Home About us Contact
|
Home About us Contact | ||
|
|
||
Anticoagulation
Kinds of Anticoagulation Terms modified by Anticoagulation Selected AbstractsThe Debate Over Anticoagulation in Patients With Heart FailureCONGESTIVE HEART FAILURE, Issue 5 2006Rubinder S. Ruby MD No abstract is available for this article. [source] Anticoagulation in haemophilia patients with prosthetic valve replacementHAEMOPHILIA, Issue 6 2004K. Ghosh No abstract is available for this article. [source] Rheumatological presentations of anticoagulation related hemorrhagesINTERNATIONAL JOURNAL OF RHEUMATIC DISEASES, Issue 2 2003S. R. Cox Abstract Background: Joint, back and muscle pain are common in patients referred to a rheumatology unit. Acute pain due to hemorrhage may be difficult to distinguish from more common causes of pain in these patients. This article describes a small case-series of patients who presented acutely with hemarthroses, spinal hemorrhage or muscle hematomas while receiving anticoagulant treatment. Methods: Case notes of nine patients were reviewed retrospectively. The demographic characteristics, indication for anticoagulation, international normalized ratio, and management were evaluated. Results: The majority of hemorrhages occurred when the INR was within the therapeutic range. Anticoagulation was held in all cases. Joint aspiration was performed in all cases of hemarthrosis. Surgical intervention was required in management of the spinal epidural bleed and also in one case of muscle hematoma. Conclusion: Cases described represent major hemorrhages in anticoagulated patients. There is little literature on specific treatment and prognosis, particularly with respect to hemarthrosis, and further studies are needed. [source] Anticoagulation to Prevent Strokes in Older People with Atrial Fibrillation: Assembling Individualized Risk and Benefit InformationJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2004MRCP(UK), Richard Fuller MA No abstract is available for this article. [source] Increased Incidence of Gastrointestinal Bleeding Following Implantation of the HeartMate II LVADJOURNAL OF CARDIAC SURGERY, Issue 3 2010David R. Stern M.D. To avoid device-related thromboembolic complications, antiplatelet, and anticoagulation therapy are routinely administered. A worrisome frequency of gastrointestinal (GI) bleeding events has been observed. Methods: A retrospective review of all 33 patients undergoing long-term LVAD implantation between June 1, 2006 and July 31, 2008 at our institution for any indication was conducted. Anticoagulation consisted of heparin (intravenous or subcutaneous) followed by transition to Coumadin therapy to a target INR of two to three. Antiplatelet therapy consisted of low-dose aspirin and dipyridamole. Results: Twenty patients received the HMII and 13 patients received other devices. Eight (40%) HMII recipients suffered at least one episode of GI bleeding while no GI bleeding occurred in recipients of other devices (p = 0.012). Of 17 total bleeding episodes, no definitive source could be identified in 11 instances (65%). Conclusions: Although definitive source identification remains elusive, we believe that the majority of bleeding arises in the small bowel, possibly due to angiodysplasias, similar to the pathophysiology encountered in patients with aortic stenosis and GI bleeding. As we move toward wider use of the HMII and other axial continuous-flow devices in both bridge-to-transplant patients and for destination therapy, more studies will be necessary to understand the mechanisms of this obscure GI bleeding and develop treatment strategies to minimize its development.,(J Card Surg 2010;25:352-356) [source] Anticoagulation After Coronary Artery Surgery in Patients With Polycythemia Vera: Report of Two CasesJOURNAL OF CARDIAC SURGERY, Issue 5 2007Bilgehan Sava, Oz M.D. Normalization of the hematocrit and elevated platelet counts is obligatory to reduce the thrombotic risk of patients with PV. Therapeutic strategies include phlebotomy, myelosuppressive agents, and, more recently, interferon-,. In addition, appropriate antiplatelet therapy should be administered to prevent life-threatening complications and reducing the viscosity of the blood. Although aspirin is widely preferred in such patients, this monodrug therapy or combined with clopidogrel as an alternative approach might not be enough, especially after coronary artery surgery. Therefore, warfarin should be added to anticoagulant therapy. This short report describes the use of warfarin, associated with aspirin and