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Media, News & Topics on prevention, diagnosis & treatment of cardiovascular disease
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Blood Thinners: JAMA patient page

Blood Thinners: JAMA patient page | Heart and Vascular Health | Scoop.it

There are 2 types of blood thinners, anticoagulants and antiplatelet drugs. Blood clots can cause problems when they prevent blood from flowing freely, especially to the heart and brain. Sometimes a doctor may not want a patient’s blood to clot as easily and will prescribe a blood thinner.

Seth Bilazarian, MD's insight:

Nice graphic that helps patients understand the differences between antiplatelet & anticoagulant therapy. This is an important source of confusion for patient's who believe that aspirin is an effective therapy for stroke prevention in atrial fibrillation (it is not).  Another potential confusion is why blood thinners or anticoagulants like warfarin or the newer agents (Pradaxa, Xarelto, Eliquis) are not effective treatments after placement of a stent in the coronary artery. Antiplatelet therapies like Plavix, Effient, or Brilinta are needed.

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Deborah Verran's curator insight, May 18, 1:56 AM

This is a good example of the type of reliable factual online information that is available to patients. Some transplant recipients will end up having to take these types of medications (for the appropriate indications). Hence the importance of this particular information.

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Xarelto (rivaroxaban) approved for stroke prevention in atrial fibrillation 2 years ago

Xarelto (rivaroxaban) approved for stroke prevention in atrial fibrillation 2 years ago | Heart and Vascular Health | Scoop.it

#OnThisDay (11/4/2011) two years ago the first Factor Xa inhibitor and second novel oral anticoagulant (NOAC) was approved to prevent stroke in atrial fibrillation.  We now have three NOACs available.

Seth Bilazarian, MD's insight:

There are now three NOACs available as an alternative to warfarin (coumadin) and one on the horizon in 2014.   The uptake in the US has been slow.  Xarelto is the only one of the NOACs that has been approved for other indications such as DVT's (clots in the leg), PE (clots in the lung), or the prevention of these problems after knee and hip surgery. Physician and patient familairity and comfort with these new options is slowly growing.

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Patients underestimate risk of warfarin emergencies

Patients underestimate risk of warfarin emergencies | Heart and Vascular Health | Scoop.it

Long-term users of warfarin (coumadin, a blood thinner) had difficulty recognizing the clinical severity and urgency of anticoagulation-related situations such as stroke symptoms and medication mismanagement.

69% of patients correctly answered questions about warfarin.  More than 50% of respondents correctly identified four of six urgent risk scenarios: acute chest pain (95%), taking the wrong dose of warfarin for a week or more (79%), head trauma (56%), and sudden headache (87%). Just 25% of respondents, however, recognized the urgency of acute unilateral vision loss as a possible sign of stroke and 20% recognized the urgency of a hit or bump on the head for bleeding risk.


Seth Bilazarian, MD's insight:

Warfarin is a complex medication that takes an enormous investment in teaching to be used safely.  All anticoagulants including the newer ones such as Pradaxa, Xarelto, Eliquis can cuase bleeding in the brain which is serious and life threatening.

 

The AHA has a public service program "Give me Five" warning signs of a stroke:

Sudden weakness or numbness of the face, arm or leg, especially on one side of the body
Sudden confusion, trouble speaking or understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden, severe headache with no known cause

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Caution on initial bleeding risk with warfarin

Caution on initial bleeding risk with warfarin | Heart and Vascular Health | Scoop.it

My comment: We have new options for patients with atrial fibrillation.  These new drugs Pradaxa and Xarelto are under scrutiny because they are new nadn bleeding hazard has been reprted.  This study helps us understand that warfarin (coumadin) also has significcant risk and the risk is high in the first week of starting thsi medicine.  This early hazard but be an advatage for the newer options.

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Rates of serious bleeding among patients taking warfarin are much higher than those found in clinical trials of the drug and are even greater during the first month of use, according to a five-year study of 125,195 seniors with atrial fibrillation.

The findings complicate an already difficult decision-making process for patients with atrial fibrillation (AF) and highlight the importance of careful management of warfarin, especially during the first month of use, experts said. Warfarin is a generic anticoagulant that is marketed under brand names such as Coumadin and Jantoven.

Compared with clinical trials for warfarin that found serious hemorrhaging rates of between 1% and 3% per year, bleeding problems are more common in real-life clinical practice, said the study, published Nov. 26 in the Canadian Medical Assn. Journal. In the study, the overall rate of hemorrhaging — bleeds serious enough to send patients to the hospital — was 3.8% per person, per year.

However, during the first month of treatment, the annualized hemorrhage rates were 11.8% in all patients and 16.7% among patients with higher risk of stroke. 

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HAS-BLED Bleeding Risk Score in Atrial Fibrillation treated with Warfarin

HAS-BLED Bleeding Risk Score in Atrial Fibrillation treated with Warfarin | Heart and Vascular Health | Scoop.it

Take Home Message:  In cardiovascular medicine there are several circumstances when it is valuable to give anticoagulant medications (blood thinners). These medicines reduce the chance of clot formation and lower the risk of strokes and heart attacks.  Because it is harder to form clots patient will have a higher risk of bleeding.  In atrial fibrillation, we have good criteria for evaluating the risk of clotting and stroke (CHADS2 and CHADS-VASC) but are in search of a good score to help doctors and patients predict bleeding risk when on the blood thinner coumadin  (warfarin).  The HAS-BLED score http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/ ;  performed best, but not very well in this analysis except for its ability to predict the most serious type of bleeding called intracranial hemmorhage.

