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5

A man with rust coloured urine and normocytic anaemia

A 65 year old man presented to the emergency department with a 10 day history of dark urine, general malaise, and progressive shortness of breath. He had a history of rheumatic heart disease and had been on warfarin since he had a metallic mitral valve replacement in 1984. He was a retired teacher, drank a minimal amount of alcohol, and was a non-smoker. He had no family history of cancer.  
feeds.bmj.com
about 5 years ago
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Meta-analysis should not be subject to selectivity and imbalance

The final study sample of 46 163 patients included 4907 using dabigatran, 1649 using rivaroxaban, and 39 607 using warfarin. After adjustment for potentially confounding covariates, there was no …  
feeds.bmj.com
about 5 years ago
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Patients can self monitor oral anticoagulation, study shows

The study, reported in the British Journal of General Practice, included 296 patients requiring oral anticoagulation who had bought a device to self monitor their international normalised ratio (INR). Most patients (97%) had warfarin prescribed, and this was for a range of conditions including thrombosis (35.8%), having a mechanical heart valve (32.8%), atrial fibrillation (23.0%), and …  
feeds.bmj.com
about 5 years ago
Www.bmj
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Patients can self monitor oral anticoagulation, study shows

The study, reported in the British Journal of General Practice, included 296 patients requiring oral anticoagulation who had bought a device to self monitor their international normalised ratio (INR). Most patients (97%) had warfarin prescribed, and this was for a range of conditions including thrombosis (35.8%), having a mechanical heart valve (32.8%), atrial fibrillation (23.0%), and …  
feeds.bmj.com
about 5 years ago
Www.bmj
0
15

Peri-procedural management of patients taking oral anticoagulants

The use of oral anticoagulants is becoming increasingly common. For many years warfarin was the main oral anticoagulant available, but therapeutic options have expanded with the introduction of oral direct thrombin (dabigatran) and factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban). Management of patients taking any oral anticoagulant in the peri-procedural period poses a challenge to medical and surgical providers because of the competing risks of thrombosis and hemorrhage. Bridging therapy has been used to minimize time without anticoagulation when warfarin is interrupted for invasive procedures, but validated strategies based on high quality data are lacking. Existing data suggest that the use of bridging therapy may increase the risk of bleeding for some patients without reducing the risk of thrombosis. Clinical trials are currently under way to answer these questions. Because the half lives and time to anticoagulant activity of newer oral anticoagulants are shorter than for warfarin, bridging therapy is not thought to be necessary with these agents. Peri-procedural management of patients taking these agents is complicated by the lack of demonstrated reversal agents in emergency situations, although specific antidotes are being developed and tested. Existing guidelines for peri-procedural management of patients on oral anticoagulants highlight the importance of individualized patient decision making and suggest strategies to minimize complications. From a patient’s perspective, given the uncertainties surrounding optimal management, explicit discussions regarding risks and benefits of treatment options and demonstration of effective communication among medical and surgical providers are essential.  
feeds.bmj.com
almost 5 years ago
Www.bmj
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9

Peri-procedural management of patients taking oral anticoagulants

The use of oral anticoagulants is becoming increasingly common. For many years warfarin was the main oral anticoagulant available, but therapeutic options have expanded with the introduction of oral direct thrombin (dabigatran) and factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban). Management of patients taking any oral anticoagulant in the peri-procedural period poses a challenge to medical and surgical providers because of the competing risks of thrombosis and hemorrhage. Bridging therapy has been used to minimize time without anticoagulation when warfarin is interrupted for invasive procedures, but validated strategies based on high quality data are lacking. Existing data suggest that the use of bridging therapy may increase the risk of bleeding for some patients without reducing the risk of thrombosis. Clinical trials are currently under way to answer these questions. Because the half lives and time to anticoagulant activity of newer oral anticoagulants are shorter than for warfarin, bridging therapy is not thought to be necessary with these agents. Peri-procedural management of patients taking these agents is complicated by the lack of demonstrated reversal agents in emergency situations, although specific antidotes are being developed and tested. Existing guidelines for peri-procedural management of patients on oral anticoagulants highlight the importance of individualized patient decision making and suggest strategies to minimize complications. From a patient’s perspective, given the uncertainties surrounding optimal management, explicit discussions regarding risks and benefits of treatment options and demonstration of effective communication among medical and surgical providers are essential.  
feeds.bmj.com
almost 5 years ago
Www.bmj
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7

