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Management and dosing of warfarin therapy

AMERICAN JOURNAL OF MEDICINE 2000年第6期109卷 481-488页

作者： Gage, BF Fihn, SD White, RH Washington Univ Sch Med Div Gen Med Sci St Louis MO 63110 USA Univ Washington Div Gen Internal Med Seattle WA 98195 USA VA Puget Sound Hlth Care Syst Seattle WA USA Univ Calif Davis Div Gen Med Sacramento CA 95817 USA

When initiating warfarin therapy, clinicians should avoid loading doses-that can raise the International Normalized Ratio (INR) excessively;instead, warfarin should be initiated with a 5-mg dose (or 2 to 4 mg in the very elderly). With a 5-mg initial dose, the INR will not rise appreciably in the first 24 hours, except in rare patients who will ultimately require a very small daily dose (0.5 to 2.0 mg). Adjusting a steady-slate warfarin dose depends on the measured INR values and clinical factors: the dose does not need to be adjusted for a single INR that is slightly out of range, and most changes should alter the total weekly dose by 5% to 20%. The INR should be monitored frequently (eg, 2 to 4 times per week) immediately after initiation of warfarin;subsequently, the interval between INR tests can be lengthened gradually (up to a maximum of 4 to 6 weeks) in patients with Stable INR values. Patients who have an elevated INR will need more frequent testing and may also require vitamin K1. For example, a nonbleeding patient with an INR of 9 can be given low-dose vitamin K1 (eg, 2.5 mg phytonadione, by mouth). Patients who have an excessive INR with clinically important bleeding require clotting factors leg, fresh-frozen plasma) as well as vitamin K1. Am J Med. 2000;109:481-488. (C) 2000 by Excerpta Medica, Inc.

关键词：用药计划表药物监测出血/化学诱导出血/预防和控制国际标准化比监测便携式华法林/投药和剂量华法林/血液华法林/药理学人类

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Comparison of the efficacy and safely of aspirin alone with coumadin plus aspirin after provisional coronary stenting:: Final and follow-up results of a randomised study

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AMERICAN HEART JOURNAL 1999年第4期138卷 663-669页

作者： Machraoui, A Germing, A von Dryander, S Lange, S Jäger, D Lemke, B Barmeyer, J Dept Cardiol Bochum Germany Ruhr Univ Bochum Inst Med Informat Biometry & Epidemiol D-4630 Bochum Germany

Background The antithrombotic benefit of the conventional treatment with coumadin after coronary stenting is limited by bleeding complications. However, the superiority of an antiplatelet therapy with aspirin alone compared with coumadin plus aspirin has not been proven by randomized studies. The efficacy and safety of treatment with aspirin alone in comparison to coumadin plus aspirin were evaluated in this randomized study. Methods out of 164 patients aged 59.7 +/- 9.2 years, 79 patients were randomly assigned to receive 100 mg aspirin daily (group A) and 85 patients randomly assigned to coumadin plus aspirin (group CA) after provisional coronary stenting with a high-pressure technique. The primary end point was defined as the absence of death, subacute closure of the target vessel, myocardial infarction, urgent coronary bypass surgery, repeated coronary angioplasty, and peripheral vascular complications requiring transfusion or surgery. High-pressure inflation technique was used, but ultrasound guidance was not. Results During hospitalization (median 8 days), 135 patients (82.3%) were free of events (A, 84.8%;CA, 80.8%;P = .42). Eleven (6.7%) subacute closures occurred (A, 10.1%;CA, 3.5%;P = .09);2 of them were lethal in the aspirin group. Emergency bypass surgery was performed in patient in each group. peripheral vascular complications were observed in 13 patients (7.9%) (A, 1.3%;CA, 14.1%;P < .01). At 3-month follow-up, 15 (9.1%) elective revascularization procedures (A, 7.6%;CA, 10.6%;P = .51) were performed. Conclusion Aspirin a one at the low dose of 100 mg administered or the combination of coumadin and aspirin after high-pressure coronary stenting does not prevent adverse clinical events when ultrasound guidance is not used.

关键词：血管成形术经腔经皮冠状动脉抗凝药/投药和剂量抗凝药/治疗应用阿司匹林/投药和剂量阿司匹林/治疗应用冠状血管造影术冠心病/外科学冠心病/治疗冠状动脉血栓形成/预防和控制药物疗法联合随访研究血小板聚集抑制剂/投药和剂量血小板聚集抑制剂/治疗应用安全超声检查介入性华法林/投药和剂量华法林/治疗应用女(雌)性人类男(雄)性中年人

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Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第6期33卷 1637-1641页

作者： Vitale, N De Feo, M De Santo, LS Pollice, A Tedesco, N Cotrufo, M Second Univ Naples Monaldi Hosp Sch Med Dept Cardiac Surg Naples Italy Univ Bari Dept Stat Sci Bari Italy

