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 170,190 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Clinical trials during the past 20 years have revolutionized the antithrombotic management of atrial fibrillation. Based on consideration of 30 randomized trials involving 29,017 participants, adjusted-dose warfarin remains the most efficacious prophylaxis against stroke for atrial fibrillation patients at moderate-to-high risk (compared with antiplatelet agents, warfarin reduces stroke by about 40%). The optimal INR for prevention of stroke for most atrial fibrillation patients is probably 2.0-2.5; INRs of 1.6-1.9 provide substantial protection, 80-90% of that afforded by higher intensities. Warfarin-associated intracerebral hemorrhage is an increasing problem as more elderly patients with atrial fibrillation are anticoagulated. Modest reductions in blood pressure results in large decreases in this most dreaded complication of warfarin; anticoagulation of elderly atrial fibrillation patients should be accompanied by a firm commitment to control hypertension. Warfarin-associated intracerebral hemorrhage has a 50% early mortality. A wide range of acute treatments to urgently reverse anticoagulation have been recommended by experts, but prevention is a far better option than treatment of this devastating problem.
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PMID:Anticoagulation in atrial fibrillation: selected controversies including optimal anticoagulation intensity, treatment of intracerebral hemorrhage. 1790 18

An 84-year-old female patient was scheduled to undergo AVR, CABG, and Maze procedure. She had a history of hypertension, cerebral infarction, and branch retinal vein occlusion. Warfarin was administered preoperatively. Before the cardiopulmonary bypass (CPB), heparin 5,000 units was administered. Activated coagulation times (ACTs) before and after CPB were 123 sec and 157 sec, respectively. Additional heparin of 5,000 units extended ACT to 221 seconds, which was not enough for the CPB. Heparin 10,000 units was added, and ACT was 157 sec. AntithrombinIII (ATIII) and platelet counts were 75% and 270,000 mm(-3), respectively. ATIII 1,500 units was administered. ACT and ATIII became 133 sec and 123%, respectively. Because heparin resistance did not respond to ATIII, the operative method was changed to off-pump CABG. A postoperative examination revealed high factor VIII activity of 263%. Other results were as follows: protein C antigen, 40%; protein S antigen, 65%; factor VII, 50%; platelet factor 4, 12%; heparin cofactor II, 104%; von Willebrand factor antigen, 181%; heparin-PF4-IgG antibody, negative; factor VIII inhibitor, negative. The low values of protein C, protein S, and factor VII may have been caused by warfarin. Other values were normal, except for the von Willebrand factor antigen.
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PMID:[Heparin resistance associated with elevated factor VIII]. 1841 8

Non-valvular atrial fibrillation (NVAF) is responsible for up to 10% of all ischaemic strokes. The risk of stroke in these patients is substantial, particularly when associated with past cerebral ischaemia, hypertension, diabetes and age over 65. Warfarin has recently been shown to reduce this risk by two-thirds with relative safety. The files of 103 patients with chronic NVAF on recent presentation to hospital were studied to see if they had been given warfarin beforehand. Two-thirds would have been ideal candidates, having at least one added risk factor for stroke, and no contraindication for the use of warfarin. Yet fewer than 10% were taking it. Sixteen of these 103 patients had an ischaemic event at presentation, mostly stroke. Twelve were ideal candidates for warfarin prophylaxis, but none had received it for this purpose. Much more must be done to prevent stroke in these patients.
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PMID:Stroke prevention in patients with non-valvular atrial fibrillation: a current community perspective. 1863 77

In pulmonary arterial hypertension (PAH), thrombosis and thromboembolism occurs as a consequence of pulmonary microvasculopathy with a change of pulmonary vascular microenviroment toward a procoagulant, prothrombotic and antifibrinolytic pattern. Circulating antiphospholipid antibodies, increased plasma levels of platelet aggregating agents (serotonin, thromboxane), adhesion molecules (P selectin, von Willebrand factor), antifibrinolytic enzymes (plasminogen activator inhibitor 1) and prothrombotic cytokines have been identified in PAH patients so far. Thrombogenic pulmonary vasculopathy has been documented in many patients with PAH. Furthermore, most patients will not be diagnosed until right heart enlargement and impaired right ventricular function has developed. Thus, there is clear rationale for a treatment with anticoagulation. In four uncontrolled studies Warfarin improved the prognosis of patients with idiopathic and other forms of PAH. However, so far there are no prospective randomised studies evaluating the role of anticoagulants in the treatment of PAH. This review summarizes the current data and guidelines concerning anticoagulation in PAH.
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PMID:[Anticoagulation in pulmonary arterial hypertension]. 1883 49

