warfarin and Ventricular-Dysfunction--Left

Inadvertent malpositioning of a cardiac implantable electronic device lead into the left ventricle is a rare complication of transvenous pacing and defibrillation. Rapid identification of lead position is critical during implantation and just after the procedure, with immediate correction required if malpositioning is detected. If lead misplacement is discovered late after implantation, the lead should be surgically removed or chronic anticoagulation with warfarin should be instituted.

Topics: Anticoagulants; Blood Vessel Prosthesis Implantation; Defibrillators, Implantable; Humans; Prosthesis Failure; Reoperation; Ventricular Dysfunction, Left; Warfarin

To review the thromboembolic risk, pathophysiology associated with the risk, and literature investigating the use of antithrombotics in patients with heart failure with reduced ejection fraction and normal sinus rhythm (HFrEF-NSR).. An English language literature search was performed with MEDLINE/PubMed and Embase from January 1950 to October 2013 using the search terms heart failure, HFrEF, systolic heart failure, cardiomyopathy, left ventricular dysfunction, sinus rhythm, thromboembolism, deep vein thrombosis, pulmonary embolism, myocardial infarction, acute coronary syndrome, acute coronary events, coronary artery disease, stroke, and cerebrovascular events to identify relevant articles. References in the retrieved articles were also assessed to identify other important articles.. All pertinent original studies, reviews, consensus documents, and guidelines were evaluated for inclusion.. Patients with HFrEF-NSR may be predisposed to developing thromboembolic events. Studies that have examined the role of antithrombotics (warfarin and/or antiplatelet therapy) for reducing thromboembolic risk have been inconclusive. The WASH and HELAS pilot trials--the only studies with a no-antithrombotics or placebo comparator group--did not find a benefit with antithrombotic therapy but found an increased risk of bleeding with warfarin and of hospitalizations with aspirin. Although the clinical outcome studies (WATCH and WARCEF) suggested that warfarin may reduce stroke risk compared with antiplatelet therapy, the lack of a placebo group and lower-than-projected enrollment prevents definitive conclusions from being made.. Current evidence does not support the routine use of antithrombotics for preventing thromboembolic events in patients with HFrEF-NSR without compelling indications.

Topics: Anticoagulants; Aspirin; Heart Failure; Humans; Platelet Aggregation Inhibitors; Thromboembolism; Ventricular Dysfunction, Left; Warfarin

The management of cardiomyopathy in pediatric patients is complicated by the risk of cardiac-associated embolism. This review examines the incidence, risk factors, and treatment of embolism in dilated cardiomyopathy (DCM), restrictive cardiomyopathy (RCM), and noncompaction of the left ventricular myocardium (NLVM) in children. The reported incidence of embolism for DCM ranges from 1 to 16%. Left ventricular ejection fraction below 25% or fractional shortening below 15% are major risk factors for intracardiac thrombus formation in this group. The risk of embolism for RCM ranges from 12 to 33%. Atrial dilation is considered the major risk factor. The reported incidence of embolism for NLVM ranges from 0 to 38%, with most studies indicating an absence of detectable thrombus or embolus. Severe systolic dysfunction exacerbates the risk of embolism in this group. On the basis of these risk factors, we propose an algorithm for the management of embolism in these groups of patients.

Topics: Anticoagulants; Aspirin; Cardiomyopathy, Dilated; Cardiomyopathy, Restrictive; Child; Disease Management; Embolism; Humans; Risk Factors; Thrombosis; Ventricular Dysfunction, Left; Ventricular Function, Left; Warfarin

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Blood Coagulation; Blood Coagulation Tests; Dabigatran; Drug Monitoring; Hemodynamics; Hemorrhage; Humans; Risk Factors; Stroke; Therapeutic Equivalency; Treatment Outcome; Ventricular Dysfunction, Left; Warfarin

Peripartum cardiomyopathy is a life-threatening condition of unknown cause that occurs in previously healthy women during the peripartum period. It is characterized by left ventricular dysfunction and symptoms of heart failure that can arise in the last trimester of pregnancy or up to 5 months after delivery. We review its possible causes and how to recognize and manage it.

Topics: Abnormalities, Drug-Induced; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Cardiomyopathies; Contraindications; Female; Heart Failure; Heart Transplantation; Humans; Postpartum Period; Pregnancy; Pregnancy Complications, Cardiovascular; Recurrence; Risk Factors; Ventricular Dysfunction, Left; Warfarin

Isolated left ventricular noncompaction (IVNC) is a congenital cardiomyopathy characterized by a loosened spongy myocardium. Recognition of this condition is extremely important because of its high mortality and morbidity due to progressive heart failure, thromboembolic events, and ventricular arrhythmias. However, IVNC is commonly misdiagnosed because of the lack of knowledge about this rare disorder. We report 2 patients with the characteristic echocardiographic presentation for IVNC. Echocardiography is the procedure of choice to confirm the diagnosis and perform follow-up in patients with IVNC; therefore, it is important to make echocardiographers more familiar with this condition.

Topics: Anticoagulants; Carbazoles; Cardiomyopathies; Carvedilol; Diagnosis, Differential; Echocardiography; Electrocardiography; Humans; Male; Middle Aged; Propanolamines; Vasodilator Agents; Ventricular Dysfunction, Left; Warfarin

The American College of Cardiology provided much useful new information to inform those who care for patients with heart failure about what they should and should not adopt into current clinical practice. The EPHESUS trial suggests a much wider role for aldosterone antagonists for the management of heart failure and left ventricular systolic dysfunction. SPORTIF-III indicates we may have a safer, simpler warfarin substitute soon. ASCOT reinforces the potential futility of statin therapy unless it is well targeted. The results of the COMPANION study investigating cardiac resynchronisation devices and implantable defibrillators were encouraging but inconclusive and/or hard to interpret. UK-PACE again questions the use of dual chamber pacing. T-wave alternans is an interesting experimental technique that may be useful in selecting which patients need an implantable defibrillator, although the technology needs testing in an appropriate patient population.

Topics: Anticoagulants; Cardiac Pacing, Artificial; Defibrillators, Implantable; Electrocardiography; Eplerenone; Heart Failure; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Mineralocorticoid Receptor Antagonists; Pacemaker, Artificial; Spironolactone; Ventricular Dysfunction, Left; Warfarin

There are no clear data regarding whether to use warfarin, aspirin, or no therapy in patients with left ventricular systolic dysfunction. Aspirin use is widespread in patients with vascular disease but it can decrease renal blood flow in low output states. Warfarin may be used in patients with advancing heart failure due to the perceived risk of in situ thromboembolism. However, we know that ejection fraction and symptom class do not always match and that the regulation of warfarin dosing is more difficult in worsening heart failure. Drug use must be individualized, based on knowledge of underlying heart failure etiology, functional class, drug side effects, and renal function. We await ongoing studies to elucidate the differential effects of these drugs on global outcome as well as on the mechanisms by which they achieve their results.

