Author + information
- Philip C. Adams, BA, MRCP*,1,
- Marc Cohen, MD, FACC*,
- James H. Chesebro, MD, FACC† and
- Valentin Fuster, MD, FACC*,a
- ↵aAddress for reprints: Valentin Fuster, MD, Division of Cardiology, Mount Sinai Medical Center, One Gustave Levy Place, New York, New York 10029.
In a number of cardiac conditions (acute myocardial infarction, chronic left ventricular aneurysm, dilated cardiomyopathy, infective endocarditis and atrial fibrillation in the absence of valvular disease), the risk of embolism gives cause for concern. Although anticoagulation with warfarin (Coumadin)-derivatives has been shown to be effective in some of these situations, there is no evidence regarding the role of antiplatelet agents.
The common factor in the thromboembolic potential of acute myocardial infarction, chronic left ventricular aneurysm and dilated cardiomyopathy is mural thrombus. This can be detected by two-dimensional echocardiography and indium-111 platelet scintigraphy. Although of value in elucidating the natural history of mural thrombus, in most cases, management is not substantially aided by these investigations.
In patients with extensive myocardial infarction, particularly anterior infarction, moderate intensity anticoagulation started soon after hospital admission reduces the rate of embolism. After 8 to 12 weeks, embolic risk is low so that anticoagulants can usually be discontinued. Patients with chronic left ventricular aneurysm have a low incidence of embolism; anticoagulation is, therefore, inappropriate. Dilated cardiomyopathy is associated with a high risk of embolism; moderate intensity anticoagulation may be advisable in many such cases. Little information is available regarding the incidence of thromboembolism or the role of antithrombotic therapy in the patient with a diffusely dilated left ventricle due to ischemic heart disease.
In native valve infective endocarditis, the risk of hemorrhage is high, and the efficacy of conventional anticoagulants unclear; thus, anticoagulation should not be instituted for the cardiac condition as such. However, in prosthetic valve endocarditis, the risk of embolism seems to be very high, and anticoagulant therapy should be continued, but with great care because there is a substantial risk of cerebral hemorrhage.
Atrial fibrillation in patients with valvular heart disease is dealt with in a previous review. Patients with nonvalvular atria! fibrillation are at varying risk of embolism, depending on the etiology of the arrhythmia; trials of antithrombotic therapy are needed for the various subsets of patients. In most elderly patients, the etiology is not known, and their stroke risk is high. The risk of embolism in younger patients with idiopathic atrial fibrillation is so low as to make any antithrombotic therapy unnecessary. Patients with atrial fibrillation due to hypertrophic cardiomyopathy are at a high risk of embolism, while for patients with atrial fibrillation due to ischemic heart disease, the risk is uncertain. Anticoagulation is appropriate in some patients around the time of direct current cardioversion. In addition, in those conditions that would of themselves merit long-term anticoagulation, this should be continued after cardioversion.
For each patient, the potential benefits of anticoagulation have to be carefully balanced against the risks of bleeding. The intensity of anticoagulant therapy applied should be matched to the patient's clinical condition.
- American College of Cardiology Foundation