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2012 ACCP Guidelines – DVT and PE: Highlights and Summary

2012 ACCP Guidelines – DVT and PE: Highlights and Summary | Heart and Vascular Health | Scoop.it

The 2012 ACCP Guidelines on treatement for DVT and PE is 802 pages long.  What it has in comprehensiveness it lacks in user friendliness.  This highlight & summary document on one page is a great resource.  It highlights changes especially in duration of treatment for Pulmonary embolism (PE) & Deep venous thrombosis (DVT) patients.

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Rethinking Warfarin for Atrial Fibrillation

Rethinking Warfarin for Atrial Fibrillation | Heart and Vascular Health | Scoop.it

Full-page newspaper advertisements and a series of television commercials have urged patients with atrial fibrillation to “rethink warfarin” in favor of Eliquis (apixaban – Bristol-Myers Squibb). Apixaban is the latest of 3 new oral anticoagulants now competing with warfarin (Coumadin, and others) for the oral anticoagulant market.

Seth Bilazarian, MD's insight:

The authors of the medical letter have rightly urged clinicians to consider warfarin as a good alternative in patients who are clinically stable on warfarin and doing well. I certainly agree with this. However it accounts for only a minority of patients. My estimate is that only about 10% of patients have stable warfarin therapy.

For myself, I created mnemonic to try to help me quickly go through the important issues for determining whether a patient was a good candidate for one of the novel oral anticoagulants (Praqdaxa, Xarelto, Eliquis). CRABI is the one I use and the "I"is for instability on warfarin. To viewer download the slides from my blog checkout.

 http://news.theheart.org/static/drop/Private-practive-theheartorg-Dr-Seth-Bilazarian-KISS-CRABI.ppt

 

 

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What to do about bridging with novel oral anticoagulants

What to do about bridging with novel oral anticoagulants | Heart and Vascular Health | Scoop.it

Sharing a rare moment of person-to-person time during the scientific sessions in San Francisco, Dr Seth Bilazarian asks Dr. Samuel Goldhaber how he goes about bridging with "Novel oral anticoagulants" (NOACs) #dabigatran, #rivaroxaban, and #apixaban.

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Eliquis: New Medication for Atrial Fibrillation

An in-depth conversation between Pentucket Medical cardiologists Seth Bilazarian and Sunny Srivastava, focusing on a newly released medicine to reduce the risks of atrial fibrillation. The latest among recently approved blood thinners, Eliquis joins Pradaxa and Xarelto as an alternative to Coumadin, a drug that has been in use since the 1950s. Like Pradaxa and Xarelto, Eliquis has been shown to reduce risk of stroke and bleeding, as well as mortality. All the new drugs eliminate the need for regular blood testing that Coumadin necessitates.

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Warfarin in the Prevention of Stroke Associated with Nonrheumatic Atrial Fibrillation — NEJM

Warfarin in the Prevention of Stroke Associated with Nonrheumatic Atrial Fibrillation — NEJM | Heart and Vascular Health | Scoop.it

20 years ago today the SPINAF trial was published.  This was one of the last studies to compare warfarin to placebo in atrial fibrillation (Afib)  for the prevention of stroke.  For the lsat 20 years warfarin has been the standard of care.  Anticoagulants (blood thinners) prevent stroke in Afib.  After this there were only a few more studues that were done comparing warfarin to placebo or aspirin (SPAF-II in 1994)  because it was felt to not be ethical since the benefits of warfarin are so clear for stroke prevnetion.  

AIn teh US, we've had only warfarin (coumadin) until 2 years ago (10/2010) when the first of the novel oral anticoagulants (NOACs) were introduced.  Pradaxa (dabigatran) and Xarelto (rivaroxaban) are now available in the US.  We expext Eliquis (apixiban) in 2013 with others to follow.

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Anticoagulation in AF: Fork in the road or four-way-stop?

Anticoagulation in AF: Fork in the road or four-way-stop? | Heart and Vascular Health | Scoop.it

The FDA's recent decisions on novel anticoagulants in atrial fibrillation have stirred debate and generated some consternation. For the clinical practitioner, how can we efficiently and effectively communicate the issues related to anticoagulation choice to the patient?  Dr Bilazarian proposes -CRABI:

C - Prescription coverage?
R - Normal renal function?
A - Early adopter?
B - GI bleeding?
I - Instability on warfarin?

Download the powerpoint presentation and the comparative Excel sheet.

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Bridging Anticoagulation

Bridging Anticoagulation | Heart and Vascular Health | Scoop.it

Cardiology Patient Page
Bridging Anticoagulation
Is it Needed When Warfarin Is Interrupted Around the Time of a Surgery or Procedure?

from the  The BRIDGE Study Investigators

 

There are many patients who are receiving long-term treatment with the blood thinner warfarin, whether because of atrial fibrillation (the commonest reason for taking warfarin) or a mechanical heart valve. Such patients frequently require warfarin to be stopped because of an upcoming surgery/procedure. There is uncertainty whether such patients should receive bridging anticoagulation before and after the surgery/ procedure.

 

For patients interested in learning more about this trial happening in Haverhill at PMA see...

 

http://www.pmaonline.com/clinical-trials.htm

 

 

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