a question for the doctors?

Question

A pt was adm with A-fib. no order was written for heparin for 2 days...later coumadin was ordered... but coumadin is long lasting and takes a few days to build up to therapeutic level...we talked to the attending..he said the order was textbook perfect...what if the pt develops some complication such as stroke during hospital stay

I am only asking if heparin should have been ordered prior to coumadin. In another way, is it really textbook perfect skipping heparin for the initial tx or somebody is just trying to cover their butt?

No. Pt had a hx of A fib. She was adm for CP and DIB this time. NSR.

I didn't mean NSR. I mean Not SR.

Answer 1

The simple answer is that he may have reverted to sinus rhythm and not required anticoagulation. I take it this was the first episode of atrial fibrillation? It was reasonable to wait until it was clear that the arryhtmia was going to be chronic. After all you would not anticoagulate a patient who had a transient atrial fibrillation and then reverted to sinus rhythm.

Answer 2

I'm not quite sure i know exactly what you mean. Are you asking what treatments are available if cerebral thrombosis (stroke) occurs during the hospital stay, or are yo confused about the treatment that the person in question is getting?

With any form of thrombosis, there is a chance that part of the thrombosis will break away and become lodged, usually within the small vessels of the lungs (as in pulmonary embolism, AKA pulmonary thrombosis) or very rarely in the blood vessels that supply the brain, this of course causes stroke. There are no treatments available to prevent this from happening though (very rare that it is) if it does cause stroke then the damage to the brain will be determined by both the size of the embolism, and where it becomes lodge, and the swiftness of the medical staff in treating the embolism. I do have to highlight though that stroke is rare, usually due to the constant anticoagulants in the blood (the Warfarin (Coumadin) you mentioned).

Warfarin (Coumadin) is always given after Heparin. Failing to anticoagulate with heparin before starting warfarin causes clot extension and recurrent thromboembolism in approximately 40% of patients compared to 8% of those who receive full-dose heparin before starting warfarin.

Hope This Helped You

The Neurosurgeon

Answer 3

Perhaps the chance of hamful side effects from 2-3 days of heparin is greater than the chance of complication from A-Fib?

maybe the patient can be sent home right away where the attending would be forced to keep an otherwise healthy patient in the hospital if heparin was initiated.

Answer 4

No, A fib is a risk, but a small one, and it's normal not to sweat the first couple of weeks. The bleeding complications from heparin or one of the LMW heparins outweighs the risk of thromboembolic disease in the short term. Even with anticoagulation the difference in embolic disease is small enough that routine anticoagulation was not recommended until fairly recently except in those who were being planned for cardioversion.

Answer 5

There are different strategies for anticoagulation depending on teh patient's risk of stroke. High risk patients DO go on heparin first, followed by coumadin. Medium risk patients are started directly on coumadin. Low risk patients are started on aspirin.

If the patient was at moderate risk, then the therapy was appropriate.

Read this:
http://www.aafp.org/afp/20020715/261.html