Download ATRIAL FIBRILLATION AND FLUTTER

ATRIAL FIBRILLATION AND FLUTTER
Atrial fibrillation and/or atrial flutter are abnormal heart rhythms when the heart beats irregularly and too
rapidly. This may cause symptoms such as fatigue, shortness of breath or chest pain. Sometimes just the feeling
or sensation of an irregular rhythm is bothersome. Therapy should be aimed at restoring normal rhythm or
controlling the heart rate so that it is in a normal range (50-80 beats per minute).
One of the complications of atrial fibrillation is the potential to develop blood clots in the heart that can lead to
stroke, heart attack or kidney disease. To prevent this from occurring, some patients need to be on a blood
thinner called warfarin (Coumadin or Jantoven). Not all patients however need to be on Coumadin and this is a
subject that needs to be discussed with your physician.
ALL OF THESE PATIENTS REQUIRE COUMADIN IF THEY HAVE:
 History of prior stroke
 History of TIA (mini-stroke or transient ischemic attack)
 History of blood clot to any other artery
 Mitral stenosis
 Mechanical heart valves (the dose of Coumadin should be higher, with an INR of 2.5-3.5)
 More than one moderate risk factor:

Age 75 or higher

High blood pressure or hypertension (BP over 160)

Congestive heart failure

Left ventricular ejection fraction 35% or less

Diabetes mellitus (sugar diabetes)
PATIENTS THAT PERHAPS SHOULD RECEIVE COUMADIN:
 Those with only one moderate risk factor (see above)
 One moderate risk factor with an additional minor risk factor such as:

Female

Age 65-74

Coronary artery disease (hardening of the arteries in the heart)

Overactive thyroid (hyperthyroidism)
PATIENTS WHO MIGHT BE ABLE TO AVOID COUMADIN AND HAVE ONLY ONE MODERATE
RISK FACTOR:
 Strong patient preference not to use Coumadin
 Possibility of increased bleeding from other causes that could be worse with Coumadin (prior ulcers)
 Difficulty in regulating the INR or dose of warfarin
 Increased potential for falls
PATIENTS WHO DO NOT NEED WARFARIN:
No high risk or moderate risk factors
These patients with atrial fibrillation should take a daily aspirin instead of warfarin.
ATRIAL FIBRILLATION AND FLUTTER, UPDATED 2/2/07
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PATIENTS WHO SHOULD TAKE WARFARIN BUT IN WHOM IT IS CONTRAINDICATED OR NOT
WISE TO USE:
 Unable to regulate the dosage or INR for any reason

Patient forgets to take medication regularly

Major fluctuations in INR in spite of good adherence
 Recurrent life-threatening episodes of bleeding on warfarin which cannot be treated or prevented
 Recurrent falls or fainting episodes
Patients in this category may be suitable for aspirin and/or Plavix.
ADDITIONAL ISSUES:
 For most patients with atrial fibrillation who have stable coronary artery disease (hardening of the
arteries), warfarin alone (target 2.0-3.0) should provide adequate blood thinner for both stroke and heart
attack. Aspirin in addition, is not needed.
 In those patients with a stent inserted, the most important medication is Plavix. Coumadin should also be
used in the presence of atrial fibrillation. The addition of aspirin as a third drug may contribute more risk
than benefit. Immediately following the stent procedure, aspirin should be given temporarily until
warfarin is at the appropriate dose.
 Atrial fibrillation and atrial flutter are treated essentially the same in regards to the use of Coumadin.
 There is a benefit from the use of Warfarin with aspirin if the patient has a mechanical valve.
 If Warfarin needs to be discontinued for elective surgical procedures in patients with mechanical valves,
it is generally appropriate to substitute unfractionated or low molecular-weight heparin when Warfarin is
discontinued.
 In patients who do not have mechanical valves, Warfarin can be discontinued for up to one week. In
high risk patients (those with prior stroke, TIA, blood clot) or if Warfarin is interrupted more than one
week, heparin may be used.
I have been informed of the above considerations and I am aware of warfarin (Coumadin) use, and agree with
the plans and recommendations as provided.
REFERENCE:
1. ACC/AHA/ESC 2006: Guidelines for the management of patients with atrial fibrillation – executive
summary.
2. Arch Intern Med; vol 167: ACC: Combined aspirin –oral anticoagulant therapy, 1/22/07
ATRIAL FIBRILLATION AND FLUTTER, UPDATED 2/2/07
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