Topics: Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Aspirin; Heart Failure; Humans; Platelet Aggregation Inhibitors; Thromboembolism; Ventricular Dysfunction, Left; Warfarin

The current published literature does not indicate whether the long-term effect of anticoagulant or antiplatelet therapy contributes to mortality reduction in patients with LV dysfunction. Evaluating patients for personal risk for emboli or for ischemic coronary artery events may influence the choice of therapies. As more is learned about the mechanisms of drug effects in different populations, physicians may be better able to direct appropriate therapies. Until that time, one must weigh the risks and benefits of each drug alone and in combination. In NYHA class IV patients, the risk for thrombosis owing to spontaneous clotting increases as does the adverse potential of warfarin and the adverse effects of inhibiting prostaglandin mediated vasodilation by aspirin. In NYHA class I and II patients, the quality of life and convenience of multidrug therapy is weighed against the devastating effect of a major stroke. In less symptomatic patients, the long-term risk for acute coronary events may be higher than previously identified. This would suggest that all patients with depressed LV function should be on some type of antiplatelet or anticoagulant therapy. The current WATCH study will provide much needed information about the outcome differences between these agents. Conclusions based on available data include the following: Heart failure is increasing in incidence and prevalence. Atherosclerotic disease is an important causative factor for the development of heart failure or may be a comorbid condition in these patients. There is a measurable rate of stroke in patients with heart failure, although the cause of death in large studies is more often owing to sudden death or progressive heart failure. Sudden death may be from new ischemic events, asystole, or from ventricular tachyarrhythmias. In patients with heart failure, not all strokes are cardioembolic in origin. The benefits and risks of warfarin may be increased as the EF worsens or heart failure functional class declines. The interactions of aspirin and ACE inhibitors have been best evaluated for the hemodynamic effects. There may be additional factors hitherto not studied. The hemodynamic effect of ACE inhibitors may be more important in NYHA classes III and IV than in less symptomatic patients. Warfarin use has clear indications for patients in atrial fibrillation with mechanical prosthetic valves, in hypercoagulable states, and with a previous history of embolization. Aspirin is inexpensive and commo

Topics: Anticoagulants; Cardiomyopathies; Comorbidity; Heart Failure; Humans; Life Style; Stroke; Ventricular Dysfunction, Left; Warfarin

Systemic embolic complications in patients with cardiomyopathy are associated with significant morbidity and mortality. Despite the lack of prospective, randomized control data, the literature supports the use of left ventricular ejection fraction as an important determinant of the need for systemic anticoagulation therapy in patients with systolic dysfunction. This review discusses the risks and benefits of systemic anticoagulation for patients with cardiomyopathy and proposes a treatment algorithm for its initiation.

Topics: Algorithms; Anticoagulants; Cardiomyopathies; Humans; Intracranial Embolism; Randomized Controlled Trials as Topic; Stroke; Stroke Volume; Ventricular Dysfunction, Left; Warfarin

Despite the remarkable advances in cardiovascular therapeutics over the past four decades, little impact has been made on either the incidence or mortality rate of congestive heart failure and it remains a major clinical and public health problem. Recent practice audits have suggested that proven efficacious therapies are not maximally applied in patients with this condition. An approach to the patient with congestive heart failure is presented, emphasizing the two distinct syndromes of systolic dysfunction and diastolic dysfunction. Treatment recommendations are derived from consideration of the underlying pathophysiology and the evidence from randomised clinical trials.

Topics: Adrenergic beta-Antagonists; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Clinical Trials as Topic; Diet, Sodium-Restricted; Diuretics; Drinking; Female; Heart Failure; Humans; Male; Middle Aged; Myocardial Ischemia; Prevalence; Risk Factors; Severity of Illness Index; Ventricular Dysfunction, Left; Ventricular Dysfunction, Right; Warfarin

We sought to assess the performance of existing bleeding risk scores, such as the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) score or the Outpatient Bleeding Risk Index (OBRI), in patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm (SR) treated with warfarin or aspirin. We calculated HAS-BLED and OBRI risk scores for 2,305 patients with HFrEF in SR enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial. Proportional hazards models were used to test whether each score predicted major bleeding, and comparison of different risk scores was performed using Harell C-statistic and net reclassification improvement index. For the warfarin arm, both scores predicted bleeding risk, with OBRI having significantly greater C-statistic (0.72 vs 0.61; p = 0.03) compared to HAS-BLED, although the net reclassification improvement for comparing OBRI to HAS-BLED was not significant (0.32, 95% confidence interval [CI] -0.18 to 0.37). Performance of the OBRI and HAS-BLED risk scores was similar for the aspirin arm. For participants with OBRI scores of 0 to 1, warfarin compared with aspirin reduced ischemic stroke (hazard ratio [HR] 0.51, 95% CI 0.26 to 0.98, p = 0.042) without significantly increasing major bleeding (HR 1.24, 95% CI 0.66 to 2.30, p = 0.51). For those with OBRI score of ≥2, there was a trend for reduced ischemic stroke with warfarin compared to aspirin (HR 0.56, 95% CI 0.27 to 1.15, p = 0.12), but major bleeding was increased (HR 4.04, 95% CI 1.99 to 8.22, p <0.001). In conclusion, existing bleeding risk scores can identify bleeding risk in patients with HFrEF in SR and could be tested for potentially identifying patients with a favorable risk/benefit profile for antithrombotic therapy with warfarin.

Topics: Aged; Anticoagulants; Aspirin; Female; Heart Failure; Hemorrhage; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Proportional Hazards Models; Risk Assessment; Stroke; Stroke Volume; Ventricular Dysfunction, Left; Warfarin

In the current era of early revascularization and routine use of dual antiplatelet therapy, the incremental benefit of warfarin to reduce the incidence of left ventricular thrombus (LVT) in patients with impaired left ventricular ejection fraction post anterior ST-elevation myocardial infarction (aSTEMI), remains uncertain. The purpose of this study is to assess the feasibility of evaluating the added benefit and safety of triple therapy (TT-warfarin, ASA, and clopidogrel) versus dual therapy (DT-ASA and clopidogrel) in patients at risk of LVT post aSTEMI.. Open-label randomized controlled trial.. aSTEMI, ejection fraction <40%, and no evidence of LVT. EXCLUSION: contraindication to, or alternate indication for anticoagulation.. TT versus DT.. pre-discharge and 3 month echocardiogram.. composite of death, MI, stroke, systemic embolizarion, LVT or major bleeding at three months. 295 patients with aSTEMI were screened: 27% of patients with LVEF < 40% had an LVT; 20/52 eligible patients were randomized to receive TT (n = 10) or DT (n = 10). Baseline characteristics: mean age 60 years, male gender 65%, diabetics 20%, and in hospital PCI 95%. There was no significant difference in the composite endpoint at 3 months (TT-20% with 1 LVT and 1 major bleed versus DT-10% with 1 MI). The incidence of definite or probable LVT in the screened population of patients post aSTEMI with an LVEF < 40% was 26.6% despite 94% having early revascularization. STEMI patients have a high incidence of LVT despite the routine use of early revascularization and dual antiplatelet therapy. More effective antithrombotic strategies merit evaluation in adequately powered randomized trials.