Coumarins are a group of important natural compounds, and have been found to have multi-biological activities such as anti-HIV, anti-tumor, anti-hypertension, anti-arrhythmia, anti-osteoporosis, assuaging pain, preventing asthma and antisepsis. One of which is its anti-tumor effect and that is a research focus on. Therefore, we believe that it is necessaryto carry out further studies on the effect of coumarins compounds in anti-tumor. Investigation should emphasize on improving techniques for extraction and separation, searching the effective precursory compound, and synthesizing and screening out courmarin derivatives with high activity and low toxicity. Here the recent research progress in anti-tumor effect of coumarins compounds is reviewed.
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PMID:[Research progress on effect of coumarins compounds in anti-tumor]. 1916 Jul 74

Stroke recurrence continues to be the major risk for stroke survivors. Risk factor control and antithrombotic medication are two major strategies for patients with a prior stroke or transient ischaemic attack (TIA) to prevent stroke recurrence. Hypertension, dyslipidaemia and diabetes mellitus are risk factors that are modifiable by pharmacotherapy, as well as by lifestyle modification. Antihypertensive treatment is recommended for secondary stroke prevention for both hypertensive and normotensive patients. HMG-CoA reductase inhibitor (statin) therapy to obtain an intensive lipid-lowering effect is also highly recommended. A recent trial indicated that treatment with pioglitazone is effective for patients with type 2 diabetes. However, the evidence for risk factor control is relatively new, and further studies are needed for better evidence-based prevention. For patients with noncardioembolic ischaemic stroke or TIA, antiplatelet therapy rather than anticoagulation is recommended to reduce the risk of recurrent stroke and other cardiovascular events. Aspirin was the first antiplatelet agent to have established evidence for secondary stroke prevention. Currently, aspirin monotherapy, the combination of aspirin and extended-release dipyridamole, and clopidogrel monotherapy are recommended as the major choices. The combination of aspirin and clopidogrel is not routinely recommended. Adjusted-dose warfarin with a target international normalized ratio range between 2.0 and 3.0 is recommended after an ischaemic stroke or TIA associated with nonvalvular atrial fibrillation. Bleeding complications are a critical problem with antithrombotic therapy. Warfarin, as well as antiplatelet therapy, increases the incidence of bleeding and worsens the severity of the bleeding events. Choosing antithrombotic agents and their intensity (dosage) appropriate to the stroke mechanism and the patient's condition are essential for secondary stroke prevention.
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PMID:Pharmacotherapy for the secondary prevention of stroke. 1940 47

Atrial fibrillation is the most common arrhythmia in clinical practice, may coexist with conditions common to both cardiovascular and noncardiovascular diseases and is associated with considerable morbidity and mortality. Atrial fibrillation is often asymptomatic and diagnosed only when it has caused a potentially serious complication, such as an ischemic stroke. When atrial fibrillation has been identified, 2 objectives have to be addressed--the antiarrhythmic therapy based on rate control or rhythm control, and prevention of thromboembolism. A rhythm or rate control strategy can be chosen indifferently because they have comparable efficacy for the outcome measure of mortality, but the antithrombotic therapy is ever mandatory. The risk of stroke increases cumulatively with increasing age, previous transient ischemic attack or stroke, hypertension, diabetes mellitus, impaired left ventricular function and heart failure. Warfarin reduces the risk of stroke by about two thirds; and aspirin, by about one fifth, but its use must be weighted with the risk of bleeding. The risk of anticoagulant-associated hemorrhage increases with age, the presence of serious concomitant diseases, with poorly controlled hypertension and poorly controlled anticoagulation.
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PMID:Management of nonvalvular atrial fibrillation: a comprehensive approach. 1980 24

