Warfarin Therapy in Patients with Cardiac Disease: Review

Yıl 2008, Cilt: 2 Sayı: 2, 342 - 347, 27.07.2008

Murat Akçay

Öz

Although development of treatment and definition of cardiovascular diseases and progresses in operating technique, thromboembolic complications remain a troublesome cause of mortality and morbidity. New agents are being researched, nevertheless warfarine has been used to be an effective agent, but close monotarization and cautious use is necessary due to hemorrhagic complications. Sometimes it is given at indications where it is not supposed to be used or at insufficient dosage resulting at suboptimal therapy. Warfarin inhibits hepatic synthesis of clotting factors II, VI-I, IX, and X, which depend on vitamin K for activation; it also inhibits the anticoagulant proteins C and S. Warfarin is completely absorbed when given orally and produces an anticoagulant effect within 24 hours, but the peak effect may not occur until 3 to 4 days after drug administration. A steady anticoagulation state requires 5 to 7 days because existing clotting factors must be depleted first. Warfarin accumulates in the liver until it’s broken down into inactive metabolites and excreted in urine. Patients who need rapid anticoagulation usually are started on oral warfarin and intravenous heparin concurrently, until the patient’s international normalized ratio (INR) is in the therapeutic range for at least 2 days; the heparin then can be tapered and discontinued. When a patient starts warfarin therapy, he’ll need daily monitoring of his prothrombin time (PT) and INR from after his second or third dose until he reaches the target therapeutic range and stays in that range for at least 2 consecutive days. Once a patient reaches the therapeutic range, the frequency of monitoring usually is decreased, typically to two to three times weekly for 1 or 2 weeks, then monthly. Herein we are discussing warfarine therapy in the cardiovascular diseases and predisposition to thromboembolic situations.

Anahtar Kelimeler

Warfarin; coronary artery disease; pregnancy; heart valve prosthesis; atrial fibrillation

Kardiyak Hastalarda Warfarin Tedavisi

Öz

kardiyovasküler hastalıkların tanı ve tedavisindeki gelişmeler ve operasyon tekniklerindeki ilerlemelere rağmen tromboembolik komplikasyonlar mortalite ve morbiditenin en korkulan sebebi olarak kalmıştır. Antikoagülan tedavide yeni araştırılan ajanlar olmakla birlikte halen warfarin elde bulunan en etkili ajan olarak kullanılmaktadır. Ancak kanama komplikasyonlan nedeniyle yakın monitörizasyonu ve dikkatli kullanılması gerekmektedir. Bazen gereksiz endikasyonlarda kullanıldığı gibi genellikle yetersiz dozda kullanılarak yetersiz antikoagulasyon sağlanmakta ve optimal tedavi hedeflerine ulaşılamamaktadır. Warfarin, aktivasyonu için K vitaminine bağımlı olan pıhtılaşma faktörleri II, VII, IX ve X un karaciğerde sentezini inhibe eder. Warfarin ayni zamanda anti-koagulan protein C ve S’yi de inhibe eder. Warfarin ağızdan verildiğinde tamamen emilir ve 24 saat içinde antikoagülan etkisi baslar. Fakat pik etki 3-4 gün sonra oluşur. Tam bir antikoagülan etki için 5-7 gün geçmesi gerekir. Çünkü var olan pıhtılaşma faktörlerinin tükenmesi gereklidir. Warfarin inaktif metabolitlerine dönüşünceye kadar karaciğerde birikir ve idrarla atılır. Hızlı antikoagulasyon gerektiren hastalar oral antikoagülan ile birlikte intravenöz heparin beraber başlanır ve INR veya protrombin zamanının hedef değerine ulaşıncaya kadar en azından 2 gün birlikte verilir ve sonrasında heparin dozu azaltılarak kesilir. Hastaya warfarin başlandığında hedef değere ulaşıncaya kadar günlük olarak 2-3 gün takip edilir. Sonrasında 1-2 hafta, haftada 2-3 kez daha sonra aylık takip edilir. Burada kalp hastalıklarından özellikle atriyal fibrilasyon, mekanik kalp kapağı, akut miyokard in-farktüsü ve ilgili tromboemboliye yatkınlık durumlarında warfarin tedavisini tartıştık.

Anahtar Kelimeler

Warfarin; koroner arter hastahğı; gebelik; protez kalp kapak; atriyal fibrilasyon, ,kardiyo, ,koroner

Kaynakça

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