ABSTRACT
Introducción: El tratamiento anticoagulante, pese a conseguir un claro beneficio para prevenir y tratar la patología tromboembólica, presenta dificultades para su manejo en la práctica habitual. Ello debido a la variabilidad individual de dosificación, estrecho margen terapéutico, interacciones farmacológicas y efectos secundarios graves. Los pacientes ingresados en residencias geriátricas presentan cada vez más indicaciones para seguir un tratamiento anticoagulante oral, producto de trombosis venosa profunda y, muy especialmente, fibrilación auricular. Se trata de pacientes con un perfil que dificulta la prescripción del tratamiento anticoagulante: edad avanzada, polimedicación y pluripatologías. Objetivos: nos planteamos la hipótesis de que la implantación desde atención primaria de un programa de seguimiento farmacoterapéutico del tratamiento anticoagulante oral en pacientes ingresados en residencias geriátricas, que coordine a distintos profesionales de diferentes estamentos y niveles asistenciales, ha de mejorar su beneficio y disminuir los efectos secundarios. Métodos: se realiza un estudio descriptivo tipo cohorte prospectiva, de un año de evolución, de 27 pacientes ingresados en residencia geriátrica que realizan tratamiento anticoagulante controlado por el equipo de atención primaria. Se analizan distintas variables obtenidas a partir de la historia clínica informatizada, a partir de las cuales se establecen indicadores sobre el procedimiento del programa (indicadores de cobertura y registro) y otros sobre el resultado (indicadores definidos por el Comité Británico de Estándares en Hematología). Resultados: los resultados muestran que el perfil del paciente ingresado en una residencia geriátrica tratado con anticoagulantes es de edad avanzada (84 años), con predominio de mujeres (70 por ciento), con fibrilación auricular como indicación más frecuente (70,4 por ciento)...
Introduction. Anticoagulant treatment, despite providing a clear benefit to prevent and treat thrombo-embolic disease, is difficult to manage in routine practice. This is due to individual variability of dosing, narrow therapeutic margin, drug interactions, and side effects. An increasing number of patients admitted to nursing homes are under oral anticoagulant therapy because of deep venous thrombosis and, especially, atrial fibrillation. These are patients with a profile that makes prescription of anticoagulant treatment more difficult - elderly, taking multiple concomitant medications and with multiple ailments. Objetive. We hypothesized that the implementation of a primary care pharmacological follow-up program of oral anticoagulant therapy in patients admitted to nursing homes, with the purpose of coordinating the different professionals and care levels, would lead to greater benefit and reduction of side effects. Methods. A one-year descriptive prospective cohort study was conducted of 27 patients admitted to nursing homes who are under anticoagulation therapy followed by the primary care team. We analyzed different variables obtained from computerized medical records, from which indicators on the program were established (coverage and registration) as well as outcome indicators (as defined by the British Committee for Standards in Haematology). Results. The profile of patients under anticoagulation and admitted to nursing homes is elderly (84 years), with a predominance of women (70 percent), atrial fibrillation as most frequent indication (70.4 percent), hypertension as major cardiovascular risk factor (92 percent) and most of them on multiple drugs (92 percent). The analysis of the program results showed excellent coverage and registration indicators (100 percent)...
Subject(s)
Humans , Male , Female , Aged , Aged, 80 and over , Anticoagulants/administration & dosage , Homes for the Aged , Drug Monitoring/methods , Nursing Homes , Primary Health Care , Administration, Oral , Anticoagulants/adverse effects , Cohort Studies , Atrial Fibrillation/drug therapy , Polypharmacy , Risk AssessmentABSTRACT
Oral anticoagulant therapy is generally being used in patient with a high thromboembolic risk such as cerebrovascular or cardiovascular accident, in spite of increased bleeding tendencies and most of them are old-age patients. A stroke frequently leads to a fall, which in turn causes a minor trauma, and it is often reported that anticoagulant therapy for treatment of stroke may aggravate traumatic brain injury. The authors report a case that required surgical treatments for subacute subdural hematoma which was found during antiplatelets and anticoagulant therapy for acute ischemic stroke. The hematoma had not been found at the time of head injury accompanied by a cerebral infarction.
Subject(s)
Humans , Brain Injuries , Cerebral Infarction , Craniocerebral Trauma , Hematoma , Hematoma, Subdural , Hemorrhage , Stroke , WarfarinABSTRACT
Oral anticoagulant therapy is generally being used in patient with a high thromboembolic risk such as cerebrovascular or cardiovascular accident, in spite of increased bleeding tendencies and most of them are old-age patients. A stroke frequently leads to a fall, which in turn causes a minor trauma, and it is often reported that anticoagulant therapy for treatment of stroke may aggravate traumatic brain injury. The authors report a case that required surgical treatments for subacute subdural hematoma which was found during antiplatelets and anticoagulant therapy for acute ischemic stroke. The hematoma had not been found at the time of head injury accompanied by a cerebral infarction.