clopidogrel as an anticoagulant regimen after coronary artery bypass surgery in two cases with polycythemia vera. We believe that a combination of warfarin with other oral antiplatelet agents may be more effective in preventing the coronary artery bypass graft thrombosis. [source] Deep Hypothermic Circulatory Arrest and Bivalirudin Use in a Patient With Heparin-Induced Thrombocytopenia and Antiphospholipid SyndromeJOURNAL OF CARDIAC SURGERY, Issue 1 2007Kay B. Leissner M.D. Methods: Bivalirudin was used during CPB and deep hypothermic circulatory arrest (DHCA) for resection of multiple right atrial masses in a patient with HIT II and antiphospholipid antibodies syndrome (APS). Anticoagulation was monitored with the activated clotting time (ACT) and a target ACT of 450 seconds or greater was maintained. Results: Surgical removal of multiple right atrial masses was successful and there was no evidence of thromboembolic events. Clot was noticed in the cardiotomy and venous reservoir after CPB was discontinued and the system flushed. The postoperative course was uneventful. Conclusions: Anticoagulation was successfully managed with bivalirudin, a new short-acting, and direct thrombin inhibitor. Further studies are necessary to evaluate the safety of bivalirudin during DHCA. [source] Periprocedural Anticoagulation for Atrial Fibrillation AblationJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2008M. EYMAN MORTADA M.D. Background: Catheter ablation for atrial fibrillation (AF) can increase risk of left atrial (LA) thrombi and stroke. Optimal periprocedural anticoagulation has not been determined. Objective: We report the role of administering warfarin and aspirin without low molecular weight heparin in patients undergoing AF ablation. Methods: A total of 207 patients underwent ablation for AF. Transesophageal echocardiography (TEE) guided transseptal puncture and ruled out clot in the LA. After first puncture, the sheath was flushed with heparin (5,000 Units/mL). After second puncture, a bolus of 80 units/kg of heparin was given, followed by an infusion to maintain activated clotting time (ACT) around 300,350 seconds. Warfarin was stopped and aspirin was started (325 mg/day) 3 days preprocedure. Warfarin was restarted on the day of the procedure. Both medications were continued for 6 weeks postablation. Warfarin was continued for 6 months in patients with prior history of persistent or recurrent AF. Thirty-seven patients who showed smoke in the LA on TEE were given low molecular weight heparin postprocedure until international normalized ratio (INR) was therapeutic. Results: Thirty-two patients had persistent and 175 had paroxysmal AF; 87 were cardioverted during ablation. Two patients had transient ischemic attack (TIA) on the sixth and eighth days, respectively, following ablation, with complete recovery. Both had subtherapeutic INRs. Conclusion: In patients without demonstrable clot or smoke in the LA, starting aspirin 3 days prior and warfarin immediately post-radiofrequency ablation, without low molecular weight heparin, with meticulous anticoagulation during the procedure, appears to be a safe mode of anticoagulation. [source] Device Implantation and AnticoagulationJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2002MICHAEL C. GIUDICI M.D. [source] Iatrogenic Forearm Compartment Syndrome in a Cardiac Intensive Care Unit Induced by Brachial Artery Puncture and Acute AnticoagulationJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2002M.H.A, SHAY SHABAT M.D. A previously healthy patient developed late compartment syndrome in the cardiac intensive care unit after a brachial artery puncture due to acute heparinization after successful percutaneous transluminal coronary angioplasty (PTCA) and stent implantation. The cardiologists recognized the problem and immediately consulted an orthopedic surgeon, who promptly performed surgery. The latter consisted of decompression and fasciotomy. The patient recovered excellent hand function without any neurologic or muscular deficits. Knowledge and understanding of the clinical aspects of this complication are crucial in this devastating syndrome. [source] The cost-effectiveness of computer-assisted anticoagulant dosage: results from the European Action on Anticoagulation (EAA) multicentre studyJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 9 2009S. JOWETT Summary. Background: Increased demand for oral anticoagulation has resulted in wider adoption of computer-assisted dosing in anticoagulant clinics. An economic evaluation has been