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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The authors examined warfarin use in elderly patients with atrial fibrillation. Medical records were abstracted from a random sample of Medicare beneficiaries with atrial fibrillation who were discharged from Kansas hospitals. Data were analyzed for warfarin and aspirin use and risk factors for stroke or bleeding in patients 65-79 years of age or 80 years and older. Stroke risk factors other than age and atrial fibrillation were seen in 98% of 142 patients less than 80 years of age and 100% of 141 octogenarians. Warfarin use was similar in the younger and older age groups (50% vs. 45%, respectively; p = ns) and was not associated with the number of stroke or bleeding risk factors. Compared to patients less than 80 years of age, octogenarians were less likely to receive aspirin (38% vs. 27%, respectively; p < 0.05). Anticoagulation rates for high-risk patients with atrial fibrillation were low and poorly explained by stroke or bleeding risks.
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PMID:Warfarin for stroke prevention in octogenarians with atrial fibrillation. 1136 Aug 38

Atrial fibrillation increases in prevalence with advancing age and is the major precursor of embolic stroke in an elderly population. Currently about 2.2 million people in the United States have atrial fibrillation and their median age is 75 years. Patients older than 75 years of age with atrial fibrillation and those with underlying coronary heart disease or with heart failure are at highest risk of stroke. Long-term warfarin anticoagulant therapy, in a number of randomized controlled trials of its use in nonvalvular atrial fibrillation, substantially decreased stroke risk, with benefit maintained at elderly age. Warfarin anticoagulation at elderly age, with careful monitoring and attention to concomitant therapies, can be safely accomplished with an acceptably low rate of bleeding complication.
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PMID:Atrial Fibrillation at Elderly Age: The Importance of Stroke Prevention. 1141 7

Nonvalvular atrial fibrillation (NVAF) is frequently seen in elderly people and has become a main cause of cardioembolic stroke. The efficacy of anticoagulation for primary prevention of stroke or transient ischaemic attacks (TIAs) in patients with NVAF has been established by prospective, randomised and controlled trials. Warfarin decreased the frequency of all strokes by 68% and the rate of the combined outcome of stroke, systemic embolism or death by 48%. Anticoagulation with warfarin using international normalised ratios (INRs) ranging from 2.0 to 3.0 is recommended for patients with NVAF, who have any of the risk factors identified by the Atrial Fibrillation Investigators (AFI) [previous stroke or TIA, history of hypertension, diabetes mellitus, advanced age (> or = 65 years old), congestive heart failure and coronary artery disease], the American College of Chest Physicians (ACCP) [increased age (> 75 years old), prior stroke, hypertension and heart failure], or the Stroke Prevention in Atrial Fibrillation (SPAF) investigators [women > 75 years old, prior stroke, systolic blood pressure > 160mm Hg, recent heart failure, and fractional shortening < 25% on echocardiography]. For the secondary prevention of stroke, the efficacy of adjusted-dose warfarin therapy has been demonstrated by 2 major randomised trials. SPAF III (INR 2.0 to 3.0) demonstrated a lower incidence of ischaemic stroke or systemic embolism (3.4 %/year) compared with low fixed-dose warfarin plus aspirin (acetylsalicylic acid) [11.9%]. The European Atrial Fibrillation Trial [EAFT] (INR 2.5 to 4.0) showed a lower incidence of all stroke (4.0 %/year) with adjusted-dose warfarin compared with placebo (12.0 %/year). The incidence of major bleeding in the adjusted-dose warfarin group in SPAF III and EAFT was 2.4 and 2.8 %/year, respectively. EAFT incidence rates for the occurrence of a first ischaemic or haemorrhagic complication analysed by INR range indicated that the rate was lowest at INRs of 2.0 to 2.9, and higher with INRs of 3.0 to 3.9. Therefore, the optimal intensity of anticoagulation for prevention of recurrent stroke seems to be an INR of between 2.0 and 3.0, as for primary prevention. Retrospective and prospective studies from Japan reported that in the elderly, haemorrhagic complications occur frequently with INRs above 2.6 and major ischaemic events cannot be prevented at INRs below 1.6. Therefore, an INR target between 1.6 and 2.6 may be an alternative for secondary prevention of stroke in elderly patients with NVAF who have a potential risk of bleeding, to avoid both major ischaemic and haemorrhagic events. Antiplatelets may be administered in patients who are unable to manage taking warfarin properly or who have a high risk of falling and subsequently sustaining a head injury, although the efficacy of antiplatelets for secondary prevention of stroke in NVAF has not yet been established.
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PMID:Secondary prevention of stroke in patients with nonvalvular atrial fibrillation: optimal intensity of anticoagulation. 1152 34

