Recurrent, bilateral, and severe conjunctival hemorrhages mandate the search for an underlying etiology, such as a blood dyscrasia, blood clotting disorder, or recurrent increased intrathoracic pressure caused by repetitive vomiting or coughing spells. Medical and ophthalmic management is discussed in a case of subconjunctival and external hemorrhage from the eye secondary to prolonged prothrombin time in oral anticoagulation therapy.

Topics: Administration, Oral; Anticoagulants; Conjunctival Diseases; Fundus Oculi; Hemorrhage; Heparin; Humans; Hypertension; Male; Middle Aged; Ophthalmic Solutions; Prothrombin Time; Warfarin

To assess the aetiological contribution made to spontaneous epistaxis in adults over the age of 50 years by various groups of drugs, a controlled study was designed. Fifty-three consecutive epistaxis patients were compared with 50 controls. Significant differences were found between the groups in their consumption of warfarin, dipyridamole and non-steroidal anti-inflammatory drugs. Hypertension was equally common in the two groups, but tended to be less well controlled in the epistaxis patients compared to the controls. It is thought that the link between the use of nonsteroidal anti-inflammatory drugs and the occurrence of epistaxis may be due to alteration of platelet function.

Topics: Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Arthritis; Coronary Disease; Dipyridamole; Epistaxis; Female; Humans; Hypertension; Lung Diseases, Obstructive; Male; Middle Aged; Prospective Studies; Warfarin

1 To assess the potential value of low-dose phenobarbitone (PB) as a marker of compliance we studied the relationship between plasma level of PB and dose (2-16 mg daily) following 3 or 4 weeks treatment in healthy volunteers (n = 26) and in-patient volunteers (n = 7). 2 Also, to simulate poor compliance, PB levels were measured in some volunteers following alternate-day (n = 6) or short-term (n = 5) treatment with similar doses. These levels, expressed as the level: dose ratios (LDRs), did not overlap with those obtained following 3 or 4 weeks of daily PB intake. 3 To evaluate the efficacy of this marker in patients taking other drugs we gave a group of out-patients (n = 24) compound tablets containing B vitamins and a small dose (16 mg) of PB; their compliance over 2-5 weeks was assessed both by measuring plasma levels of PB and residual tablet counting. 4 In the latter study, as well as providing absolute evidence of good compliance by many patients, the plasma levels of PB proved particularly valuable when non-compliant individuals 'forgot' to bring their residual tablets. 5 We suggest that phenobarbitone, in doses low enough to be non-sedative and non-enzyme inducing, is potentially useful as a pharmacological indicator of compliance with drug therapy.

Topics: Adult; Aged; Antihypertensive Agents; Female; Humans; Hypertension; Male; Middle Aged; Patient Compliance; Phenobarbital; Valproic Acid; Warfarin

The clinical pharmacology and pharmacokinetics of acebutolol are summarized. Acebutolol and its longer-acting metabolite, diacetolol, are rapidly absorbed into the circulation from the gastrointestinal tract, and their bioavailability, unlike that of propranolol and metoprolol, is not significantly altered by whether the patient has recently eaten. Acebutolol is extensively metabolized by the liver, and elimination pathways involve approximately 30% to 40% through renal excretion and 50% to 60% by nonrenal mechanisms, including the bile and direct passage through the intestinal wall. The decreased hepatic metabolism and renal clearance rates seen in elderly patients may lead to the accumulation of both acebutolol and its metabolite, as has been reported with propranolol. In studies conducted to ascertain acebutolol's possible effect on common concurrently administered medications, the drug did not significantly alter either serum digoxin levels or serum insulin levels in diabetic patients treated with tolbutamide, nor did it change prothrombin time in patients treated with sodium warfarin.

Topics: Acebutolol; Adrenergic beta-Antagonists; Adult; Aged; Digoxin; Drug Interactions; Female; Humans; Hypertension; Kinetics; Male; Metabolic Clearance Rate; Middle Aged; Prothrombin Time; Tolbutamide; Warfarin

Clinical pharmacy services provided by pharmacists to patients in a rehabilitation facility through a contracted arrangement with a local hospital are described. Two staff pharmacists from a community hospital oversee the drug-distribution process and provide clinical services at a 40-bed private rehabilitation facility. During alternate four-week periods, each pharmacist works at the rehabilitation facility; the other four-week period is spent in traditional drug-distribution activities at the hospital. The hospital is reimbursed for clinical services separately from drug-distribution services; by keeping records of the time spent in clinical activities at the facility, the pharmacists have obtained increased reimbursement for these services since initiation of this program. Clinical services provided by pharmacists at the institute include patient education, drug-therapy monitoring and consultation, drug information activities, and management of drug therapy in selected patients. In 1982, pharmacists provided 230 drug-therapy consultations to physicians and received referrals for drug-therapy management of 47 patients on warfarin sodium, 46 on antihypertensive drugs, and 27 on phenytoin sodium. The provision of a variety of clinical pharmacy services to patients in a rehabilitation facility offers a unique and professionally rewarding practice.