performed to investigate the cost-effectiveness of computer-assisted dosing in comparison with manual dosing in patients on oral anticoagulant therapy. Methods: A trial-based cost-effectiveness analysis was conducted as part of the EAA randomized study of computer-assisted dosage vs. manual dosing. The 4.5-year multinational trial was conducted in 32 centres with 13 219 anticoagulation patients randomized to manual or computer-assisted dosage. The main outcome measures were total health care costs, clinical event rates and cost-saving per clinical event prevented by computer dosing compared with manual dosing. Results: Mean dosing costs per patient were lower (difference: ,47) for computer-assisted dosing, but with little difference in clinical event costs. Total overall costs were ,51 lower in the computer-assisted dosing arm. There were a larger number of clinical events in the manual dosing arm. The overall difference between trial arms was not significant (difference in clinical events, ,0.003; 95% CI, ,0.010,0.004) but there was a significant reduction in events with DVT/PE, suggesting computer-assisted dosage with the two study programs (dawn ac or parma 5) was at least as effective clinically as manual dosage. The cost-effectiveness analysis indicated that computer-assisted dosing is less costly than manual dosing. Conclusions: Results indicate that computer-assisted dosage with the two programs (dawn ac and parma 5) is cheaper than manual dosage and is at least as effective clinically, indicating that investment in this technology represents value for money. [source] Review article: the modern management of portal vein thrombosisALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 9 2009Y. CHAWLA Summary Background, Portal vein thrombosis (PVT) is an important cause of portal hypertension. It may occur as such with or without associated cirrhosis and hepatocellular carcinoma. Information on its management is scanty. Aim, To provide an update on the modern management of portal vein thrombosis. Information on portal vein thrombosis in patients with and without cirrhosis and hepatocellular carcinoma is also updated. Methods, A pubmed search was performed to identify the literature using search items portal vein thrombosis-aetiology and treatment and portal vein thrombosis in cirrhosis and hepatocellular carcinoma. Results, Portal vein thrombosis occurs because of local inflammatory conditions in the abdomen and prothrombotic factors. Acute portal vein thrombosis is usually symptomatic when associated with cirrhosis and/or superior mesenteric vein thrombosis. Anticoagulation should be given for 3,6 months if detected early. If prothrombotic factors are identified, anticoagulation should be given lifelong. Chronic portal vein thrombosis usually presents with well tolerated upper gastrointestinal bleed. It is diagnosed by imaging, which demonstrates a portal cavernoma in place of a portal vein. Anticoagulation does not have a definite role, but bleeds can be treated with endotherapy or shunt surgery. Rarely liver transplantation may be considered. Conclusion, Role of anticoagulation in chronic portal vein thrombosis needs to be further studied. [source] Travel and Oral AnticoagulationJOURNAL OF TRAVEL MEDICINE, Issue 4 2009Jürgen Ringwald MD First page of article [source] Perioperative Management of Anticoagulation in Patients Undergoing Cardiac Rhythm Device Procedures: A Bridge to Nowhere?PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 4 2010CHARLES J. LOVE M.D. No abstract is available for this article. [source] Management Options to Treat Gastrointestinal Bleeding in Patients Supported on Rotary Left Ventricular Assist Devices: A Single-Center ExperienceARTIFICIAL ORGANS, Issue 9 2010Helen M. Hayes Abstract Gastrointestinal (GI) bleeding in ventricular assist devices (VADs) has been reported with rotary devices. The pathophysiological mechanisms and treatments are in evolution. We performed a retrospective review of GI bleeding episodes for all VADs implanted at our institution. Five male patients experienced GI bleeding,age 63.6 ± 3.64 years. VAD type VentrAssist n = 1, Jarvik 2000 n = 2, and HeartWare n = 2. All patients were anticoagulated as per protocol with antiplatelet agents (aspirin and/or clopidogrel bisulfate [Plavix] and warfarin (therapeutic international normalized ratio 2.0,3.5). There was no prior history of gastric bleeding in this group. Ten episodes of bleeding requiring blood transfusion occurred in five patients. Some patients had multiple episodes (1 × 5, 1 × 2, 