Sudden onset double vision

An 83 year old woman was admitted to the acute stroke unit with sudden onset double vision that had lasted for three hours. She had a medical history of monoclonal gammopathy of uncertain significance and atrial fibrillation, for which she was not receiving anticoagulation because of an adverse reaction to warfarin. She had no history of transient ischaemic attack or stroke. She had diplopia only when looking through her right. On examination she was unable to adduct her left eye, with nystagmus in her right eye when she attempted to do this. Her neurological examination was otherwise normal. Computed tomography of the head on admission was normal, as was magnetic resonance imaging of the head, which was requested the next day. Figure 1⇓ shows T2 weighted (A) and diffusion weighted (B) sequences at the level of the upper pons.  
feeds.bmj.com
almost 5 years ago
Www.bmj
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18

Retrospective cohort studies: advantages and disadvantages

Researchers investigated whether differences exist between the sexes in the risk of ischaemic stroke in patients with atrial fibrillation.1 A nationwide retrospective cohort study design was used. Data were taken from the Swedish national discharge register. Participants were 100 802 patients with a first diagnosis of atrial fibrillation between 1 July 2005 and 31 December 2008, with a total follow-up of 139 504 years at risk (median 1.2). Information about drug treatment was taken from the Swedish drug register. Patients were excluded if at baseline they were prescribed warfarin, had mitral stenosis, or had previous valvular surgery. Patients who died less than 14 days from baseline were also excluded.  
feeds.bmj.com
almost 5 years ago
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Real world effectiveness of warfarin among ischemic stroke patients with atrial fibrillation: observational analysis from Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) study

Objective To examine the association between warfarin treatment and longitudinal outcomes after ischemic stroke in patients with atrial fibrillation in community practice.  
feeds.bmj.com
almost 5 years ago
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Drug interactions with warfarin: what clinicians need to know

Remaining vigilant for interactions between medications is a formidable challenge for several reasons. The science of drug interactions is dauntingly complex and constantly evolving, the patient's medication list is often a moving target with prescription and nonprescription elements, and dozens of new drugs arrive at our pharmacies each year, often with incompletely characterized drug interaction profiles.  
cmaj.ca
almost 5 years ago
Healio safe image
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Triple therapy has similar outcomes, more bleeding than dual therapy in older patients

Older patients with atrial fibrillation who received triple therapy consisting of aspirin, clopidogrel and warfarin at discharge after PCI for acute MI had a similar risk for major adverse cardiac events at 2 years, but higher rates of major bleeding compared with patients who received aspirin and clopidogrel only. Researchers analyzed 4,959 patients aged 65 years or older from the Acute  
healio.com
almost 5 years ago
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Dancing with the Devil: Taking Dabigatran to the OR - R.E.B.E.L. EM - Emergency Medicine Blog

If you are like me, you are seeing more and more patients on Dabigatran. This drug is touted to be superior to traditional warfarin for reduction of stroke in Afib patients and has had a lot of momentum by many other studies.  
rebelem.com
almost 5 years ago
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Risk of Adverse GI Effects of Dabigatran vs Warfarin in AF

Which agent has greater GI bleeding risk among patients with atrial fibrillation?  
medscape.com
almost 5 years ago
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Nil nocere: do no harm reversing warfarin! - St.Emlyn's

reversing warfarin . risks in the emergency department. head injury critical appraisal  
feedproxy.google.com
almost 5 years ago
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Nil nocere: do no harm reversing warfarin! - St.Emlyn's

reversing warfarin . risks in the emergency department. head injury critical appraisal  
stemlynsblog.org
almost 5 years ago
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Edoxaban vs Warfarin in Patients With AF on Amiodarone

What's the effect of amiodarone on the relative efficacy and safety profile of edoxaban?  
medscape.com
over 4 years ago
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Pharmacogenomic Testing and Warfarin Management

Learn how advances in pharmacogenomic research can improve anticoagulant management.  
medscape.com
over 4 years ago
Ht 120306 watchman laa closure device 800x600.
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Amid Class 2 Watchman Recall, CMS Proposes Limits on Coverage

While the CMS proposes reimbursement only for afib patients not on warfarin, the FDA warns of blood-leakage risks if the device's hemostasis valve is "tightened with the dilator in place."  
medscape.com
over 4 years ago
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Effect of Body Weight on Dose of Vitamin K Antagonists

Should body weight be taken into consideration when prescribing warfarin, especially in obese patients?  
medscape.com
over 4 years ago