Subject(s)
Humans , Brain Injuries , Cerebral Infarction , Craniocerebral Trauma , Hematoma , Hematoma, Subdural , Hemorrhage , Stroke , WarfarinABSTRACT
El objetivo de este trabajo fue determinar la efectividad de un rango de la Razón Normalizada Internacional (INR) entre 1,5 y 1,9 en la prevención de la recurrencia de trombosis venosa y de las complicaciones hemorrágicas asociadas al uso de warfarina. Entre enero del 2006 y noviembre del 2009, se estudiaron 39 pacientes, con edades entre 10 y 78 años y diagnóstico de trombosis venosa profunda y/o embolismo pulmonar que recibieron warfarina al menos durante 6 meses. Los sujetos fueron separados aleatoriamente en dos grupos: a 20 pacientes se le ajustó la dosis para mantener el INR entre 1,5 y 1,9 y a 19 pacientes se les mantuvo el INR entre 2 y 3. A cada individuo se le cuantificó la actividad plasmática de los factores II, VII, IX y X a la primera y entre la cuarta y quinta semanas, luego de estabilizado el INR. En ambos grupos, la actividad de los factores se encontró por debajo del valor normal con diferencia significativa entre los grupos (p<0,05). No se detectó recurrencia de trombosis durante el seguimiento. Solo se presentaron manifestaciones hemorrágicas menores en un sujeto con INR entre 1,5 y 1,9 y en cuatro del otro grupo (p = NS). Los resultados del presente trabajo sugieren que un rango de INR entre 1,5 y 1,9, provee un esquema de anticoagulación eficaz para la prevención de recurrencia de trombosis venosa con menor frecuencia de hemorragias. Sin embargo, es necesario seguir incorporando más individuos en el estudio para obtener mayor certeza en el análisis de estos resultados.
The object of this work was to determine the efficacy of a low range International Normalized Ratio (INR) between 1.5 and 1.9, in preventing recurrent venous thrombosis and the hemorrhagic manifestations that can complicate anticoagulation with warfarin. Thirty nine patients, 10 to 78 years of age were studied between January 2006 and November 2009. All of them had been treated with warfarin, for at least 6 months, due to deep venous thrombosis or pulmonary embolism. The subjects were separated, at random, into two groups. In group A (20 patients), the doses of warfarin were adjusted until the INR was stabilized between 1.5 and 1.9; in group B, the INR was maintained between 2 and 3. The coagulant activities of plasma factors II, VII, IX and X were determined in a week and between the fourth and fifth weeks, after stabilization of the INR. Plasma activities of the coagulation factors assayed were abnormally low in both groups, in the two opportunities they were determined, although significantly lower in group B (p<0.05). No thromboembolic episodes occurred during the study, in any of the patients. One of the patients from group A and four from group B, presented minor hemorrhagic manifestations (p N.S.) The above results suggest that a range on INR lower that 2, could be sufficient to prevent recurrent thrombotic episodes while diminishing the frequency of hemorrhagic complications associated with the use of warfarin. However, it is necessary to continue incorporating more individuals in the study to obtain greater certainty in the analysis of these results.
Subject(s)
Adolescent , Adult , Aged , Child , Female , Humans , Male , Middle Aged , Young Adult , Anticoagulants/therapeutic use , International Normalized Ratio , Pulmonary Embolism/drug therapy , Venous Thrombosis/drug therapy , Warfarin/therapeutic use , Anticoagulants/administration & dosage , Anticoagulants/adverse effects , Blood Coagulation Factors/analysis , Dose-Response Relationship, Drug , Drug Monitoring , Hemorrhage/chemically induced , Pulmonary Embolism/blood , Recurrence , Venous Thrombosis/blood , Warfarin/administration & dosage , Warfarin/adverse effectsABSTRACT
BACKGROUND: In order to achieve a maintenance level and to prevent hemorrhagic complications, regular monitoring of the INR is mandatory for patients on oral anticoagulation therapy (OAT). A point-of-care instrument for INR monitoring is convenient for users, but the accuracy of the results has been controversial, and so this calls for exact evaluation of the point-of-care instrument that is used for INR monitoring. METHODS: From Aug 2007 through Feb 2008, 85 patients on OAT among the all the patients who were admitted to Soonchunhyang University Bucheon Hospital were involved in this study. Parallel measurements of the PT INR were performed using a CoaguChek-XS and, a CA-7000 laboratory reference instrument and the results were analyzed. In addition, the patients' clinical data, including the diagnosis and the frequency and interval of the INR measurements, were also analyzed. RESULTS: Of the 85 patients, 25 were admitted more than once to undergo INR testing and the mean interval between testing was 8.6 weeks with 39% and 38% of the tests being less than INR 2 units with using the CoaguChek-XS and the reference method, respectively. The coefficients of variation of CoaguChek-XS were 4.50 and 2.45 for the high and low INR patients, respectively. An excellent correlation was found between the two methods with a R2 of 0.966 (p<0.001). Through Bland-Altman analysis, the mean INR difference between the two methods was 0.13 with the limit of agreement being -0.47 +0.72 with a 95% confidence interval. CoaguChek-XS was shown to overestimate the INR value for patients with an increasing INR, as compared to the reference method. CONCLUSION: CoaguChek-XS demonstrated great precision and accuracy for patients on OAT when compared to the laboratory INR results. Accordingly, the instrument should help to monitor the INR in the patients on OAT.