OBJECTIVES The purpose of this study was to assess the incidence of warfarin fetal complications and whether they are dose-dependent. BACKGROUND Gravid patients with mechanical heart valves require long-term anticoagulant therapy. Controversy exists concerning the appropriate treatment of these patients. METHODS Forty-three women on warfarin carrying out 58 pregnancies were studied. For each patient with full-term pregnancy a caesarian section was scheduled for the 38th week during brief warfarin discontinuation. Maternal and fetal complications were evaluated. Fetal complications were divided according to the warfarin dosage less than or equal to 5 mg and >5 mg necessary to keep an international normalized ratio (INR) of 2.5 to 3.5, and analyzed subsequently. RESULTS A total of 58 pregnancies were observed: 31 healthy babies (30 full term, 1 premature) and 27 fetal complications (22 spontaneous abortions, 2 warfarin embryopathies, 1 stillbirth, 1 ventricular septal defect, 1 growth retardation) were recorded. Two maternal valve thromboses occurred. No fetal or maternal bleeding was observed during caesarian sections or premature vaginal delivery. Patients whose warfarin doses during pregnancy were >5 mg had 22 fetal complications, whereas those taking a dose less than or equal to 5 mg had only five fetal complications (p = 0.0001). For an increase of the warfarin dose there was a substantially increased probability of fetal complications (p < 0.0001;rho < 0.7316). CONCLUSIONS There is a dose dependency between warfarin dosage and fetal complications. Patients on warfarin anticoagulation may be delivered by planned caesarian section at the 38th week while briefly interrupting anticoagulation. (C) 1999 by the American College of Cardiology.

关键词：畸形药物性/病因学抗凝药/投药和剂量抗凝药/副作用剖宫产术剂量效应关系药物死胎/病因学心脏瓣膜假体植入国际标准化比妊娠并发症心血管/药物疗法假体失效血栓形成/药物疗法华法林/投药和剂量华法林/副作用女(雌)性人类婴儿新生男(雄)性妊娠

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Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations

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BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY 2000年第2期38卷 124-126页

作者： Webster, K Wilde, J Selly Oak Hosp Univ Hosp Birmingham NHS Trust Dept Oral & Maxillofacial Surg Birmingham B29 6JD W Midlands England

There is wide variation in the management of patients with mechanical prosthetic valves who are taking anticoagulants and who require non-cardiac surgery. In this paper, we outline a pragmatic, practical approach to the adjustment of anticoagulation in relation to both the degrees of surgical trauma during oral and maxillofacial surgery and the risk of thromboembolism associated with the prosthetic valve. For minor surgery, no adjustment of anticoagulation is undertaken if the International Normalized Ratio is less than 4.0, if local haemostatic methods and tranexamic acid mouthwashes are used. For major surgery, warfarin is stopped preoperatively and low-molecular-weight heparin is used. For emergency surgery, partial reversal of anticoagulation with low-dose parenteral vitamin K is obtained.

关键词：投药口服抗凝药/投药和剂量抗凝药/治疗应用抗纤维蛋白溶解药/投药和剂量抗纤维蛋白溶解药/治疗应用心脏瓣膜人工出血/预防和控制止血手术止血技术肝素低分子量/治疗应用国际标准化比漱口药/治疗应用口腔外科手术危险因素外科手术小血栓栓塞/预防和控制氨甲环酸/投药和剂量氨甲环酸/治疗应用维生素K/投药和剂量维生素K/治疗应用华法林/投药和剂量华法林/治疗应用人类

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Seven cases of interaction between warfarin and cyclooxygenase-2 inhibitors

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AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY 2001年第21期58卷 2076-2080页

作者： Stading, JA Skrabal, MZ Faulkner, MA Creighton Univ Sch Pharm & Allied Hlth Profess Dept Pharm Practice Omaha NE 68178 USA

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Exaggerated initial response to warfarin following heart valve replacement

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第8期84卷 905-908页

作者： Ageno, W Turpie, AGG Hamilton Hlth Sci Corp Gen Div Hamilton ON L8L 2X2 Canada