The Coumadin Aspirin Reinfarction Study demonstrated that combination treatment with fixed dose warfarin (1 or 3 mg) + aspirin 80 mg was not superior to aspirin 160 mg alone after myocardial infarction for reducing nonfatal reinfarction, nonfatal stroke, and cardiovascular death. In this analysis, we examined the importance of aspirin dose in the protection against the secondary end point of ischemic stroke. The comparison arms for this analysis were warfarin 1 mg + aspirin 80 mg versus aspirin 160 mg. In the Coumadin Aspirin Reinfarction Study, 2,028 patients were randomized to aspirin 80 mg plus warfarin 1 mg, and 3,393 were randomized to aspirin 160 mg alone. A predictive model for ischemic stroke was developed using the Cox proportional-hazards model. A reduced Cox proportional-hazards model was developed to test for the effect of aspirin dose on ischemic stroke in predefined subgroups. The incidence of ischemic stroke was lower in patients treated with aspirin 160 mg than in patients treated with aspirin 80 mg + warfarin 1 mg (0.6% vs 1.1%; p = 0.0534). Age, previous stroke or transient ischemic attack, and aspirin dose were independent predictors of ischemic stroke. In addition, the highest risk patients, those with Q-wave myocardial infarction and male patients, appeared to receive greater benefit from aspirin 160 mg than from aspirin 80 mg + warfarin 1 mg. The results of this secondary analysis suggest that aspirin 160 mg is more effective than aspirin 80 mg + warfarin 1 mg in preventing ischemic stroke in post-myocardial infarction patients.
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PMID:Comparison of two aspirin doses on ischemic stroke in post-myocardial infarction patients in the warfarin (Coumadin) Aspirin Reinfarction Study (CARS). 1152 65

The objective was to determine the proportion of patients presenting to the Emergency Department (ED) in atrial fibrillation (AF) who are at high risk of thromboembolic stroke as defined by the American Heart Association and who might benefit from anticoagulation therapy. We enrolled all patients identified as having AF between 28th June 1999 and 26th March 2000. Data collected included demographic information, presenting complaint, discharge diagnosis, risk factors for thromboembolic stroke, contraindications to anticoagulation (as defined by the Stroke Prevention in AF Investigators), admission and discharge medications, and cardiac rhythm on presentation and at discharge. 193 patients were identified within the study period. Two patient histories were not available for review. 121 patients had a prior history of AF. Of these, 65 patients were at high risk for thromboembolic stroke and had no contraindication to anticoagulation therapy 43 (66%) were on Warfarin at presentation but 14 (22%) were on Aspirin and 8 (12%) were on neither. 34% of patients with chronic atrial fibrillation presenting to the ED, at high risk of thromboembolic stroke and without contra-indication to anticoagulation, were not anticoagulated on presentation. ED attendance provides an opportunity for intervention for the prevention of stroke in this group.
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PMID:Prevention of stroke in chronic and recurrent atrial fibrillation: role of the emergency department in identification of "at-risk" patients. 1166 27

