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Old 09-21-2011
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Blood Doubt about heparin and warfarin

MTB says that there's no need to give heparin before warfarin in AF if there's no current clot in the atrium.
Well, warfarin has a temporary procoagulant effect (due to its effect on protein C and S) so I thought we should ALWAYS give simultaneously heparin for a couple of days (until INR is in range), most times SC, while starting warfarin.
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Old 09-22-2011
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ya i checked in uworld /kaplan book, they just have mentioned that warfarin is given to prevent embolisation in atrial fribillation maintianing INR of 2- 3 for chads score of 2 or more than 2. If in case it is lone atrial fibrillation, u can simply give aspirin. But they haven't mentioned anything about heparin before warfarin therapy in case of atrial fibrillation as it is prolonged t/t which is otherwise generally given in other types of thromboembolism.
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Old 09-22-2011
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Quote:
Originally Posted by iron View Post
ya i checked in uworld /kaplan book, they just have mentioned that warfarin is given to prevent embolisation in atrial fribillation maintianing INR of 2- 3 for chads score of 2 or more than 2. If in case it is lone atrial fibrillation, u can simply give aspirin. But they haven't mentioned anything about heparin before warfarin therapy in case of atrial fibrillation as it is prolonged t/t which is otherwise generally given in other types of thromboembolism.
I know, that's what I read, too. But it still sounds weird to me.
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Old 10-07-2011
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hey i just came across the same ques on uworld and also needed clarification. When I was on rotations my attending and chief resident both said for new onset of a. fib you give them warfarin without bridging. I verified this on uptodate too.

However seeing how usmle never always coincides with clinical knowledge, i want to know if that answer holds true for Step 2..........especially since uworld mentions "warfarin is typically preceded by heparin"

thanks
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Old 10-07-2011
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Management of A Fib:
Acute & the patient is hemodynamically unstable do cardioversion.
Acute but the patient is hemodynamically stable:
  • Rate control: target pulse between 60 100 bpm. Calcium blockers are preferred, if ventricular dysfunction is present consider digoxin.
  • Conversion to sinus rhythm after rate control is achieved. Electrical (preferred) or chemical.
  • Anticoagulation: if A fib is present for more than 48 Hrs or the period of time is unknown, there is a risk of embolization during cardioversion, to prevent that, you need to anticoagulate 3 weeks before & continue 4 weeks after cardioversion. Of course you are not going to wait, so do TEE to image the Lt atrium, if no thrombus is present, then start IV HEPARIN & perform cardioversion within 24 Hrs.
Chronic A Fib:
  • Rate control
  • Anticoagulation: lone A Fib, under age of 60, do not require anticoagulation, aspirin may be appropriate.
  • All other patients with warfarin. No need to start with heparin.
So the answer to the Q depends on the scenario of the Q.
I hope that help.
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Old 10-07-2011
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Quote:
Originally Posted by ag2011n View Post
Management of A Fib:
Acute & the patient is hemodynamically unstable do cardioversion.
Acute but the patient is hemodynamically stable:
  • Rate control: target pulse between 60 100 bpm. Calcium blockers are preferred, if ventricular dysfunction is present consider digoxin.
  • Conversion to sinus rhythm after rate control is achieved. Electrical (preferred) or chemical.
  • Anticoagulation: if A fib is present for more than 48 Hrs or the period of time is unknown, there is a risk of embolization during cardioversion, to prevent that, you need to anticoagulate 3 weeks before & continue 4 weeks after cardioversion. Of course you are not going to wait, so do TEE to image the Lt atrium, if no thrombus is present, then start IV HEPARIN & perform cardioversion within 24 Hrs.
Chronic A Fib:
  • Rate control
  • Anticoagulation: lone A Fib, under age of 60, do not require anticoagulation, aspirin may be appropriate.
  • All other patients with warfarin. No need to start with heparin.
So the answer to the Q depends on the scenario of the Q.
I hope that help.
yes that does help. thanks!
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