Topics: Aged; Anticoagulants; Aspirin; Clopidogrel; Drug Therapy, Combination; Embolism; Feasibility Studies; Female; Hemorrhage; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Ontario; Platelet Aggregation Inhibitors; Recurrence; Stroke; Thrombosis; Ticlopidine; Time Factors; Treatment Outcome; Ultrasonography; Ventricular Dysfunction, Left; Warfarin

To examine further the relations of plasma von Willebrand factor (vWf, an index of endothelial damage and dysfunction) and soluble P-selectin (sP-sel, an index of platelet activation) concentrations to the presence and onset of clinical congestive heart failure (CHF) and the degree of left ventricular (LV) dysfunction in patients taking part in the SPAF (stroke prevention in atrial fibrillation) study.. Plasma concentrations of vWf and sP-sel were measured by enzyme linked immunosorbent assay (ELISA) in 1321 participants in the SPAF III study and related to the presence and onset of clinical CHF, as well as echocardiographic findings. Of the 1321 patients with atrial fibrillation (AF), 331 (25%) had a documented history of clinical heart failure, of which 168 cases were related to a new or recurrent episode of acute decompensated heart failure occurring within the preceding three months.. Mean plasma vWf was higher among patients with AF and CHF (154 (29) v 144 (31) IU/dl, p < 0.001), particularly those with acute or recent decompensated symptoms. Patients with severe LV dysfunction on two dimensional echocardiography and low fractional shortening also had significantly higher vWf concentrations than those with no LV dysfunction. CHF patients with clinical features--with (156 (28) IU/dl) and without (152 (31) IU/dl) LV dysfunction--also had higher mean vWf concentrations than patients with asymptomatic LV dysfunction (146 (31) IU/dl, p < 0.001). The presence of mitral regurgitation in CHF was associated with lower vWf concentrations. Plasma sP-sel concentrations were not affected by presence, onset, or severity of heart failure.. CHF may contribute to hypercoagulability and thrombotic risk in AF through increased endothelial damage and dysfunction. Patients with acute or recent decompensated features have the highest degree of endothelial damage and dysfunction. The presence of CHF clinical features was an important determinant of plasma vWf concentrations.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Enzyme-Linked Immunosorbent Assay; Female; Heart Failure; Humans; Male; P-Selectin; Platelet Aggregation Inhibitors; Risk Factors; Stroke; Ventricular Dysfunction, Left; von Willebrand Factor; Warfarin

The American College of Cardiology provided much useful new information to inform those who care for patients with heart failure about what they should and should not adopt into current clinical practice. The EPHESUS trial suggests a much wider role for aldosterone antagonists for the management of heart failure and left ventricular systolic dysfunction. SPORTIF-III indicates we may have a safer, simpler warfarin substitute soon. ASCOT reinforces the potential futility of statin therapy unless it is well targeted. The results of the COMPANION study investigating cardiac resynchronisation devices and implantable defibrillators were encouraging but inconclusive and/or hard to interpret. UK-PACE again questions the use of dual chamber pacing. T-wave alternans is an interesting experimental technique that may be useful in selecting which patients need an implantable defibrillator, although the technology needs testing in an appropriate patient population.

Topics: Anticoagulants; Cardiac Pacing, Artificial; Defibrillators, Implantable; Electrocardiography; Eplerenone; Heart Failure; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Mineralocorticoid Receptor Antagonists; Pacemaker, Artificial; Spironolactone; Ventricular Dysfunction, Left; Warfarin

Implantable cardioverter defibrillator (ICD) therapy with backup ventricular pacing increases survival in patients with life-threatening ventricular arrhythmias. Most currently implanted ICD devices provide dual-chamber pacing therapy. The most common comorbid cause for mortality in this population is congestive heart failure.. To determine the efficacy of dual-chamber pacing compared with backup ventricular pacing in patients with standard indications for ICD implantation but without indications for antibradycardia pacing.. The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial, a single-blind, parallel-group, randomized clinical trial.. A total of 506 patients with indications for ICD therapy were enrolled between October 2000 and September 2002 at 37 US centers. All patients had a left ventricular ejection fraction (LVEF) of 40% or less, no indication for antibradycardia pacemaker therapy, and no persistent atrial arrhythmias.. All patients had an ICD with dual-chamber, rate-responsive pacing capability implanted. Patients were randomly assigned to have the ICDs programmed to ventricular backup pacing at 40/min (VVI-40; n = 256) or dual-chamber rate-responsive pacing at 70/min (DDDR-70; n = 250). Maximal tolerated medical therapy for left ventricular dysfunction, including angiotensin-converting enzyme inhibitors and beta-blockers, was prescribed to all patients.. Composite end point of time to death or first hospitalization for congestive heart failure.. One-year survival free of the composite end point was 83.9% for patients treated with VVI-40 compared with 73.3% for patients treated with DDDR-70 (relative hazard, 1.61; 95% confidence interval [CI], 1.06-2.44). The components of the composite end point, mortality of 6.5% for VVI-40 vs 10.1% for DDDR-70 (relative hazard, 1.61; 95% CI, 0.84-3.09) and hospitalization for congestive heart failure of 13.3% for VVI-40 vs 22.6% for DDDR-70 (relative hazard, 1.54; 95% CI, 0.97-2.46), also trended in favor of VVI-40 programming.. For patients with standard indications for ICD therapy, no indication for cardiac pacing, and an LVEF of 40% or less, dual-chamber pacing offers no clinical advantage over ventricular backup pacing and may be detrimental by increasing the combined end point of death or hospitalization for heart failure.

Topics: Adrenergic beta-Antagonists; Aged; Amiodarone; Angiotensin-Converting Enzyme Inhibitors; Anti-Arrhythmia Agents; Anticoagulants; Arrhythmias, Cardiac; Cardiac Pacing, Artificial; Cardiovascular Agents; Catheter Ablation; Defibrillators, Implantable; Digoxin; Diuretics; Female; Heart Failure; Humans; Male; Middle Aged; Pacemaker, Artificial; Single-Blind Method; Survival Analysis; Tachycardia, Ventricular; Ventricular Dysfunction, Left; Warfarin

This paper describes a preliminary experiment-conducted jointly by 2 centers-of permanent left ventricular pacing using leads inserted by the transvenous route and through the coronary sinus into the cardiac veins of the left ventricle free wall. The aim was to obtain permanent biventricular pacing in a totally endocavitary configuration in patients with severe LV dysfunction and drug-refractory heart failure. Two types of leads were used: nonspecific unipolar leads at the beginning of the experiment, followed by leads specifically designed to be used in the coronary sinus in a second step. The electrode could be fitted in an adequate location in 35 of the 47 patients (75.4%), with a 1.15 +/- 0.7 V acute pacing threshold and 11.8 +/- 5.7 mV R wave amplitude. The success rate was significantly higher with the specific electrodes (81.8% vs 53.3%, p < 0.001). The pacing and sensing thresholds upon implantation were not influenced by the type of lead or by the localization of the cardiac vein that was catheterized (great cardiac vein, lateral vein, postero-lateral or posterior vein, mid cardiac vein). In contrast, the pacing threshold was significantly lower (0.8 +/- 0.2 vs 1.8 +/- 0.8 V; p = 0.002) and the R wave amplitude tended to be greater (13.1 +/- 4.5 mV vs 9.3 +/- 6.5 mV; p = 0.07) when the tip electrode could be inserted distally into the vein, by comparison with a proximal site near the ostium. At the end of follow-up (10.2 +/- 8.7 months), 34 out of the 35 leads were still fully functional, with a chronic pacing threshold of 1.8 +/- 0.7 V and a R wave amplitude of 10.7 +/- 6 mV. To conclude, permanent LV pacing via the transvenous route is possible in most patients, with excellent safety and long-term results.