Topics: Contract Services; Drug Information Services; Financial Management; Hospital Bed Capacity, 300 to 499; Humans; Hypertension; Missouri; Patient Education as Topic; Pharmacy Service, Hospital; Phenytoin; Referral and Consultation; Rehabilitation Centers; Warfarin; Water-Electrolyte Imbalance

We confirmed our previously reported findings that subcutaneous administration of heparin (200 U q 12 hr) in rats with experimental partial renal infarction prevents the development of progressive renal failure and hypertension, as well as the glomerular abnormalities which occur in the remaining viable renal tissue. In the present study, heparin, in the dosage used to prevent progressive renal failure, caused a marked and sustained prolongation of the activated partial thromboplastin time and prothrombin time, as well as a transient prolongation of the bleeding time. Administration of coumadin at doses which caused a significant prolongation of the prothrombin time and bleeding time also inhibited the development of progressive hypertension and uremia in rats with experimental partial renal infarction. These findings indicate that inhibition of blood coagulation effectively protects rats with experimentally decreased renal mass from the development of progressive renal failure and hypertension and support the concept that the glomerular thrombosis plays an important role in the pathogenesis of these complications.

Topics: Animals; Anticoagulants; Cardiomegaly; Female; Hemostasis; Heparin; Hypertension; Infarction; Kidney; Kidney Glomerulus; Rats; Rats, Inbred Strains; Uremia; Warfarin

Two patients with progressive systemic sclerosis (scleroderma) developed renal failure which required thrice weekly hemodialysis. While receiving hemodialysis treatments and warfarin, their renal function improved and it was possible to discontinue hemodialysis after 9 mo in Case 1 and after 3 mo in Case 2. The recovery of renal function in these patients suggests therapy with warfarin may play a role in the treatment of scleroderma renal failure.

Topics: Adult; Female; Humans; Hypertension; Kidney Failure, Chronic; Male; Renal Dialysis; Scleroderma, Systemic; Warfarin

Topics: Aspirin; Brain Ischemia; Carotid Arteries; Dicumarol; Dipyridamole; Endarterectomy; Heart Murmurs; Heparin; Humans; Hypertension; Ischemic Attack, Transient; Risk; Sulfinpyrazone; Warfarin

Topics: Aged; Hemorrhage; Humans; Hypertension; Male; Medication Errors; Propranolol; 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: Abnormalities, Drug-Induced; Alcoholism; Cerebrovascular Disorders; Chondrodysplasia Punctata; Contraceptives, Oral; Diazepam; Female; Fetus; Furosemide; Humans; Hypertension; Infant, Newborn; Male; Pregnancy; Pregnancy Complications; Radiography; Rheumatic Heart Disease; Stress, Psychological; Warfarin

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

Topics: Adult; Aged; Angiography; Brain Edema; Cerebral Hemorrhage; Cerebral Ventriculography; Corpus Striatum; Diagnosis, Computer-Assisted; Female; Hematoma; Humans; Hypertension; Infant, Newborn; Infant, Newborn, Diseases; Intracranial Arteriovenous Malformations; Male; Phlebitis; Thalamus; Tomography, X-Ray; Warfarin

Topics: Adolescent; Adult; Aged; Biopsy; Cyclophosphamide; Female; Fluorescent Antibody Technique; Humans; Hypertension; Kidney Glomerulus; Male; Microscopy, Electron; Middle Aged; Nephrotic Syndrome; Prednisone; Pyuria; Sclerosis; Warfarin

Topics: Aged; Anticoagulants; Arteriosclerosis; Arthritis; Breast Diseases; Female; Gangrene; Humans; Hypertension; Mastectomy; Middle Aged; Necrosis; Penicillins; Postoperative Complications; Thrombophlebitis; Warfarin

Topics: Anticholesteremic Agents; Anticoagulants; Arteriosclerosis; Cholesterol; Choline; Diabetes Complications; Dicumarol; Humans; Hyperlipidemias; Hypertension; Nicotinic Acids; Obesity; Phospholipids; Smoking; Stress, Physiological; Thyroxine; Vasodilator Agents; Warfarin

Topics: Acute Kidney Injury; Arteriosclerosis; Cholesterol; Embolism, Fat; Gangrene; Humans; Hypertension; Male; Middle Aged; Pancreatitis; Toes; Warfarin

Topics: Anticoagulants; Biopsy; Chemical and Drug Induced Liver Injury; Diagnosis, Differential; Guanethidine; Hepatitis; Humans; Hydrochlorothiazide; Hypertension; Methylprednisolone; Polyarteritis Nodosa; Thrombophlebitis; Warfarin

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

Topics: Angina Pectoris; Coronary Disease; Digoxin; Electrocardiography; Hydrochlorothiazide; Hypercholesterolemia; Hypertension; Metaraminol; Nitroglycerin; Shock; Shock, Cardiogenic; Vasopressins; Warfarin

Topics: Arteriosclerosis; Biomedical Research; Blood Chemical Analysis; Brain Diseases; Cerebrovascular Disorders; Coronary Disease; Enzyme Inhibitors; Fats; Hydrocortisone; Hypertension; Myocardial Infarction; Pharmacology; Physiology; Rabbits; Research; Thrombin; Warfarin