3 × 1). The events occurred at varying times post-VAD implantation (days 14, 21, 26, 107, 152, 189, 476, 582, 669, and 839). Octreotide (a long-acting somatostatin analogue that reduces splanchnic arterial and portal blood flow) was administered subcutaneously or intravenously. Three patients received infusions of adrenaline at 1 µg/min to enhance pulsatility. Anticoagulation was interrupted during bleeding episodes but successfully introduced post bleeding event. GI bleeding is a significant complication of VAD therapy. In this article, we discuss diagnosis and management options. [source] The Use of Bivalirudin for Cardiopulmonary Bypass Anticoagulation in Pediatric Heparin-Induced Thrombocytopenia PatientsARTIFICIAL ORGANS, Issue 8 2010Richard Gates Abstract Infants with heparin-induced thrombocytopenia (HIT) represent a challenging and high-risk group of patients when they require cardiopulmonary bypass (CPB). Bivalirudin offers many potential pharmacologic advantages over other nonheparin anticoagulants for such patients. We describe our protocol for the use of bivalirudin in a 5-month-old infant undergoing stage 2 Norwood for hypoplastic left heart syndrome. The patient was a 5- month-old, 6-kg infant who developed HIT after a bowel resection complicating initial Norwood stage 1. After sternotomy and dissection had been redone, the child received an initial dose of bivalirudin of 1.0 mg/kg and 0.5 mg/kg 5 min later. The CPB circuit was primed with 50 mg/kg bivalirudn/400 cc volume. With the initiation of CPB, a continuous infusion of 2.5 mg/kg bivalirudin was begun. Activated clotting time (ACT) was targeted for over 400 s, with an examination prior to bypass and each 15 min thereafter. Bivalirudin was discontinued with separation from bypass and during modified ultrafiltration (MUF). The ACT was 286 s after the initial 1 mg/kg bolus and 597 s after the second 0.5 mg/kg bolus and initiation of CPB. At a rate of 2.5 mg/kg/min, ACT ranged between 461 and 597 s. At the completion of MUF, the ACT was 316 s. The ACT was 214 s 20 min after MUF. No clots were noted in the CPB circuit, and good hemostasis was achieved within 10 min after MUF was completed. Incision to closure time was 160 min; time from completion of MUF to sternal closure was 30 min. Post-MUF, 60 cc of processed cell saver blood was reinfused, and no clotting factors were required. Chest tube output was 10, 10, 3, and 4 ccs, respectively, at hours 1,4 post operation. Bivalirudin provides effective anticoagulation in infants requiring CPB in the presence of HIT. Bivalirudin's efficacy is effectively monitored by ACT, and, after CPB, its short half-life and ability to be ultrafiltered facilitate the ability to achieve hemostasis in a timely fashion. [source] Efficacy and Safety of Anticoagulation With Heparin Versus Heparin Plus Epoprostenol in Patients Undergoing Extracorporeal Liver Support With PrometheusARTIFICIAL ORGANS, Issue 1 2010Peter Krisper Abstract Anticoagulation for extracorporeal liver support is delicate due to underlying coagulation disorders in patients with liver failure and to the associated elevated bleeding risk. To date, there has been no detailed report on anticoagulation issues in patients treated with Prometheus, a device based on the principle of fractionated plasma separation and adsorption. We studied 17 patients from two centers treated with Prometheus, comparing standard anticoagulation with heparin (15 treatments) and a combination of heparin and the synthetic prostacyclin epoprostenol (22 treatments). Standard coagulation tests, proteins C and S, and thrombin,antithrombin (TAT) complex were determined, and adverse events were recorded. All but two treatments could be completed as scheduled, although filter exchange due to filter clotting was required in 24% of the treatments. Three out of 17 patients developed severe bleeding complications within 24 h of treatment. There were no overt thrombotic events. Addition of epoprostenol neither reduced coagulation-related adverse events nor improved standard coagulation parameters. Protein C, but not protein S, showed a significant reduction (23 ± 18%) after Prometheus treatments, but levels rebounded to baseline within 18 h. TAT levels,a measure for activation of coagulation,were only altered by Prometheus in patients where TAT was already elevated before treatment. In conclusion, anticoagulation of Prometheus with heparin is feasible but still associated with a relatively high frequency of filter clotting and a considerable risk of severe bleeding in this