A 63-year-old white woman with a history of hypertension, hyperlipidemia, hypothyroidism, and transient ischemic attack, on Premarin, presented with a 2-week history of worsening edema and pain on the left side of the lower extremity associated with purplish discoloration and decreased temperature after a prolonged car travel. Physical examination revealed 2+ edema from the midthigh to the toes associated with purpuric discoloration. All arterial pulses were 4+. Ultrasound examination demonstrated an acute deep vein thrombus extending from the external iliac veins down throughout the visualized veins of the left calf. The patient was started on intravenous heparin and underwent venogram with subsequent thrombolysis. After 48 hours of alteplase infusion, balloon angioplasty was performed and 2 stents were placed in the left common and external iliac veins. Premarin was discontinued and she remains on oral anticoagulation with Coumadin. The patient did well clinically and a second ultrasound showed interval improvement. There is significant family history but no personal history of thrombotic events; however, thrombophilia evaluation is unremarkable.
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PMID:Acute deep vein thrombus due to May-Thurner syndrome. 2015 6

Warfarin is a complex but highly effective treatment for decreasing thromboembolic risk in atrial fibrillation (AF). We examined contemporary warfarin treatment rates in AF before the expected introduction of newer anticoagulants and extent of practice-level variation in warfarin use. Within the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence program from July 2008 through December 2009, we identified 9,113 outpatients with AF from 20 sites who were at moderate to high risk for stroke (congestive heart failure, hypertension, age, diabetes, stroke score >1) and would be optimally treated with warfarin. Using hierarchical models, the extent of site-level variation was quantified with the median rate ratio, which can be interpreted as the likelihood that 2 random practices would differ in treating "identical" patients with warfarin. Overall rate of warfarin treatment was only 55.1% (5,018 of 9,913). Untreated patients and treated patients had mean congestive heart failure, hypertension, age, diabetes, stroke scores of 2.5 (p = 0.38) and similar rates of heart failure, hypertension, diabetes mellitus, and previous stroke, suggesting an almost "random" pattern of treatment. At the practice level, however, there was substantial variation in treatment ranging from 25% to 80% (interquartile range for practices 50 to 65), with a median rate ratio of 1.31 (1.22 to 1.55, p <0.001). In conclusion, within the Practice Innovation and Clinical Excellence registry, we found that warfarin treatment in AF was suboptimal, with large variations in treatment observed across practices. Our findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AF and define a benchmark treatment rate before the introduction of newer anticoagulant agents.
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PMID:Practice-level variation in warfarin use among outpatients with atrial fibrillation (from the NCDR PINNACLE program). 2207 80

Atrial fibrillation (AF), the most common clinically relevant arrhythmia, affects 2.2 million individuals in the USA and 4.5 million in Europe, resulting in significant morbidity and mortality. Pharmacotherapy aimed at controlling both heart rate and rhythm is employed to relieve AF symptoms, though debate continues about which approach is preferable. AF prevalence rises with age from 0.4% to 1% in the general population to 11% in those aged >70 years. AF is associated with a pro-thrombotic state and other comorbidities; age, hypertension, heart failure and diabetes mellitus all play a key role in AF pathogenesis. Anti-coagulation is essential for stroke prevention in patients with AF and is recommended for patients with one or more risk factors for stroke. Used within the recommended therapeutic range, warfarin and other vitamin K antagonists decrease the incidence of stroke and mortality in AF patients. Warfarin remains under-used, however, because of the perceived high risk of haemorrhage, narrow therapeutic window and need for regular monitoring. Several novel anti-coagulants show promise in AF-related stroke prevention. In particular, the novel, oral, direct thrombin inhibitor, dabigatran etexilate, recently licensed by the US Food and Drug Administration (FDA) and Health Canada has shown improved efficacy and safety compared with warfarin for stroke prevention in AF, and has the potential to replace warfarin in this indication. The increasing number of new therapeutic options, including improved anti-arrhythmic agents, novel anti-coagulants and more accessible ablation techniques, are likely to deliver better care for AF patients in the near future.
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PMID:Update on anti-coagulation in atrial fibrillation. 2221 Jun 2


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