Bleeding risk factors affecting warfarin therapy in the elderly with atrial fibrillation.
OBJECTIVE
Inadequate anticoagulation among elderly individuals with atrial fibrillation (AF) is a common problem. This synthesis of the literature review describes the pathophysiology of AF, explains the mechanism of action of warfarin (Coumadin), identifies factors that contribute to warfarin (Coumadin)-associated bleeding in the elderly population, and explores alternatives to warfarin (Coumadin) therapy. Implications for advanced practice nurse practice, education, and research will be discussed.


METHODS
A literature search was conducted using Academic Search Premier, CINAHL Plus with Full Text, and Medline from 1999 to 2012. Search terms included warfarin (Coumadin), warfarin (Coumadin) genetics, diet, interactions, bleeding, atrial fibrillation, genetics, anticoagulation clinic, dabigatran, apixaban, rivaroxaban, and elderly.


RESULTS
The literature indicates that the potential bleeding risk associated with warfarin (Coumadin) therapy limits its use in the elderly population. However, some studies have found warfarin (Coumadin) to be more effective than aspirin in preventing stroke. The safety profiles of both medications were comparable; also, effective alternatives to warfarin (Coumadin) that do not require routine testing are now available.


CONCLUSIONS
Atrial fibrillation increases the probability of an embolic stroke, especially for the elderly population. Stroke risk and bleeding risk tools, in conjunction with patient preference, determine the best stroke prevention treatment. Anticoagulant clinics manage long-term warfarin (Coumadin) therapy effectively. Newer anticoagulants offer effective alternatives to warfarin (Coumadin) therapy.
Stan W. Darnell, MS, APRN, AGPCNP-BC, CCRN, is an adult-gerontology nurse practitioner at the Southeastern Neurosurgical & Spine Institute of the Greenville Health System, South Carolina. Stephanie C. Davis, PhD, RN, FNP, BC, is graduate coordinator and associate professor at Clemson University School of Nursing, South Carolina. John J. Whitcomb, PhD, RN, CCRN, FCCM, is second degree coordinator and assistant professor at Clemson University School of Nursing, South Carolina. Joseph A. Manfredi, MD, is a clinical cardiac electrophysiologist at AnMed Health Arrhythmia Specialists, Anderson, South Carolina. Brent T. McLaurin, MD, is a cardiologist at Anderson Heart, AnMed Health, Anderson, South Carolina. He also serves as director for the Research Division at Anderson Heart and the AnMed Research Division.
Stan W
SW
Darnell
Stephanie C
SC
Davis
John J
JJ
Whitcomb
Joseph A
JA
Manfredi
Brent T
BT
McLaurin
D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000503:physiopathology*; D064648:Critical Care Nursing; D006470:Hemorrhage / Q000139:chemically induced* / Q000517:prevention & control*; D006801:Humans; D012307:Risk Factors; D020521:Stroke / Q000503:physiopathology / Q000517:prevention & control; D014859:Warfarin / Q000009:adverse effects / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin; D001241:Aspirin