high-risk patient population. As addition of epoprostenol did not prove beneficial, other strategies, such as regional anticoagulation with citrate, should be further evaluated. [source] Bridge-to-recovery from Acute Myocarditis in a 12-year-old ChildARTIFICIAL ORGANS, Issue 6 2004Holger Hotz Abstract:, Fulminant myocarditis causes substantial morbidity and mortality, especially in children and young adults. Mechanical circulatory support has become the standard therapy to bridge patients with intractable heart failure to either transplantation or myocardial recovery. Yet, successful weaning from biventricular support with full recovery is extremely rare in the pediatric population. This report describes the successful use of the MEDOS HIA ventricular assist device to bridge a 12-year-old girl to myocardial recovery in a biventricular bypass configuration. The left and right ventricle were completely off-loaded by the pumps and the device provided sufficient cardiac output to normalize end-organ function. Anticoagulation was maintained with i.v. heparin infusion. No neurological complications were detectable and the pump system was free of any macroscopic thrombi. After 19 days of support, cardiac function had recovered and the patient was successfully weaned from the device. Following physical rehabilitation, the patient was discharged home. [source] Bridging of Chronic Oral Anticoagulation with Enoxaparin in Patients with Atrial Fibrillation: Results from the Prospective BRAVE RegistryCARDIOVASCULAR THERAPEUTICS, Issue 4 2009C. Hammerstingl Current American College of Chest Physicians (ACCP) guidelines on the perioperative management of oral anticoagulation (OAC) suggest bridging therapy with therapeutic doses of low-molecular-weight heparin (LMWH) in patients with atrial fibrillation (AF) if at high or moderate thromboembolic (TE) risk, and with reduced doses in patients with low TE risk. Our objective was to assess the efficacy and safety of bridging OAC with enoxaparin in AF patients. These are the results of an open, prospective monocenter register. Hospitalized and ambulatory patients with AF requiring bridging therapy at high or moderate TE risk and normal renal function were treated with therapeutic LMWH doses; all other patients received reduced doses. A total of 703 patients were enrolled, of whom 358 (50.9%) were at moderate-to-high and 345 (49.1%) at low TE risk. Renal impairment was detected in 308 patients (43.8%). One hundred ninety patients (27.1%) were treated with therapeutic LMWH doses and 513 (72.9%) with reduced doses. No TE events were observed during the follow-up period (0%; 95% confidence interval [CI] 0.0,0.52). Three major bleeds (0.4%; 0.1,1.2) and 60 minor bleeds were noted (8.9%; 6.6,10.9). Age and total LMWH doses were risk factors for bleeding in the multivariate analysis. The study, under conditions of everyday clinical care, supports a predefined bridging regimen based on the individual patient's TE risk and renal function. Patients with low TE risk or with impaired renal function can be bridged effectively and safely with reduced LMWH doses. [source] Anticoagulation with the direct thrombin inhibitor argatroban in patients presenting with acute coronary syndromes,CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 2 2009Robert W. Yeh MD Abstract Objectives: This study examined the efficacy and safety of the direct thrombin inhibitor argatroban in patients presenting with acute coronary syndromes undergoing cardiac catheterization. Background: Argatroban is a direct-thrombin inhibitor approved for use in percutaneous coronary intervention in patients with heparin-induced thrombocytopenia. Few studies have examined its use in patients undergoing cardiac catheterization for acute coronary syndromes. We performed a retrospective cohort study of patients presenting with acute coronary syndromes who received argatroban anticoagulation during cardiac catheterization. Methods: Consecutive patients presenting with acute coronary syndromes who received argatroban while undergoing cardiac catheterization from 2002 to 2005 were included. Patient characteristics and in-hospital outcomes were examined retrospectively via detailed chart review. The primary endpoints of the study were combined death, myocardial infarction or urgent revascularization, and major bleeding during the index hospitalization. Results: A total of 144 patients presenting with an acute coronary syndrome received argatroban during cardiac catheterization within the study period: 25% presented with