P6285Predictors of major bleeding in patients aged 90 years or over with atrial fibrillation on anticoagulant treatment
Michela GiustozziMaria Cristina VedovatiMelina VersoSerenella ContiPaolo VerdecchiaGiulio BogliariLucia PierpaoliGiancarlo AgnelliCecilia Becattini
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Anticoagulant Therapy
Major bleeding
AbstractThe frequency of anticoagulant-related bleeding has been reported to range 1 – 7% per year, depending on the indication for anticoagulant therapy and the classification of bleeding. Although most bleeding is not life threatening, it does cause short-term morbidity and inconvenience to patients, as well as possibly diminishing their quality of life to some degree. Assessing the risk of anticoagulant-related bleeding is integral to optimising the management of anticoagulant therapy. Furthermore, early recognition and treatment of anticoagulant-related bleeding can reduce the associated morbidity. This article reviews the definitions of major and minor bleeding, the assessment of risk and preventive strategies and the management of anticoagulant-related bleeding.Keywordsanticoagulant therapybleedingmanagementrisk factors
Oral anticoagulant
Anticoagulant Therapy
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Source Citation Stroke Prevention in Atrial Fibrillation Investigators. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet. 1996 Sep 7;348:633-8.
Stroke
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Warfarin is the most commonly used oral anticoagulant in the UK. It is associated with few side effects apart from haemorrhage. The most appropriate way to reverse the anticoagulant effect of warfarin depends on the clinical circumstances. In serious bleeding, rapid reversal is required, whereas in minor bleeding or asymptomatic over anticoagulation, a more leisurely approach is usually appropriate. This review discusses the current approaches to warfarin reversal in clinical practice. The development of a uniform approach to warfarin reversal in the Northern Region is described.
Oral anticoagulant
Major bleeding
Clinical Practice
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The validity of a previously described technique for predicting warfarin requirements based on the anticoagulant response to a fixed loading dose was assessed prospectively in 57 patients. There was a close relationship between the predicted and initially observed daily warfarin dose required to maintain the patient within the therapeutic range for anticoagulation. The significant relationship between predicted and observed maintenance dose persisted at 4 and 12 weeks although it decreased with increasing time. The relationship between observed and predicted maintenance requirement of warfarin was not affected by the concomitant use of intermittent intravenous injections of heparin when 9 hr was allowed to elapse between the previous dose of heparin and the thrombotest estimation on which the prediction was based. It is concluded that the method is valuable in predicting an individual's warfarin requirement, although it does not obviate the need for regular monitoring of anticoagulant control.
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Aim Warfarin is a cornerstone for the prevention of thromboembolism in atrial fibrillation (AF), and several efforts have been taken to increase its usage and safety, including risk stratification schemes. Our aim was to investigate the temporal trends in initiation of warfarin and its effects on incidence of bleeding and thromboembolism in patients with new-onset atrial fibrillation 1996–2011. Methods All patients with a first-time diagnosis of non-valvular atrial fibrillation were identified from nationwide administrative registries. Trends were determined by linear regression. Results In total 153,682 patients were included. Initiation of warfarin increased from 14% to 41% (p<0.0001). Events of thromboembolism decreased from 3.9% to 2.6% annually (p<0.0001). The greatest decline in thromboembolic events was observed for patients with a CHA2DS2VASc score >1, where the annual decline was -0.12% (95%CI: -0.161; -0.084)) for those treated with warfarin and -0.073% (95%CI: -0.116;-0.030)) for those not treated with warfarin. Bleeding increased from 3.3% to 3.9% (p = 0.043). For those with a CHA2DS2VASc score >1 annual bleeding rates increased by 0.095% (95%CI: -0.025; -0.165) in warfarin treated and by 0.056% (95%CI: -0.013; -0.100) in patients not treated with warfarin. Conclusion Warfarin use increased by nearly a 3-fold between 1996 and 2011. During the same period, thromboembolic events declined by a third and bleeding increased by a fifth, suggesting a beneficial effect associated with higher warfarin use. Notably, a small decline in thromboembolic events and increase in bleeding events was observed for the untreated population, suggesting a changing risk profile of AF patients.
