Diet, age and dose also influence the anticoagulant effect. 6Ī patient’s response to warfarin is driven primarily through genetic variance in the hepatic clearance, and vitamin K handling. It is not the intention to use HAS-BLED scores to exclude warfarin, but to allow the clinician to identify risk factors for bleeding and to correct those that are modifiable. Scores ≥3 indicate a high risk of bleeding, the need for cautious management and regular review of the patient. The HAS-BLED score ( Table 2) 5 has been developed to determine the risk of bleeding. It is better at identifying ‘truly low-risk’ patients with atrial fibrillation, and is now preferred over CHADS 2. The CHA 2DS 2-VASc score ( Table 2), 5 introduced by the European Society of Cardiology, provides a more comprehensive assessment of the risk factors for stroke. 4 Anticoagulation with warfarin is recommended if the CHADS 2 score is ≥2 and should be considered if the score is 1. The CHADS 2 score reliably identifies patients at intermediate and high risk of stroke, but less reliably identifies those truly at low risk. This assigns 1 point each for congestive heart failure, hypertension, age 75 years and older, and diabetes mellitus, and 2 points for previous ischaemic stroke or transient ischaemic attack. In patients with non-valvular atrial fibrillation, the decision to start warfarin should be based on the CHADS 2 score. Recommended to use aspirin in addition, 50–100 mg daily, if low bleeding riskīioprosthetic valves in the mitral position.After initial triple therapy, continue warfarin and a single antiplatelet drug until 12 months after stent placement.Bare-metal stent (1 month) and drug-eluting stent (3–6 months) as triple therapy with clopidogrel and aspirin.Table 1 - Indications, goals and duration of warfarin therapy 1ĭeep vein thrombosis of the leg or pulmonaryģ weeks before scheduled cardioversion and for 4 weeks after successful cardioconversionĪfter stent placement and high risk of stroke Patients must agree to undergo regular blood tests during treatment. The safety and efficacy of warfarin is critically dependent on maintaining the INR within the target range. This includes informing them about the signs and symptoms of bleeding, the impact of diet, potential drug interactions and actions to take if a dose is missed. 3 Educating the patient is essential before they start warfarin. 2 While the risk of falls plays a part in the harm-benefit assessment, published data indicate the propensity to fall is not an important factor in this decision. This assessment should take into account the patient’s medical, social, dietary and drug history, level of education and adherence to previous therapy. The decision to start warfarin therapy requires an assessment of its harms and benefits for each patient. Bleeding, particularly in the setting of over-anticoagulation, is a major concern. 1 Its use is limited by several factors including a narrow therapeutic range, and drug–drug and drug–food interactions. However, as concordance with laboratory INR values decreases with higher INR values, it is recommended that with CoaguChek S INRs in the > 1.5 range, a standard laboratory measurement be used to confirm the results.Warfarin is recommended for the prevention of systemic embolism, stroke associated with atrial fibrillation, and venous thromboembolism ( Table 1). When used by a trained health professional in the emergency department to assess INR in acute ischemic stroke patients, the CoaguChek S is reliable and provides rapid results. In the AIS group alone, the correlation coefficient and 95% CI was also high 0.937 (0.59 - 0.74) and diagnostic accuracy of the POCT device was 94%. The interclass correlation coefficient and 95% confidence interval between overall POCT device and standard laboratory value INRs was high (0.932 (0.69 - 0.78). The INR's were measured using the Roche Coaguchek S and the standard laboratory technique. The objective of this study was to evaluate the reliability, validity, and impact on clinical decision-making of a POCT device for INR testing in the setting of acute ischemic stroke (AIS).Ī total of 150 patients (50 healthy volunteers, 51 anticoagulated patients, 49 AIS patients) were assessed in a tertiary care facility. In the emergency department, portable point-of-care testing (POCT) coagulation devices may facilitate stroke patient care by providing rapid International Normalized Ratio (INR) measurement.
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