ST-elevation myocardial infarction and 75% presented with non-ST-elevation acute coronary syndrome. The combined endpoint of death, myocardial infarction or urgent revascularization occurred in 13.2% of patients during the hospitalization. Major bleeding occurred in 2.1% of patients. Conclusions: In this cohort of patients presenting with acute coronary syndromes, patients receiving argatroban during cardiac catheterization had a moderate rate of adverse cardiac events and a very low rate of major bleeding. © 2009 Wiley-Liss, Inc. [source] Anticoagulation for mechanical valve prostheses during pregnancyCLINICAL CARDIOLOGY, Issue 7 2003C. Richard Conti M.D., M.A.C.C. Editor-in-Chief No abstract is available for this article. [source] Neurological complications in two children with Lemierre syndromeDEVELOPMENTAL MEDICINE & CHILD NEUROLOGY, Issue 8 2010BASHEER PEER MOHAMED Lemierre syndrome is a distinct clinical syndrome comprising oropharyngeal sepsis and fever, internal jugular vein thrombosis and remote septic metastases caused by Fusobacterium species. The mortality rate was historically high and although use of antibiotics led to a dramatic fall in incidence, a resurgence has been seen recently. A 14-year-old male developed Lemierre syndrome after tonsillitis. There was extensive leptomeningitis, especially over the clivus, causing 6th and 12th cranial nerve palsies, a clinical feature termed the ,clival syndrome'. He also developed an epidural abscess in the cervical spine, which was unsafe for surgical drainage. Conservative treatment with an extended course of antibiotics and anticoagulation for jugular vein thrombosis led to a good recovery. A 15-year-old female developed Lemierre syndrome after a persistent sore throat lasting 7 weeks. She had palsy of the 12th cranial nerve from clival osteomyelitis. She was treated with a 6-week course of antibiotics and anticoagulants leading to almost full recovery at 3-month review. Awareness of the potential neurological complications of Lemierre syndrome and prompt management are crucial in reducing morbidity and mortality in this ,forgotten disease'. [source] MANAGEMENT OF ANTIPLATELET THERAPY FOR ENDOSCOPIC PROCEDURES: OPTIMAL CESSATION PERIOD OF ANTIPLATELET THERAPY FOR JAPANESEDIGESTIVE ENDOSCOPY, Issue 4 2007Yoshiko Tamai Although antiplatelet agents are widely used for the treatment and prevention of thrombotic diseases, only a few studies have reported the validity of the cessation period prior to endoscopic procedures. In 2002, the American Society for Gastrointestinal Endoscopy (ASGE) published a reference on the management of anticoagulation and antiplatelet therapy for endoscopic procedures, but it should be confirmed as appropriate for use in Asian patients. To evaluate the optimal cessation period of antiplatelet agents prior to endoscopic procedures for Japanese, we have studied: (i) the current clinically adopted cessation period of antiplatelet agents prior to invasive endoscopic procedures in Japan; (ii) the relationship between the cessation period of antiplatelet agents and complications around the invasive endoscopic procedures; (iii) colonic mucosal bleeding time after aspirin ingestion; and (iv) the time course of primary hemostasis after cessation of antiplatelet agents. We conclude that 3 days cessation period for aspirin, 5 days cessation for ticlopidine and 7 days cessation for aspirin + ticlopidine administration should be sufficient for Japanese. [source] REVIEW: Aortic Atheromas: Current Concepts and Controversies,A Review of the LiteratureECHOCARDIOGRAPHY, Issue 2 2008Thenappan Thenappan M.D. The frequent use of transesophageal echocardiogram (TEE) has led to the increased recognition of aortic atheromas. Retrospective and prospective follow-up studies have reported an association between aortic atheromas and stroke in the high-risk patient population, with complex plaques being more likely to embolize than simple plaques. However, TEE-based studies in the low-risk cohorts have failed to show a similar association. There is growing body of evidence suggesting that aortic atheroma is a marker of generalized atherosclerosis. Although magnetic resonance (MR) imaging and computed tomography (CT) scan are emerging as a powerful noninvasive tool for characterization of aortic atheromas, TEE is the imaging modality of choice. Currently, treatment of aortic atheromas is not well defined, and mixed outcomes have been reported for anticoagulation therapy with warfarin. Statins appear promising based on their plaque stabilization