Anticoagulation in heart disease

doi:10.1136/bmj.318.7178.238

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Suzanna M C Hardman, senior lecturer in cardiology with an interest in community cardiologya,
Martin R Cowie, senior lecturer in cardiologyb

^aAcademic and Clinical Department of Cardiovascular Medicine, University College London Medical School (Whittington Campus), St Mary's Wing, Whittington Hospital, London N19 5NF
^bDepartment of Medicine and Therapeutics, Polwarth Building, University of Aberdeen, Aberdeen AB25 2ZD

Correspondence to: Dr Hardman

Thromboembolism is a common complication of heart disease. The decision to prescribe an anticoagulant to prevent thromboemboli should be based on a particular patient's risk without treatment and the likely benefit and side effects of the proposed treatment. In this article we will discuss the use of warfarin and heparin in patients with heart disease.

Summary points

Whether anticoagulant treatment should be started depends on the balance between the risk of thromboemboli without treatment and the likely benefits of treatment in each patient
Factors increasing the risk of bleeding include serious concomitant disease, previous gastrointestinal bleeding, uncontrolled hypertension, and immobility
Factors that cumulatively increase the risk of thromboembolism in non-rheumatic atrial fibrillation include age over 60,recent congestive heart failure, hypertension (treated or untreated), previous thromboembolism, and the presence of a large atrium or of global left ventricular dysfunction
Cardioversion of non-rheumatic atrial fibrillation (including fibrillation of new onset) is associated with an increased thromboembolic risk, which is reduced by anticoagulant treatment
Heparin and aspirin are both beneficial in unstable angina
Anticoagulants should be considered after myocardial infarction in patients with an increased risk of thromboemboli: patients in atrial fibrillation and those with persistent heart failure

Methods

This review article is based on our chapter in Current Issues in Cardiology, which was subject to formal peer review and published in 1997.1 We undertook a full Medline search in each of the relevant subjects. We also sought references from recent papers, editorials, and review articles. When a choice was available we chose large well conducted double blind randomised trials, but we included observational series when they were the only available evidence.

Non-rheumatic atrial fibrillation

Atrial fibrillation is not benign and is the commonest cause of cardiogenic stroke (fig 1).2 Within the general population the best available estimates suggest a prevalence of 0.5% for those …