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 commonly available, but its use must be evaluated and articulated by the prescribing physician. The current multicenter prospective trials will provide much needed guidance on this subject. The ongoing trials do not have a placebo arm, however, indicating a consensus among clinicians that patients with cardiomyopathy should be on an antiplatelet or anticoagulant drug until further data emerge.
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PMID:To anticoagulate or not to anticoagulate patients with cardiomyopathy. 1171 81

Anticoagulation regimens vary according to surgeon, nature of the valve (mechanical or biological), its position and other risk factors for stroke. The American College of Chest Physicians (2001) have made the following recommendations to protect patients with prosthetic heart valves from developing a stroke: (i) For mechanical heart valves: Anticoagulation with Warfarin at an INR range 2-3 for patients with a bileaflet mechanical valve in the aortic position; (ii) in the mitral position, an INR of 2.5-3.5 is recommended; an alternative recommendation is an INR of 2-3 in combination with aspirin (80 mg/day); and (iii) in patients with a mechanical valve and a history of systemic embolization, an INR of 2.5-3.5 combined with low-dose aspirin (80-100 mg) is recommended; when Warfarin therapy is initiated, the doses for patients aged <70 years is 4 mg, and for patients aged >70 years it is 3 mg. While it is important to recognize that the therapeutic range for Warfarin is narrow, recommendations have also been established to manage patients with high INRs and for the temporary discontinuation of anticoagulant therapy when they undergo surgical procedures. Rapid anticoagulation can be achieved either with unfractionated heparin or with low-molecular weight heparin (LMWH). Heparin is initiated with an intravenous bolus of 80 U/kg bodyweight, and an infusion of 18 U/kg/h. The activated thromboplastin time should be 60-80 s. An alternative to intravenous heparin is subcutaneous LMWH, which is prescribed in a mg/kg dose. In the event of valve thrombosis in patients who are hemodynamically unstable, surgical exploration with thrombectomy is indicated, with or without valve replacement. In patients who are hemodynamically stable, thrombolytic therapy is recommended initially.
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PMID:Anticoagulation management of valve replacement patients. 1184 22

Electroconvulsive therapy (ECT) is an effective and safe treatment for depression. Anticoagulation therapy is used to reduce morbidity or mortality from stroke or recurrent pulmonary embolus in various cardiac and vascular conditions. We report in detail the successful ECT treatment of a patient suffering from major depression with psychotic features who continued warfarin (Coumadin) anticoagulant therapy.
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PMID:ECT and Anticoagulation. 1194 Sep 20

An elderly lady developed an epidural hematoma following combined spinal-epidural anesthesia with a local anesthetic-opioid mixture for a vaginal hysterectomy. This occurred in association with the use of prophylactic subcutaneously administered unfractionated heparin. She had diabetes, hypertension and had previously undergone coronary artery bypass surgery and right carotid endarterectomy. Warfarin and aspirin were discontinued 2 weeks before the surgery. Postoperatively, an atypical presentation of backache, bilateral sensory loss and left lower limb monoplegia ensued. The initial clinical impression was of a cerebrovascular accident. Magnetic resonance imaging, however, revealed an extensive epidural hematoma that necessitated decompression laminectomy. Progression to paraparesis occurred but the patient gradually regained much of her functionality over the next 2 years.
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PMID:Postoperative epidural hematoma or cerebrovascular accident? A dilemma in differential diagnosis. 1194 75

The role of anticoagulation in the secondary prevention of noncardioembolic stroke has long been an area of debate. Previous evidence has shown that anticoagulation is unsafe at an International Normalized Ratio between 3.0 and 4.5. Results of the recently published Warfarin-Aspirin Recurrent Stroke Study (WARSS) suggest that there is no difference between warfarin and aspirin in the prevention of recurrent ischemic stroke or death or in the rate of major hemorrhage. Differences in the therapeutic interventions used may have had an effect on the differences in endpoints achieved as compared with previous studies. Results of ongoing trials are anticipated to further clarify the role of anticoagulation in the secondary prevention of stroke.
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PMID:Warfarin versus aspirin in the secondary prevention of stroke: the WARSS study. 1205 84


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