Anticoagulation post STEMI: warfarin for wall motion abnormality in the era of triple antithrombotics. Jenelle Rogers VCH-PHC Pharmacy Resident 2009-2010. Outline. Objectives Case Background Clinical Question Review of Literature Recommendations Follow-up Monitoring. Objectives.
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VCH-PHC Pharmacy Resident
O2 97% ORA
-epinephrine 1mg iv given x2
Hypokinesis- decreased systolic inward motion
Akinesis- no systolic inward motion
Dyskinesis- outward systolic bulging
Class I recommendation:
STEMI patients who have a cardiac source of embolism (atrial fibrillation, mural thrombus, or akinetic segment) should receive moderate-intensity (INR 2 to 3) warfarin therapy (in addition to aspirin). The duration of warfarin therapy should be dictated by clinical circumstances (eg, at least 3 months for patients with an LV mural thrombus or akinetic segment and indefinitely in patients with persistent atrial fibrillation). The patient should receive LMWH or UFH until adequately anticoagulated with warfarin. (Level of Evidence: B)
Class IIa recommendation
It is reasonable to prescribe warfarin to post-STEMI patients with LV dysfunction and extensive regional wall-motion abnormalities. (Level of Evidence: A)
Johannessen et al.
Euro Heart Journal. 1987;8:975-80
“The previous ACC/AHA guidelines strongly recommended the use of oral anticoagulants with an INR of 2.0 to 3.0 in patients with a ventricular mural thrombus or large akinetic region of the left ventricle for at least 3 months. Despite a number of small observational studies demonstrating a higher risk of embolic stroke in patients treated with large anterior infarction and a better outcome with warfarin after demonstration of LV mural thombus by echocardiography, randomized controlled trials are not available to support this recommendation.”