Topics: Aged; Anticoagulants; Cardiac Pacing, Artificial; Coronary Vessels; Electrodes, Implanted; Feasibility Studies; Female; Follow-Up Studies; Heart Failure; Humans; Male; Pacemaker, Artificial; Time Factors; Ventricular Dysfunction, Left; Warfarin

We sought to evaluate the relation between warfarin anticoagulation and survival and morbidity from cardiac disease in patients with left ventricular (LV) dysfunction.. Warfarin anticoagulation plays a major role in the management of patients who have had a large myocardial infarction and in those with atrial fibrillation. However, its use in patients with LV systolic dysfunction has been controversial.. We reviewed data on warfarin use in 6,797 patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial and analyzed the relation between warfarin use and all-cause mortality, as well as the combined end point of death or hospital admission for heart failure. We used Cox regression to adjust for differences in baseline characteristics and to test for the interaction between warfarin use and selected patient variables in relation to outcome.. On multivariate analysis, use of warfarin was associated with a significant reduction in all-cause mortality (adjusted hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.65 to 0.89, p = 0.0006) and in the risk of death or hospital admission for heart failure (HR 0.82, 95% CI 0.72 to 0.93, p = 0.0002). Risk reduction was observed when each trial or randomization arm was analyzed separately, as well as in both genders. It was not significantly influenced by the presence of atrial fibrillation, age, ejection fraction, New York Heart Association functional class or etiology.. In patients with LV systolic dysfunction, warfarin use is associated with improved survival and reduced morbidity. This association is primarily due to a reduction in cardiac events and does not appear to be limited to any particular subgroup.

Topics: Angina, Unstable; Anticoagulants; Cardiac Output, Low; Cardiovascular Diseases; Cause of Death; Cohort Studies; Female; Hospitalization; Humans; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Proportional Hazards Models; Randomized Controlled Trials as Topic; Risk Factors; Ventricular Dysfunction, Left; Warfarin

Oral anticoagulation is increasingly used in elderly patients with atrial fibrillation to prevent embolic phenomena. The use of anticoagulants in this population is prophylactic rather than therapeutic and so there is no urgency to establish anticoagulation within the desired therapeutic range. The aim of the study was to develop an out-patient regimen for initiation of oral anticoagulation with warfarin which requires only weekly monitoring of the International Normalized Ratio (INR).. The study was undertaken in two phases. In the first phase, factors which predict the final maintenance dosage of warfarin were defined and used to build a decision tree and dosage algorithm. In the second study the algorithm was tested. Patients were given 2 mg warfarin daily for 2 weeks and the INR at this time was used to predict the maintenance dose. Patients then attended for weekly measurements of the INR until steady state had been reached. Dosage adjustments were not made unless the INR was >4.0 or <1.5 for 2 consecutive weeks. The accuracy of the prediction was measured by calculating the mean INR of weeks 6-8 and the number of patients in the target range 2.0-3.0 was determined.. One hundred and seven consecutive out-patients (mean age 70 years range 64-86) completed the first study. The age, sex, height, weight, alcohol intake, number of cigarettes smoked, concomitant medication, clinical evidence of right heart failure, liver failure, abnormalities in liver enzyme estimations, baseline INR and INR after 2 weeks of 2 mg warfarin daily were used in a polytomous logistic regression analysis with stepwise inclusion of factors to determine which factors influenced the eventual maintenance dosage of warfarin. The INR after 2 weeks of 2 mg warfarin therapy predicted 70% of the variability of the maintenance dose. Of other factors only the sex of the patient had a large enough effect to be included in the prediction algorithm. One hundred and six patients (mean age 71 years range 50-85 years) completed the second study. Only one patient needed a dose adjustment in the first 2 weeks of warfarin 2 mg daily (INR 4.4). Overall, 60% patients were in the narrow target range (INR 2.0-3.0) at steady state. In five patients the INR was >4.0 at any visit after the second week and needed dosage adjustment. In four patients the INR was <1.5 at steady state.. We have developed a method of predicting the maintenance dose of warfarin in an elderly population based on the INR after 2 weeks of warfarin 2 mg daily, and the sex of the patient. This is a safe and convenient way of initiating warfarin therapy as an out-patient which requires only weekly INR checks.

Topics: Aged; Aged, 80 and over; Algorithms; Anticoagulants; Atrial Fibrillation; Female; Humans; International Normalized Ratio; Male; Middle Aged; Outpatients; Prospective Studies; Ventricular Dysfunction, Left; Warfarin

Cardiac impairment in patients is associated with intracardiac thrombus formation and thromboembolism. A high prothrombotic state may exist in such patients, and abnormalities in plasma markers of thrombogenesis may be indicative of such a state. The aim of this study was to determine the associations of left ventricular (LV) aneurysm formation and dysfunction with plasma fibrinogen, von Willebrand factor, and fibrin D-dimer, which are markers associated with thrombus formation (thrombogenesis) and to investigate the effects of warfarin given to patients with LV aneurysms on fibrinogen and D-dimer levels. A cross-sectional study of 112 patients with coronary artery disease was initially performed: 34 patients had normal LV function (group 1); 30 had LV dysfunction without aneurysm formation (group 2); 29 had LV aneurysms without anticoagulation (group 3a); and 19 patients had LV aneurysms with warfarin therapy (group 3b). Results were compared with 158 population controls from a random population sample. A longitudinal study of 10 patients given warfarin was also performed. In group 1, plasma fibrinogen (median difference 0.36 g/L; p = 0.0009) and von Willebrand factor (median difference 17 IU/dl; p = 0.04) were elevated, whereas plasma D-dimer levels (median difference 23.0 ng/ml; p = 0.001) were lower than those in population control subjects. There were no significant differences in plasma fibrinogen, von Willebrand factor, or D-dimer levels between groups 1 and 2. In group 3a, plasma fibrinogen was elevated when compared with group 1 (median difference 0.6 g/L; p = 0.0001), with a trend toward high von Willebrand factor levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Analysis of Variance; Coronary Disease; Cross-Sectional Studies; Female; Fibrin Fibrinogen Degradation Products; Fibrinogen; Heart Aneurysm; Heart Ventricles; Humans; Longitudinal Studies; Male; Middle Aged; Prospective Studies; Thromboembolism; Ventricular Dysfunction, Left; von Willebrand Factor; Warfarin

left ventricular thrombus (LVT) may lead to thromboembolism and has been associated with increased morbidity and mortality. Little is known about the incidence, etiology and outcomes in patients with LVT in Africa. The objective was to determine the etiology, treatment practices, rate of resolution and clinical outcomes in patients with LVT in the region.. a review of all echocardiograms performed in 2017 and 2018 at the Aga Khan University Hospital, Nairobi was carried out and patients with LVT identified. Physician review of charts was performed to document clinical characteristics and outcomes.. during the study period 100 patients with LVT were identified (1.3% of adult echoes). The mean LVEF was 28.5% (±11.0%) and 88 (88%) patients had an LVEF of less than 40%. Underlying etiology of LV dysfunction was post myocardial infarction (MI) in 28 (28%), chronic ischemic cardiomyopathy in 42(42%) and non-ischemic cardiomyopathy in 30 (30%) patients. In 15 (15%) patients a stroke or TIA predated the diagnosis of LVT. Long term anticoagulation was given to 92 (92%) patients. Among these, 34 (37%) received warfarin while 58 (63%) were treated with a DOAC. In the 64 patients who had reassessment imaging (median duration 177 days), complete thrombus resolution was noted in 38 (59.4%). One-year clinical outcome data was available for 85 patients: 13 (15.3%) patients had died, 4 (4.7%) had suffered a stroke, and 8(9.4%) had had a bleeding episode. Rates of thrombus resolution (warfarin 64%, DOAC 55.6%, p=0.51), stroke (warfarin 2.9%, DOAC 1.7%, p=1.0) and bleeding (warfarin 5.9%, DOAC 5.2%, p = 1.00 were not significantly different among patients treated with warfarin and DOAC.. we noted a high incidence of LVT compared to contemporary Western series. The majority of our patients were treated with DOACs. There were no significant differences in outcomes between patients treated with a DOAC and those receiving warfarin. Prospective evaluation on the efficacy and safety of DOACs for this indication is needed.