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Anticoagulant Therapy
Oral anticoagulant
Major bleeding
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Warfarin is a commonly prescribed anticoagulant medication used for the treatment and prevention of venous and arterial blood clots. This update article about warfarin covers the following: how it works, what it is used for, the potential side effects, when it should be avoided and practical considerations of warfarin therapy.
Anticoagulant drug
Anticoagulant Therapy
Oral anticoagulant
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The objective of this study was to examine and evaluate the frequency of bleeding and serious drug interactions among patients with atrial fibrillation (AF) treated with oral anticoagulant [Warfarin]. A random sample of 59 patients from Al-Watni government hospital in Nablus with a principal or secondary discharge diagnosis of AF was identified. All drug and clinical data were abstracted from the patient's files. We excluded patients who were less than 65 years of age, or left the hospital against medical advice, and those whose AF was transient or could not be confirmed. Of the original 59 AF patients, 19 were cliagnosed who were discharged on Warfarin. The mean age for these patients was 71.7 years. Among the patients discharged on Warfarin, 94.7 % had one or more drug – drug interactions that could lead to increased risk of bleeding. Many patients discharged on Warfarin were having multiple interacting drugs. Patient counseling and follow-up monitoring are essential and should be carried out to minimize the risk of bleeding and other complications. الاهداف: اختبار وتقييم احتمالية الإصابة بالنزيف والتداخلات الدوائية عند المرضى المصابين ب atrial fibrillation ويستخدمون المميعات الدموية (warfarin). طريقة البحث: عينة عشوائية مكونة من 59 مريضا"" تم تشخيصهم ب atrial fibrillation في المستشفى الوطني الحكومي – نابلس. وقد تم استخلاص جميع الأدوية والمعلومات السريرية من ملفات المرضى. كما تم استثناء المرضى الذين تقل اعمارهم عن 65 سنة، أو الذين خرجوا من المستشفى خلافا"" لنصيحة الطبيب، أو اولئك الذين كانو يعانون من حالة atrial fibrillation مؤقتة أو لم يتم تأكيدها. النتائج: لقد توصلت الدراسة إلى أنه من أصل 59 مريضا"" مصاباً atrial fibrillation، هناك 19 مريضا"" تم اخراجهم من المستشفى بوصفة warfarin. وكان معدل أعمار هؤلاء المرضى 71.7 سنة. ومن بين المرضى الذين تم صرف دواء warfarin لهم كان 94.7% لديهم تداخلات دوائية (واحد أو أكثر) من هذه التداهلات قد تؤدي الى خطر النزيف. المناقشة والاستنتاج: عدد كبير من المرضى الذين تم صرف دواء warfarin
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Abstract: For many decades, the vitamin K antagonist warfarin has been the mainstay of treatment for various conditions that require anticoagulation, including atrial fibrillation. Although the efficacy of warfarin in both prevention and treatment of thrombosis has been demonstrated in numerous randomized clinical studies, one of the major concerns that remains is the risk of bleeding. Although the net benefit of warfarin has been demonstrated in large clinical trials, physicians and patients alike are often reluctant to use warfarin because of the bleeding risk. Bleeding in patients on warfarin is generally minor requiring no intervention, but the development of a major bleeding complication is associated with significant morbidity and can even be fatal. Numerous risk factors that increase the probability of having a hemorrhage while on warfarin have been identified, and bleeding risk scores have been developed. Various strategies to reduce bleeding risks have been developed and have become more important, since the use of warfarin and other anticoagulants continues to increase. This paper provides a concise review of bleeding risk factors, while outlining recommendations both physician and patients can incorporate to help reduce the risk of bleeding. Keywords: hemorrhage, warfarin, thrombosis, anticoagulants, dabigatran, vitamin K antagonist
Vitamin K antagonist
Major bleeding
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The relationships between the anticoagulant effect and the concentrations of free and total (sum of free and protein-bound) warfarin in plasma were determined in rats following intravenous administration of single doses of racemic warfarin or S(-)-warfarin. The concentration of total warfarin required to elicit a defined anticoagulant effect varied widely between animals while the concentration of free warfarin showed much less variation. This indicates that the anticoagulant effect of warfarin is a function of its free concentration in plasma.
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