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Station 4 ( Counselling Station):

Subject Mr Lee- 72 years old gentleman

You are required to see Mr Lee who was admitted due to decompensated cardiac failure. He has background history of diabetes mellitus and hypertension. He was diagnosed to have ischaemic dilated cardiomyopathy. You also noticed that he has atrial fibrillation. He refused any form of cardiac intervention.

Your task is to explain to Mr Lee about warfarin therapy and possible concerns arising from this therapy.

Discussion:

Warfarin prescription is common in daily clinical practice and also MRCP PACES. Warfarin is an anticoagulant which acts by inhibiting vitamin K-dependent coagulation factors ( Factor II, VII, IX and X). Chemically, it is 3-(α-acetonylbenzyl)-4-hydroxycoumarin and is a racemic mixture of the R- and S-enantiomers. I always remember as a medical student, there are a few groups of patients who need long term warfarin therapy as below,

1) Patients with chronic atrial fibrillation

2) Patients with recurrent thromboembolic events.

3) Patients with mechanical heart valve.

There are a few issues that you might want to explain to Mr Lee while talking about Warfarin treatment, these issues are,

1) Why is warfarin needed for him? Since he has atrial fibrillation, it will be important also to ask about previous history of thromboembolic event.

2) Importance of compliance and initial frequent clinic follow up ( therefore social history is of vital importance because Mr Lee might need family members help to come to hospital for follow up)

3) Possible complications of warfarin and what Mr Lee should do if he encounters this complication ( bleeding tendency). Of course, you have to advise him about how to pick up bleeding tendency signs and symptoms.

4) Possible drug-drug interactions with emphasis on NSAID, antibiotics etc. ( There is a huge list for drug interaction! Just explain to him it is very important to inform his GP about this warfarin prescription)

5) Diet. I find this site very useful, please click HERE to read more about warfarin!

Of course besides all about warfarin and heart failure, you need to advise him about control of diabetes mellitus as well as hypertension. And certainly about drug compliance and fluid restriction!

Extra points:

Breaking trial in Clinical Medicine/Nephrology

Background History:

    ARB is well known long time to retard progression of diabetic nephropathy in the stage of overt proteinuria as well as microalbuminuria. IRMA trial has shown the benefit of ibersartan.In this latest trial, olmersartan has been proven in randomised trial to delay the progression of diabetic nephropathy.

Click HERE to look at the report.

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