Topics: Adult; Aged; Anticoagulants; Echocardiography; Female; Hemorrhage; Humans; Kenya; Male; Middle Aged; Retrospective Studies; Stroke; Thrombosis; Ventricular Dysfunction, Left; Warfarin

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

The contemporary role of prophylactic anticoagulation following extensive anterior wall ST-segment myocardial infarction (STEMI) is unclear.. We evaluated anterior STEMI patients with left ventricle dysfunction (left ventricular ejection fraction ≤40%) ("high risk"), categorized by prophylactic warfarin use, within a regional STEMI. Patients with pre-existing atrial fibrillation were excluded. The primary outcome was an adjusted (for Global Registry of Acute Coronary Events risk score) 1-year composite of recurrent ischemia, stroke/transient ischemic attack/systemic embolism, or all-cause death. Of the 2032 STEMI admissions, 436 (21.5%) were high risk. After excluding 19 (4.4%) patients with definite left ventricle thrombus and 21 (4.8%) in-hospital deaths (2 had left ventricle thrombus), prophylactic warfarin was utilized in 236/398 (59.3%) high-risk survivors. Prescriptions were comparable across sex, but recipients were on average younger (58.5 years versus 64.0 years,. A high utilization of prophylactic warfarin occurs in anterior STEMI patients with left ventricle dysfunction, yet appears to provide no additional benefit on the ischemic composite. The association with lower all-cause mortality, but higher bleeding, calls for an improved understanding of its role in high-risk STEMI.

Topics: Administration, Oral; Aged; Alberta; Anterior Wall Myocardial Infarction; Anticoagulants; Chi-Square Distribution; Female; Hemorrhage; Humans; Logistic Models; Male; Middle Aged; Odds Ratio; Propensity Score; Registries; Risk Factors; ST Elevation Myocardial Infarction; Stroke; Stroke Volume; Thromboembolism; Time Factors; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left; Warfarin

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

Candidates for chronic warfarin therapy often have co-morbid conditions, such as heart failure, with reduced left ventricular ejection fraction. Previous reports have demonstrated an increased risk of over-anticoagulation due to reduced warfarin dose requirement in patients with decompensated heart failure. However, the influence of left ventricular systolic dysfunction (LVSD), defined as left ventricular ejection fraction <40%, on warfarin response has not been evaluated. Here, we assess the influence of LVSD on warfarin dose, anticoagulation control (percent time in target range), and risk of over-anticoagulation (international normalized ratio >4) and major hemorrhage. Of the 1,354 patients included in this prospective cohort study, 214 patients (16%) had LVSD. Patients with LVSD required 11% lower warfarin dose compared with those without LVSD (p <0.001) using multivariate linear regression analyses. Using multivariate Cox proportional hazards model, patients with LVSD experienced similar levels of anticoagulation control (percent time in target range: 51% vs 53% p = 0.15), risk of over-anticoagulation (international normalized ratio >4; hazard ratio 1.01, 95% confidence interval 0.82 to 1.25; p = 0.91), and risk of major hemorrhage (hazard ratio 1.11; 95% confidence interval 0.70 to 1.74; p = 0.66). Addition of LVSD variable in the model increased the variability explained from 35% to 36% for warfarin dose prediction. In conclusion, our results demonstrate that patients with LVSD require lower doses of warfarin. Whether warfarin dosing algorithms incorporating LVSD in determining initial doses improves outcomes needs to be evaluated.

Topics: Aged; Algorithms; Anticoagulants; Atrial Fibrillation; Cohort Studies; Comorbidity; Dose-Response Relationship, Drug; Drug Dosage Calculations; Female; Heart Failure; Hemorrhage; Humans; International Normalized Ratio; Ischemic Attack, Transient; Linear Models; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Peripheral Arterial Disease; Proportional Hazards Models; Prospective Studies; Risk Factors; Stroke; Stroke Volume; Venous Thromboembolism; Ventricular Dysfunction, Left; Ventricular Function, Left; Warfarin

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

The use of oral anticoagulation in patients with heart failure in sinus rhythm remains controversial as previous large randomized controlled trials (RCTs) have not shown a survival benefit. However, heterogeneity exists among heart failure patients and it is possible that high-risk subgroups may benefit from anticoagulation (warfarin). We hypothesize that one such subgroup are patients with heart failure and pulmonary hypertension (PH), conditions associated with coagulation abnormalities.. We conducted a retrospective, population-based, longitudinal cohort study in patients with left ventricular systolic dysfunction (LVSD) and PH [defined as a right ventricular systolic pressure (RVSP) >35 mmHg] identified from echocardiograms performed between January 1994 to May 2011. This data was linked using a unique patient-specific identifier to community-dispensed prescriptions, hospital admissions, and mortality data. For comparison, we included patients with LVSD and no PH.. A total of 2619 subjects with LVSD and a measurable RVSP were identified (mean ± SD age of 73 ± 12 years); 1606 out of 2619 had PH and 1013 out of 2619 had no PH. The overall mean follow-up period was 2.56 ± 3.0 years. In patients with LVSD and PH, the use of warfarin was associated with an improved survival [hazard ratio (HR) = 0.72 95% confidence interval (CI) 0.58-0.90, P = 0.0003], fewer non-cardiovascular disease-related deaths (HR = 0.65, 95%CI 0.49-0.87, P = 0.0033 and showed a trend towards reduced cardiovascular disease-associated mortality (HR = 0.72, 95%CI 0.51-1.02). Warfarin did not improve survival in those with LVSD with no PH.. In patients with both LVSD and PH, the use of warfarin is associated with a 28% reduction in mortality. Further prospective trials are required to confirm our findings.

Topics: Aged; Aged, 80 and over; Anticoagulants; Case-Control Studies; Cohort Studies; Female; Heart Failure; Humans; Hypertension, Pulmonary; Longitudinal Studies; Male; Middle Aged; Proportional Hazards Models; Retrospective Studies; Systole; Ventricular Dysfunction, Left; Warfarin

We present the case of a 57-year-old female with no significant history of cardiac disease admitted to our service with stress-induced cardiomyopathy (Takotsubo's cardiomyopathy). Admission echocardiography with contrast showed a non-mobile apical-filling defect, consistent with laminar thrombus. After 1 month of anticoagulation with warfarin (bridged with inpatient intravenous heparin), follow-up echocardiography with contrast showed resolution of the thrombus. Although reported in the literature, to our knowledge, there are no consensus guidelines for the surveillance and treatment of left ventricular thrombus in patients with Takotsubo's cardiomyopathy. An awareness of this adverse effect and its treatment implications is imperative for any clinician caring for these patients.

