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Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.
SUMMARIES FOR PATIENTS
A Program To Prevent Bleeding Complications in Older Patients Taking Warfarin
7 November 2000 | Volume 133 Issue 9 | Page S-7
Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician.
The summary below is from the full report titled "A Multicomponent Intervention To Prevent Major Bleeding Complications in Older Patients Receiving Warfarin. A Randomized, Controlled Trial." It is in the 7 November 2000 issue of Annals of Internal Medicine (volume 133, pages 687-695). The authors are RJ Beyth, L Quinn, and CS Landefeld.
What is the problem and what is known about it so far?
Warfarin (sold under the brand name Coumadin) is a medicine that interferes with blood clotting. Warfarin can prevent some conditions that result from blood clots, such as stroke, pulmonary emboli (blood clots in the lung), and deep venous thrombosis (blood clots in the legs). People taking warfarin need careful monitoring with blood tests to be sure that the dose being given reduces the blood's ability to clot enough to prevent clots from forming, but not so much that bleeding occurs spontaneously. Serious bleeding (for example, into the digestive tract or into the brain) can occur when warfarin levels are too high. Many doctors' practices and hospitals have set up special programs to monitor patients taking warfarin, but little is known about how well these programs work.
Why did the researchers do this particular study?
To see whether a special program for patients taking warfarin decreased warfarin-related bleeding complications.
Who was studied?
325 patients 65 years of age or older who started warfarin therapy during a hospitalization at a teaching hospital in Cleveland, Ohio.
How was the study done?
The researchers assigned patients at random to either the special warfarin program or to usual care by their personal physicians. The program included patient education about warfarin, training to increase patients' participation in monitoring (including use of a home blood test), and warfarin dose adjustments by the researchers according to guidelines. The researchers then followed patients to see who developed bleeding complications and how often a patient's warfarin levels were in the appropriate range over the next 6 months. They also collected information about death and any new episode of a condition associated with blood clots.
What did the researchers find?
After 6 months of taking warfarin, 12% of patients in the usual care group experienced a bleeding complication compared with only 6% in the special program. Patients in the special program had warfarin levels in the appropriate range more often than did patients in the usual care group. There was no difference between the groups in death or new episodes of a condition associated with blood clots.
What were the limitations of the study?
The study was done at a single hospital, and its results might not apply in other settings. In addition, it cannot tell us whether the costs of the special program are worth the observed benefits.
What are the implications of the study?
A special program for warfarin management that includes patient education, patient participation, home blood testing by patients, and warfarin dosing according to guidelines can decrease the frequency of bleeding complications in patients 65 years of age or older who take warfarin.
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G. Ruiz-Irastorza, M. A. Khamashta, B. J. Hunt, A. Escudero, M. J. Cuadrado, and G. R. V. Hughes Bleeding and Recurrent Thrombosis in Definite Antiphospholipid Syndrome: Analysis of a Series of 66 Patients Treated With Oral Anticoagulation to a Target International Normalized Ratio of 3.5 Arch Intern Med, May 27, 2002; 162(10): 1164 - 1169. [Abstract] [Full Text] [PDF]
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V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology Circulation, October 23, 2001; 104(17): 2118 - 2150. [Full Text] [PDF]
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 Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology Eur. Heart J., October 2, 2001; 22(20): 1852 - 1923. [PDF]
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A. C. Spyropoulos Prevention of Bleeding in Older Patients Taking Warfarin Ann Intern Med, October 2, 2001; 135(7): 548 - 548. [Full Text] [PDF]
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S. Kajubi Prevention of Bleeding in Older Patients Taking Warfarin Ann Intern Med, October 2, 2001; 135(7): 548 - 549. [Full Text] [PDF]
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Other Articles Noted Evid. Based Nurs., October 1, 2001; 4(4): E1 - 11. [Full Text] [PDF]
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V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary: A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1231 - 1265. [Full Text] [PDF]
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V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1266 - 1266. [Full Text] [PDF]
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J. V.L. Sheffield and E. B. Larson Update in General Internal Medicine Ann Intern Med, August 21, 2001; 135(4): 269 - 278. [Full Text] [PDF]
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 B. Bartle Multicomponent comprehensive care was as effective as usual care for decreasing major bleeding in older patients on warfarin Evid. Based Med., July 1, 2001; 6(4): 116 - 116. [Full Text] [PDF]
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 M. Laposata Point-of-Care Coagulation Testing: Stepping Gently Forward Clin. Chem., May 1, 2001; 47(5): 801 - 802. [Full Text] [PDF]
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 Prevention of Major Bleeding in Elderly Patients on Warfarin Journal Watch Cardiology, February 2, 2001; 2001(202): 4 - 4. [Full Text]
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