properties. However, there are no randomized control trials to establish the role of both anticoagulation and statins in patients with aortic atheromas, and are warranted in the future. [source] Prosthetic Valve Thrombosis Presenting as an Acute Embolic Myocardial Infarction in a Pregnant Patient: Issues on Anticoagulation Regimens and Thrombolytic TherapyECHOCARDIOGRAPHY, Issue 9 2006Padmini Varadarajan M.D. Mechanical valves are inherently thrombogenic and require meticulous anticoagulation. Pregnancy produces a hypercoagulable state and achieving adequate anticoagulation is difficult. We present a pregnant patient who had a nonobstructive thrombus of mechanical mitral valve causing embolic acute myocardial infarction. Issues surrounding management of anticoagulation and use of thrombolytic therapy during pregnancy are discussed. Education regarding the critical nature of adequate anticoagulation in these patients is important. [source] Course of Intraatrial Thrombi Resolution Using Transesophageal EchocardiographyECHOCARDIOGRAPHY, Issue 2 2003Jennifer A. Larsen M.D. Thromboembolic events are associated with atrial fibrillation and with cardioversion to sinus rhythm. Although studies have demonstrated the risk of this complication is reduced by a 3-week period of anticoagulation prior to cardioversion, limited data have suggested a longer period of anticoagulation is necessary for thrombus resolution. We identified and followed 25 patients noted to have intraatrial thrombi on an initial transesophageal echocardiogram (TEE) who subsequently had a follow-up TEE. The majority of patients had a single thrombus, often but not uniformly located in the left atrial appendage with the largest found in those patients with mitral stenosis. Repeat TEE was performed at a mean of 4 ± 6 months and persistent thrombus was noted in 19 of 25 patients (76%). Seven of 19 patients with persistent thrombi were cardioverted and one of these patients had a neurologic event following the procedure (14%). The only findings associated with persistent thrombus were the presence of mitral valve disease and atrial fibrillation.. Our findings suggest that intraatrial thrombi do not generally resolve following several weeks of anticoagulation and that persistent left-sided intraatrial thrombi may be associated with an increased risk for events following cardioversion. Given that a TEE-guided approach to cardioversion is being utilized more frequently, it may be important to determine thrombus characteristics on follow-up that would be predictive of embolic events following cardioversion. (ECHOCARDIOGRAPHY, Volume 20, February 2003) [source] Is It Open or Is It Closed?ECHOCARDIOGRAPHY, Issue 4 2002Thrombosis of a St. Jude's Tricuspid Valve Prosthesis A 49-year-old woman with mitral and tricuspid mechanical valve prostheses developed marked weight gain with increasing abdominal girth and facial plethora 4 weeks after anticoagulation was temporarily interrupted for abdominal surgery. Transthoracic and transesophageal echocardiography documented severe tricuspid stenosis and regurgitation. The two discs of the tricuspid prosthesis were immobilized, half open and half closed. The prosthesis was replaced and the patient did well. [source] Role of Transthoracic Echocardiography in Atrial FibrillationECHOCARDIOGRAPHY, Issue 4 2000RICHARD W. ASINGER M.D. Atrial fibrillation is a major clinical problem that is predicted to be encountered more frequently as the population ages. The clinical management of atrial fibrillation has become increasingly complex as new therapies and strategies have become available for ventricular rate control, conversion to sinus rhythm, maintenance of sinus rhythm, and prevention of thromboembolism. Clinical and transthoracic echocardiographic features are important in determining etiology and directing therapy for atrial fibrillation. Left atrial size, left ventricular wall thickness, and left ventricular function have independent predictive value for determining the risk of developing atrial fibrillation. Left atrial size may have predictive value in determining the success of cardioversion and maintaining sinus rhythm in selected clinical settings but has less value in the most frequently encountered group, patients with nonvalvular atrial fibrillation, in whom the duration of atrial fibrillation is the most important feature. When selecting pharmacological agents to control ventricular rate, convert to sinus rhythm, and maintain normal sinus rhythm, transthoracic echocardiography (TTE) allows noninvasive