Topics: Anticoagulants; Echocardiography; Female; Heart Ventricles; Humans; Middle Aged; Takotsubo Cardiomyopathy; Thrombosis; Ventricular Dysfunction, Left; Warfarin

This study sought to determine the benefits of adding oral anticoagulation therapy in patients with anterior wall ST-segment elevation myocardial infarction (STEMI) patients after primary percutaneous coronary intervention (PCI).. Guidelines suggest adding oral anticoagulation to dual-antiplatelet therapy in patients with STEMI when left ventricular apical akinesis or dyskinesis is present to prevent thromboembolic complications. The benefits of this triple therapy remain unknown.. We identified patients with anterior STEMI referred (PCI) between July 2004 and June 2010 with apical akinesis or dyskinesis on transthoracic echocardiography. We compared patients who were prescribed warfarin to patients who were not. We excluded patients with left ventricular thrombus, a separate need for oral anticoagulation, and previous intracranial bleeding. The primary outcome was a composite of net adverse clinical events (NACE) consisting of all-cause mortality, stroke, reinfarction, and major bleeding at 180 days.. Among 460 patients who qualified, 131 were discharged on warfarin therapy and 329 without warfarin therapy. Dual-antiplatelet therapy was prescribed for 99.2% of the patients in the warfarin group and for 97.6% of the patients in the no warfarin group (p = 0.46). Compared with patients in the no warfarin group, patients in the warfarin group had higher rates of NACE (14.7% vs. 4.6%, p = 0.001), death (5.4% vs. 1.5%, p = 0.04), stroke (3.1% vs. 0.3%, p = 0.02), and major bleeding (8.5% vs. 1.8%, p < 0.0001). By propensity score analysis, allocation to warfarin therapy was an independent predictor of NACE (odds ratio [OR]: 4.01, 95% confidence interval: 2.15 to 7.50, p < 0.0001). In a separate multivariable analysis, the OR of NACE remained significantly higher compared with patients who were not prescribed warfarin (OR: 3.13, 95% confidence interval: 1.34 to 7.22, p = 0.007).. Our results do not support the addition of warfarin therapy after primary PCI in patients with apical akinesis or dyskinesis.

Topics: Administration, Oral; Aged; Anterior Wall Myocardial Infarction; Anticoagulants; Drug Therapy, Combination; Female; Hemorrhage; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Propensity Score; Recurrence; Risk Factors; Stroke; Time Factors; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left; Warfarin

Topics: Anticoagulants; Blood Coagulation Factors; Cardiomyopathies; Cardiopulmonary Bypass; Factor VII Deficiency; Heart-Assist Devices; Humans; Male; Middle Aged; Ventricular Dysfunction, Left; Warfarin

Left ventricular (LV) pacing through the coronary sinus is the standard approach for cardiac resynchronization therapy. When this route is unavailable, the alternatives have major limitations. LV endocardial pacing through the interventriuclar septum may offer a simpler solution. We describe an initial case series to demonstrate technical feasibility and to describe our refinement of the puncture technique.. Ten patients with previous failed coronary sinus lead implant or with nonresponse to cardiac resynchronization therapy and a suboptimal LV lead position were selected. All patients were anticoagulated. Left ventriculography and coronary angiography were performed to identify LV borders and septal vessels. Subclavian vein access was used for a superior approach ventricular transseptal puncture under fluoroscopic guidance, using a steerable sheath and a standard transseptal needle, radiofrequency needle, or radiofrequency energy delivered through a guidewire. An active-fixation pacing lead was successfully delivered to the endocardial wall of the lateral LV in all patients (9 men; age, 62±10 years). LV lead implant procedure time shortened with experience. The use of radiofrequency energy delivered through a guidewire was the most effective technique. Mean threshold and R wave at implant were 0.8±0.3 V and 10.8±3.9 mV. At follow-up (mean, 8.7 months; minimum, 0; and maximum 19), thresholds were stable, and there were no thromboembolic events. Of 9 patients, 8 were classed as clinical responders (1 had inadequate follow-up to assess response).. LV endocardial pacing through a ventricular septal puncture is a feasible approach for cardiac resynchronization therapy.

Topics: Aged; Anticoagulants; Cardiac Catheterization; Cardiac Resynchronization Therapy; Coronary Angiography; Electrocardiography; Feasibility Studies; Female; Humans; Male; Middle Aged; Punctures; Radiography, Interventional; Radionuclide Ventriculography; Stroke Volume; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left; Ventricular Septum; Warfarin

We prospectively evaluated long-term clinical outcomes of patients diagnosed with isolated left ventricular noncompaction (ILVNC) and heart failure from a sub-Saharan African population.. Patients in this single-center study were followed at a tertiary care institution. Clinical follow-up was performed with the use of protocol-driven echocardiographic screening for ventricular thrombus every 4 months. Warfarin was maintained or initiated only if thrombus was detected with the use of echocardiography. Fifty-five patients were followed for 16.7 ± 5.9 (range 12-33) months. All individuals had left ventricular (LV) ejection fraction <50% (mean 29.6 ± 11.8%). Of the 55 patients, 7 (12.7%) died, and sudden cardiac death was the cause in 5 (71.4%). There were no differences in baseline clinical, echocardiographic, or electrocardiographic characteristics between survivors and nonsurvivors. Recurrent heart failure developed in 12 patients (21.8%); 1 patient developed a ventricular arrhythmia. No thromboembolic or major bleeding complications occurred in the 16 patients on warfarin; 1 episode of thromboembolism occurred in the 39 patients not on warfarin. Mean survival probability at 33 months was 0.64.. Sudden cardiac death was the most common cause of death in patients with ILVNC and heart failure. Recurrent heart failure occurred in 21.8% of patients. Development of LV thrombus and cardioembolism is uncommon in this population.

Topics: Adult; Africa South of the Sahara; Anticoagulants; Death, Sudden, Cardiac; Echocardiography; Female; Follow-Up Studies; Heart Failure; Humans; Male; Middle Aged; Prognosis; Prospective Studies; Stroke Volume; Survival Analysis; Thrombosis; Ventricular Dysfunction, Left; Ventricular Function, Left; Warfarin

Topics: Adult; Aged; Antibodies; Anticoagulants; Blood Coagulation; Factor X; Female; Heart Failure; Heart-Assist Devices; Heparin; Humans; Incidence; Male; Middle Aged; Partial Thromboplastin Time; Prospective Studies; Risk Factors; Thrombosis; Ventricular Dysfunction, Left; Warfarin

Left ventricular thrombosis (LVT) is a possible complication of acute myocardial infarction. Aim of our study was to evaluate incidence and clinical characteristics of patients with LVT after ST elevation myocardial infarction (STEMI) using contrast- enhanced magnetic resonance (CMR).. In a prospective cohort of 36 consecutive patients with STEMI acutely reperfused with primary percutaneous coronary intervention, CMR was performed within one week. LVT was found in 7 patients (19%), and was located in left ventricle apex or adherent to antero-septum. Compared to the rest of population patients with LVT have lower ejection fraction (38 ± 7% versus 51 ± 6%, P = 0.009), larger left ventricle end systolic volume (95.8 ± 19 ml versus 68.9 ± 19 ml, P = 0.02), higher time to reperfusion (9.3 ± 7.2 versus 5 ± 3.6, P = 0.03) and left anterior descending artery was constantly involved (100% versus 41 %, P = 0.06). In 5 cases the LVT was also detected by echocardiography, however, in 2 cases it was missed.. The incidence of LVT after STEMI is not negligible and was accurately detected by CMR. Localization of myocardial infarction, time to reperfusion, ejection fraction and left ventricle end systolic volume are the most important predictors of left ventricle thrombus formation.