The response to initiation of oral anticoagulants at a usual dose of 5 mg of warfarin has been retrospectively evaluated in patients following heart valve replacement (HVR), Patients starting oral anticoagulants after HVR have a lower target International Normalized Ratio (INR) (1.5 to 2.6) until the pacing wires are removed after operation. The mean daily doses and INR responses after HVR and nonsurgical patients were retrospectively compared during the first 5 days of warfarin treatment. In a subset from both groups, the mean dose of warfarin was correlated with age, body weight, and albumin levels. Eighty-four HVR and 32 nonsurgical patients were studied. The mean daily warfarin dosage was 3.29 +/- 1.29 mg after HVR and 4.96 +/- 1.76 mg in controls (p <0.001), and the mean INRs 2.08 +/- 0.60 and 1.60 +/- 0.54, respectively (p <0.001), Of the HVR patients and controls, 48.8% and 21.8%, respectively, exceeded the upper level of the targeted range (p = 0.014), 86.9% and 40.6% had the dose reduced after the first 5 mg (p <0.001), and 54.7% and 28.1%, respectively, had warfarin withheld for at least 1 day(p = 0.015). Thirty-nine patients were included in the subset analysis. Patients with serum albumin levels <35 g/L required significantly less warfarin (3.84 mg/day) than patients with levels greater than or equal to 35 g/L (5.37 mg/day;p <0.05). Thus, patients starting oral anticoagulation after HVR are significantly more sensitive to warfarin than nonsurgical patients, Patients with serum albumin levels below the normal values require less warfarin than patients with normal values during the initial phase of treatment, (C) 1999 by Excerpta Medica, Inc.

关键词：抗凝药/投药和剂量抗凝药/治疗应用病例对照研究卡方分布剂量效应关系药物心脏瓣膜假体植入国际标准化比回顾性研究血清白蛋白/代谢华法林/投药和剂量华法林/治疗应用老年人女(雌)性人类男(雄)性中年人

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Update on coagulopathies

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ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY ORAL RADIOLOGY AND ENDODONTICS 2000年第5期90卷 559-563页

作者： Schardt-Sacco, D Hill, C Univ N Carolina Dept Oral & Maxillofacial Surg Chapel Hill NC 27599 USA

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 90l559-63)

关键词：抗凝药/投药和剂量抗凝药/治疗应用血液凝固障碍/药物疗法血液凝固障碍/病因学血液凝固障碍/遗传学慢性病患者口腔医疗基因疗法血友病A/遗传学血友病A/治疗国际标准化比自我遵嘱服药华法林/投药和剂量 vonWillebrand病/病因学 vonWillebrand病/遗传学人类男(雄)性

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Evaluation of an alternative model of anticoagulant care

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IRISH JOURNAL OF MEDICAL SCIENCE 2000年第1期169卷 34-36页

作者： Hennessy, BJ Vyas, M Duncan, B Allard, SA Northwick Pk Hosp Dept Haematol Harrow HA1 3UJ Middx England

Background Alternative models for the delivery of anticoagulant care are required in view of an estimated increase of 20% per annum in patients requiring treatment, and an inability for the present service to deal with this increase. This led to a restructuring of the anticoagulant service, which included the appointment of a nurse specialist and the implementation of a computer-assisted warfarin dosing system. Aim To assess the impact of changes in the delivery of anticoagulant care in one unit. Methods A previous consultant-led delivery service of anticoagulant care was compared with the current nurse-led service. Two six month periods was compared. The end points of the study were INR control, appointment intervals and clinic size. A patient questionnaire was completed to assess patient satisfaction and education. Results In two years, attendance at walk-in clinics increased by 43% but the number attending anticoagulant clinics decreased by 50%. There was a parallel increase in the number of patients presenting on a flexible 'walk-in' basis for phlebotomy with postal dosing with 76% of patients now being managed on a flexible postal system. Anticoagulant control and reattendance intervals compare favourably, the percentage of patients attending at the maximal reattendance interval of eight weeks has increased from 3% to 15%. Patient knowledge and satisfaction scores were high on the questionnaire. Financially, this model of care is more cost effective than employing further doctors. Conclusion The introduction of a nurse specialist managed service has allowed us to accommodate a 21% annual increase in patient numbers while improving the overall quality, efficiency and cost-effectiveness of the service and patient care.

关键词：抗凝药/投药和剂量英格兰评价研究(主题) 医院改组给药系统医院/组织和管理模型组织管理护士门诊部医院/组织和管理华法林/投药和剂量老年人人类中年人

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Rectal administration of warfarin

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AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY 1999年第20期56卷 2140-2141页

作者： Shepherd, MF Abbott NW Hosp Dept Med Educ Minneapolis MN 55407 USA Abbott NW Hosp Dept Pharm Minneapolis MN 55407 USA

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Transcranial Doppler evaluation of microembolism immediately after direct-current cardioversion for atrial fibrillation in anticoagulated patients

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第8期84卷 937-938页

作者： Kay, R Chung, HK Wong, KS Li, HA Wong, A Woo, KS Sanderson, J Chinese Univ Hong Kong Dept Med & Therapeut Div Neurol Hong Kong Peoples R China Chinese Univ Hong Kong Dept Med & Therapeut Div Cardiol Hong Kong Peoples R China

Transcranial Doppler monitoring showed no evidence of microemboli for 10 minutes after direct-current cardioversion for atrial fibrillation.

关键词：抗凝药/投药和剂量心房颤动/治疗颅内栓塞和血栓形成/病因学颅内栓塞和血栓形成/超声检查超声检查多普勒经颅华法林/投药和剂量成年人老年人女(雌)性人类男(雄)性中年人

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