evaluation of left ventricular function and hence guides management. The combination of clinical and transthoracic echocardiographic features also allows risk stratification for thromboembolism and hemorrhagic complications in atrial fibrillation. High-risk clinical features for thromboembolism supported by epidemiological observations, results of randomized clinical trials, and meta-analyses include rheumatic valvular heart disease, prior thromboembolism, congestive heart failure, hypertension, older (> 75 years old) women, and diabetes. Small series of cases also suggest those with hyperthyroidism and hypertrophic cardiomyopathy are at high risk. TTE plays a unique role in confirming or discovering high-risk features such as rheumatic valvular disease, hypertrophic cardiomyopathy, and decreased left ventricular function. Validation of the risk stratification scheme used in the Stroke Prevention in Atrial Fibrillation-III trial is welcomed by clinicians who are faced daily with balancing the benefit and risks of anticoagulation to prevent thromboembolism inpatients with atrial fibrillation. [source] Management of new onset atrial fibrillation in previously well patients less than 60 years of ageEMERGENCY MEDICINE AUSTRALASIA, Issue 1 2005David McD Taylor Abstract Objective:, This study reviewed the ED management of new onset atrial fibrillation (AF) in previously well patients aged less than 60 years. Methods:, We undertook a retrospective review of ED patients from 1998 to 2002 inclusive. The main outcome measures were approaches to rate or rhythm control and anticoagulation, the use of echocardiography, the value of diagnostic testing and the frequency of hospital admission. Results:, Fifty-two patients were identified. In general, all patients were haemodynamically stable. One patient had mild cardiac failure and one was clinically thyrotoxic. Serum potassium was measured in 51 (98%) patients, magnesium in 23 (44%) and cardiac enzymes in 30 (58%); results were generally unhelpful. Thyroid function tests were carried out in 40 (77%) patients; results were unremarkable except for the clinically thyrotoxic patient. No patient had echocardiography in the ED; however, 6 patients (12%) were later found to have major cardiac abnormalities. Forty-four (85%) patients received a variety of medications; 37 (71%) received an anti-arrhythmic and 24 (46%) an antithrombotic. Overall, 17 (33%) patients received theoretically effective therapy for conversion to sinus rhythm. Twenty-two (42%) patients were admitted to hospital. Conclusions:, This study reveals variation in the management of acute AF in previously well, haemodynamically stable, young patients. Pathology testing was frequently carried out with a low yield. There were high rates of attempts to cardiovert, use of antithrombotics and of admission to hospital. Although cardioversion attempts appeared to be contrary to existing guidelines, decisions may have been based primarily on patient symptoms. Echocardiography should be considered prior to anti-arrhythmic therapy. [source] Appraisal of current vitamin K dosing algorithms for the reversal of over-anticoagulation with warfarin: the need for a more tailored dosing regimenEUROPEAN JOURNAL OF HAEMATOLOGY, Issue 6 2006Elizabeth A. Sconce Abstract:, Warfarin is the most commonly prescribed oral anticoagulant in the UK for the treatment and prevention of thromboembolic disorders. Vitamin K administration is an effective way of reversing excessive anticoagulation. Over-anticoagulated patients present with a wide range of international normalized ratio (INR) values and may respond differently to a fixed dose of vitamin K. Current dosing algorithms for vitamin K administration in the non-urgent treatment of over-anticoagulation do not take this variability in response into account. Consequently, over a third of over-anticoagulated patients still remain outside their target INR 24 h after treatment. Such patients are therefore prone to either haemorrhage (if the patient is still over-anticoagulated) or thromboembolism (if the INR reversal is over-corrected). A number of factors such as patient age, body weight, co-morbidity, frailty, warfarin daily dose and CYP2C9 and VKORC1 polymorphism could affect response to vitamin K and thus the rate and extent of INR reversal. There is a need for a more individualized approach to the reversal of over-anticoagulation in asymptomatic or mildly haemorrhagic patients in order to improve the safety of warfarin therapy. [source] | ||||||||||||||||||||||||||||||||||||||||