Topics: Aged; Anticoagulants; Aspirin; Clopidogrel; Cohort Studies; Drug Therapy, Combination; Echocardiography; Female; Humans; Incidence; Magnetic Resonance Imaging, Cine; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Prospective Studies; Stroke Volume; Thrombosis; Ticlopidine; Ventricular Dysfunction, Left; Warfarin

We examined the risk of stroke or systemic embolism (SSE) conferred by heart failure (HF) and left ventricular systolic dysfunction (LVSD) in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation Trial (ARISTOTLE), as well as the effect of apixaban versus warfarin.. The risk of a number of outcomes, including the composite of SSE or death (to take account of competing risks) and composite of SSE, major bleeding, or death (net clinical benefit) were calculated in 3 patient groups: (1) no HF/no LVSD (n=8728), (2) HF/no LVSD (n=3207), and (3) LVSD with/without symptomatic HF (n=2736). The rate of both outcomes was highest in patients with LVSD (SSE or death 8.06; SSE, major bleeding, or death 10.46 per 100 patient-years), intermediate for HF but preserved LV systolic function (5.32; 7.24), and lowest in patients without HF or LVSD (1.54; 5.27); each comparison P<0.0001. Each outcome was less frequent in patients treated with apixaban: in all ARISTOTLE patients, the apixaban/warfarin hazard ratio for SSE or death was 0.89 (95% confidence interval, 0.81-0.98; P=0.02); for SSE, major bleed, or death it was 0.85 (0.78-0.92; P<0.001). There was no heterogeneity of treatment effect across the 3 groups.. Patients with LVSD (with/without HF) had a higher risk of SSE or death (but similar rate of SSE) compared with patients with HF but preserved LV systolic function; both had a greater risk than patients without either HF or LVSD. Apixaban reduced the risk of both outcomes more than warfarin in all 3 patient groups.. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Comorbidity; Embolism; Female; Heart Failure; Humans; Male; Middle Aged; Pyrazoles; Pyridones; Retrospective Studies; Risk Assessment; Stroke; Ventricular Dysfunction, Left; Warfarin

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

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

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

A 22-year old woman visited the LAMB Hospital, Parbatipur, Dinajpur, Bangladesh, in February 2010, with exertional dyspnea for three weeks. She had had a normal vaginal delivery four months ago; 2-dimensional echocardiogram showed severe left ventricular dysfunction and biventricular thrombi, which resolved without complications after anticoagulation. Biventricular thrombosis with peripartum cardiomyopathy is quite a rare finding, and its clinical course and proper management is not known. No such case has previously been reported in Bangladesh.

Topics: Bangladesh; Cardiomyopathies; Drug Combinations; Echocardiography; Enalapril; Female; Furosemide; Humans; Peripartum Period; Puerperal Disorders; Thrombosis; Ventricular Dysfunction, Left; Warfarin; Young Adult

Previous studies have not confirmed associations between some current performance measures for inpatient heart failure processes of care and postdischarge outcomes. It is unknown if alternative measures are associated with outcomes.. Using data for 20,441 Medicare beneficiaries in OPTIMIZE-HF from March 2003 through December 2004, which we linked to Medicare claims data, we examined associations between hospital-level processes of care and patient outcomes. Performance measures included any beta-blocker for patients with left ventricular systolic dysfunction (LVSD); evidence-based beta-blocker for patients with LVSD; warfarin for patients with atrial fibrillation; aldosterone antagonist for patients with LVSD; implantable cardioverter-defibrillator for patients with ejection fraction < or =35%; and referral to disease management. Outcome measures were unadjusted and adjusted associations of each process measure with 60-day and 1-year mortality and cardiovascular readmission at the hospital level.. Adjusted hazard ratios for 1-year mortality with a 10% increase in hospital- level adherence were 0.94 for any beta-blocker (95% CI, 0.90-0.98; P = .004), 0.95 for evidence-based beta-blocker (95% CI, 0.92-0.98; P = .004); 0.97 for warfarin (95% CI, 0.92-1.03; P = .33); 0.94 for aldosterone antagonists (95% CI, 0.91-0.98; P = .006); 0.92 for implantable cardioverter-defibrillator (95% CI, 0.87-0.98; P = .007); and 1.01 for referral to disease management (95% CI, 0.99-1.03; P = .21).. Several evidence-based processes of care are associated with improved outcomes, can discriminate hospital-level quality of care, and could be considered as clinical performance measures.

Topics: Adrenergic beta-Antagonists; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Evidence-Based Medicine; Female; Heart Failure; Hospitalization; Humans; Male; Medicare; Mineralocorticoid Receptor Antagonists; Patient Readmission; Proportional Hazards Models; Quality of Health Care; Registries; Survival Analysis; Treatment Outcome; United States; Ventricular Dysfunction, Left; Warfarin

Topics: Anticoagulants; Bundle-Branch Block; Contrast Media; Defibrillators, Implantable; Diagnosis, Differential; Echocardiography; Electrocardiography; Heart Failure; Humans; Male; Middle Aged; Ventricular Dysfunction, Left; Warfarin

Owing to the actual increase of mechanical circulatory support durations, total or partial replacement of ventricular assist devices (VADs) will most certainly have to be performed with increasing frequency. Herein we report the case of a patient in whom an INCOR (Berlin Heart AG, Berlin) implantable axial-flow pump was replaced without the use of cardiopulmonary bypass (CPB), underscoring some of the unique features provided by this system.

Topics: Anticoagulants; Aspirin; Clopidogrel; Equipment Design; Heart-Assist Devices; Humans; Infusion Pumps, Implantable; International Normalized Ratio; Male; Middle Aged; Myocardial Ischemia; Platelet Aggregation Inhibitors; Ticlopidine; Treatment Outcome; Ventricular Dysfunction, Left; Warfarin

Topics: Aged; Anticoagulants; Cysts; Diagnosis, Differential; Echinococcosis; Heart Ventricles; Heparin; Humans; Male; Thrombosis; Ultrasonography; Ventricular Dysfunction, Left; Warfarin

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

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

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

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

Isolated noncompaction of the myocardium (INCM) is a rare, congenital, unclassified cardiomyopathy. It is caused by a disorder in endomyocardial morphogenesis in the absence of other structural disease. INCM is characterized by numerous prominent trabeculations and deep intertrabecular recesses in the myocardium. Frequently, INCM is associated with an increased incidence of heart failure, arrhythmias, and cardioembolic events with high morbidity and mortality. We describe a 28-year-old woman experiencing symptoms of heart failure since she was 4 years old. She had been intensively investigated and misdiagnosed as having dilated, restrictive, and apical hypertrophic cardiomyopathies. Cardiac magnetic resonance and echocardiography recently revealed the actual diagnosis of INCM. The patient is alive and well, taking vasodilators and warfarin. Herein, we describe the long-term follow-up of this patient and demonstrate that some patients have a favorable prognosis. In addition, the improvement in noninvasive cardiac imaging has revealed a higher prevalence of INCM, previously undetected.

