STROKE FOLLOWING FAILURE TO ANTICOAGULATE;
67 yo WM with paroxysmal A Fib arrives at ER with TIA. He gives history of being on coumadin but his INR is 1.04 (subtherapeutic). Admitted for observation on aspirin then Plavix. No anticoagulation. About 20 hours after arrival, he has a massive stroke.
Should the patient have been anticoagulated? What anticoagulant? Would it likely have made a difference?
MEDQUEST EXPERT OPINIONS:
The patient should have been anticoagulated with coumadin or one of the new drugs (pradaxa or Xarelto). This is assuming he does not have a contra-indication to these drugs such as a history of severe bleeding or a great propensity to fall. If this were the case then Aspirin and plavix would be an acceptable, but less effective alternative.
However, the issue here is timing. One could either start one of the above anticoagulants and wait for the drug to be effective or put him on Heparin for immediate anticoagulation in addition to one of the above. However it is entirely acceptable to start the oral anticoagulants directly without heparin since the chance of embolizing in the time it takes these drugs to become effective (2-5 days) is low and the bleeding induced by heparin makes the 2 options about equal. Therefore with the stroke occurring at 20 hours after admission, he could have still had a stroke even if he had been started on anti-coagulants. Therefore, though the choice of Aspirin and Plavix was probably (? contraindication) wrong, I don’t think you could make a strong case that the outcome would have been different if he had started an anticoagulant just 20 hours before.
The real person to blame is the one who allowed his INR to be 1.04 upon admission. It was either his PCP who may have monitored him inadequately or it is often the patient who does not go for the necessary blood tests and follow-up visits best task manager software.
Therapy of choice is anticoagulation with heparin and Coumadin and then just Coumadin once PT is 2.5 times normal. However, in view of the rapid onset of CVA, it is very possible that the Heparin would have been able to prevent a stroke