Topics: Anticoagulants; Cardiomyopathies; Child, Preschool; Diagnosis, Differential; Female; Humans; Longitudinal Studies; Survival Analysis; Time Factors; Ultrasonography; Vasodilator Agents; Ventricular Dysfunction, Left; Warfarin

Atrial flutter or fibrillation with rapid, uncontrolled ventricular response may lead to left ventricular dysfunction, and conversion to sinus rhythm with control of heart rate can improve left ventricular ejection fraction. Little is known about the effects of the Cox-maze procedure on this form of tachycardia-induced cardiomyopathy.. Four hundred forty-three patients underwent the Cox-maze procedure from 1993 to 2002. Ninety-nine had atrial flutter or fibrillation without associated valvular or congenital heart disease, and 37 (37%) had decreased left ventricular function (ejection fraction < 0.35 in 11 [severe], ejection fraction 0.36 to 0.45 in 8 [moderate], and ejection fraction 0.46 to 0.55 in 18 [mild]). Ages of these 37 patients (34 male) ranged from 35 to 74 years (median, 55 years).. Atrial flutter or fibrillation was present for 3 months to 19 years (median, 48 months) preoperatively, and 24 patients (65%) exhibited symptoms of heart failure. Preoperative ejection fraction ranged from 0.25 to 0.55 (median, 0.45). At last follow-up (median, 63 months), the Cox-maze procedure eliminated atrial flutter or fibrillation in all but 1 patient, and the greatest improvement was observed in patients with severe preoperative impairment (0.31 to 0.53; p = 0.01, preoperative versus follow-up), and patients with preoperative chronic atrial flutter or fibrillation (0.43 to 0.55; p < 0.05 preoperative versus follow-up). This improvement was observed immediately postoperatively and was sustained at last follow-up. Further, improvement in left ventricular function correlated with enhancement of functional status.. In some patients, atrial flutter or fibrillation may be the cause rather than the consequence of left ventricular dysfunction. Importantly, systolic function and functional status can be significantly improved with the restoration of sinus rhythm by the Cox-maze procedure.

Topics: Adult; Aged; Atrial Fibrillation; Cardiac Surgical Procedures; Coronary Artery Bypass; Female; Heart Conduction System; Heart Rate; Humans; Male; Middle Aged; Pacemaker, Artificial; Retrospective Studies; Stroke Volume; Systole; Ventricular Dysfunction, Left; Warfarin

Stroke is a devastating complication in patients with prosthetic valves, but characterization of its late occurrence from a large cohort is lacking.. Three thousand one hundred eighty-nine adult patients who underwent a total of 3,576 operations for left-heart valve replacement were managed with contemporary anticoagulation guidelines and prospectively followed in a dedicated clinic. Total follow-up was 20,096 patient years. Bootstrapped survival analysis was used to determine the impact of patient and valve related factors on the incidence of stroke.. Most strokes were embolic. Linearized embolic stroke rates were 1.3% +/- 0.2% per year for aortic bioprostheses, 1.4% +/- 0.2% per year for aortic mechanical valves, 1.3% +/- 0.3% per year for mitral bioprostheses, and 2.3% +/- 0.4% per year for mitral mechanical valves (p = 0.002, vs other implant types). Age more than 75 years, female gender, and smoking were independent risk factors after aortic and mitral valve replacement. Atrial fibrillation, coronary disease, and tilting-disc mechanical prostheses were independent predictors of embolic stroke after aortic valve replacement. Preoperative left ventricular (LV) dysfunction was an independent risk factor in patients with mitral prostheses. Primary operative indication, diabetes, redo status, or the presence of two prosthetic valves were not associated with an increased hazard. The addition of acetyl salicylic or dipyridamole to warfarin anticoagulation did not significantly lower embolic stroke risk in patients with mechanical prostheses.. Approximately 20% of patients with valve prostheses have an embolic stroke by 15 years after valve replacement. Some risk factors such as the avoidance of smoking, mitral mechanical prostheses, aortic tilting-disc valves, and proceeding to mitral surgery before LV dysfunction occurs are potentially modifiable.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve; Aspirin; Atrial Fibrillation; Cerebral Hemorrhage; Comorbidity; Coronary Disease; Dipyridamole; Drug Therapy, Combination; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Humans; Incidence; International Normalized Ratio; Intracranial Embolism; Life Tables; Male; Middle Aged; Mitral Valve; Postoperative Complications; Proportional Hazards Models; Prospective Studies; Risk Factors; Smoking; Stroke; Ventricular Dysfunction, Left; Warfarin

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

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

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

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

A 66-year-old woman admitted with dyspnea on exertion had atrial fibrillation and left ventricular dysfunction. Echocardiography revealed an atrial septal defect (ASD) and a soft, easily deformable thrombus in the dilated left atrium. The atrial mass suddenly disappeared on the 10th day after admission, and contrast-enhanced chest computed tomography and pulmonary blood flow scintigraphy showed that the thrombus had detached from the left atrium, floated into the right atrium through the ASD and caused pulmonary embolism. This is the first documented case of a left atrial thrombus causing pulmonary embolism by passing through an ASD. When an ASD is present, it is important to consider not only paradoxical thromboembolism (from the right to the left atrium), but also pulmonary embolism caused by thromboembolism from the left to the right atrium.

Topics: Aged; Anticoagulants; Arterial Occlusive Diseases; Atrial Fibrillation; Echocardiography, Transesophageal; Female; Heart Atria; Humans; Pulmonary Embolism; Treatment Outcome; Ventricular Dysfunction, Left; Warfarin

The clinical significance of rifampin's induction of warfarin metabolism is well documented, but no published studies or case reports have quantified this interaction with respect to the international normalized ratio (INR). A patient receiving concomitant rifampin and warfarin to treat a mycobacterial infection and intraventricular thrombus, respectively, underwent routine INR testing at a pharmacist-managed anticoagulation clinic to assess his anticoagulation regimen. A 233% increase in warfarin dosage over 4 months proved insufficient to attain a therapeutic INR during long-term rifampin therapy More aggressive titration of the warfarin dosage was needed. In addition, a gradual 70% reduction in warfarin dosage over 4-5 weeks was necessary to maintain a therapeutic INR after rifampin discontinuation, demonstrating the clinically significant offset of this drug interaction. Extensive changes in warfarin dosage are required to attain and maintain a therapeutic INR during the initiation, maintenance, and discontinuation of rifampin.

Topics: Antibiotics, Antitubercular; Anticoagulants; Blood Coagulation; Drug Interactions; Humans; Male; Middle Aged; Mycobacterium avium-intracellulare Infection; Rifampin; Ventricular Dysfunction, Left; Warfarin

Topics: Accidents, Home; Adult; Anticoagulants; Antithrombin III Deficiency; Arginine; Burns; Cardiovascular Agents; Coronary Vasospasm; Debridement; Drug Therapy, Combination; Explosions; Humans; Male; Pipecolic Acids; Sulfonamides; Ventricular Dysfunction, Left; Warfarin

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Female; Humans; Incidence; Intracranial Embolism and Thrombosis; Male; Platelet Aggregation Inhibitors; Proportional Hazards Models; Risk Factors; Stroke Volume; Ventricular Dysfunction, Left; Ventricular Function, Left; Warfarin

Topics: Cardiomyopathy, Dilated; Fibrinolytic Agents; Humans; Ventricular Dysfunction, Left; Warfarin

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

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