Jornal Vascular Brasileiro
https://www.jvascbras.org/article/doi/10.1590/S1677-54492006000300007
Jornal Vascular Brasileiro
Original Article

Complicações da terapia anticoagulante com warfarina em pacientes com doença vascular periférica: estudo coorte prospectivo

Complications of anticoagulant therapy with warfarin in patients with peripheral vascular disease: a cohort prospective study

Fernada Cardoso Santos; Francisco Humberto de Abreu Maffei; Lidia Raquel de Carvalho; Izolete Aparecida Tomazini-Santos; Mariangela Gianini; Marcone Lima Sobreira; Paulo Eduardo Arbex; Ana Paula Mórbio

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Resumo

OBJETIVO: Estudar prospectivamente a freqüência de complicações em pacientes tratados com warfarina e acompanhados no Ambulatório de Anticoagulação da Faculdade de Medicina de Botucatu da Universidade Estadual Paulista. MÉTODOS: Pacientes sorteados entre os agendados para consulta de junho de 2002 a fevereiro de 2004. Na primeira consulta, foi preenchida ficha com dados de identificação e clínicos. A cada retorno, ou quando o paciente procurou o hospital por intercorrência, foi preenchida ficha com a razão normatizada internacional, existência e tipo de intercorrência e condições de uso dos antagonistas da vitamina K. RESULTADOS: Foram acompanhados 136 pacientes (61 homens e 75 mulheres), 99 com tromboembolismo venoso e 37 com doença arterial; 59 pacientes eram de Botucatu, e 77, de outros municípios. Foram registradas 30 intercorrências: nove não relacionadas ao uso da warfarina e 21 complicações hemorrágicas (38,8 por 100 pacientes/ano). Uma hematêmese foi considerada grave (1,9 por 100 pacientes/ano). As demais foram consideradas moderadas ou leves. Não houve óbitos, hemorragia intracraniana ou necrose cutânea. A única associação significante foi da freqüência de hemorragia com nível médio de razão normatizada internacional. CONCLUSÃO: Nossos resultados mostram a viabilidade desse tratamento em pacientes vasculares em nosso meio, mesmo em população de baixo nível socioeconômico, quando tratados em ambulatório especializado.

Palavras-chave

Anticoagulantes, warfarina, efeitos adversos, doenças vasculares, trombose venosa, embolia pulmonar

Abstract

OBJECTIVE: To prospectively study the frequency of complications in patients treated with warfarin followed at Botucatu Medical School. METHODS: Patients randomly selected among those with appointments scheduled from June 2002 to February 2004. At the first appointment, a protocol was filled with identification and clinical data. At every return or when the patient went to the hospital due to clinical events, another form was filled with the international normalized ratio, existence and type of clinical event and the conditions of use of vitamin K antagonists. RESULTS: A total of 136 patients (61 men and 75 women), were followed; 99 patients with venous thromboembolism and 37 with arterial disease; 59 were from Botucatu and 77 were from other municipalities. Thirty clinical events were registered: nine of them were not related to the use of warfarin and 21 were hemorrhagic complications (38.8 per 100 patients-year). One hematemesis was considered severe (1.9 per 100 patients-year). The others were considered moderate or mild. There were no deaths, intracranial hemorrhage or cutaneous necrosis. The only significant association was frequency of hemorrhage and average international normalized ratio level. CONCLUSION: Our results demonstrate the feasibility of this treatment in vascular patients in our country, even in socially and economically poor populations, when treated in specialized clinics.

Keywords

Anticoagulants, warfarin, adverse effects, vascular diseases, venous thrombosis, pulmonary embolism

References

Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:204S-33S.

Schulman S. Clinical practice: Care of patients receiving long-term anticoagulant therapy. N Engl J Med.. 2003;349:675-83.

Cortelazzo S, Finazzi G, Viero P. Thrombotic and hemorrhagic complications in patients with mechanical heart valve prosthesis attending an anticoagulation clinic. Thromb Haemost.. 1993;69:316-20.

Oral anticoagulation in patients after cerebral ischemia of arterial origin and risk of intracranial hemorrhage. Stroke. 2003;34:e45-6.

Sarac TP, Huber TS, Back MR. Warfarin improves the outcome of infrainguinal vein bypass grafting at high risk for failure. J Vasc Surg.. 1998;28:446-57.

Aithal GP, Day CP, Kesteven PJ, Daly AK. Association of polymorphisms in the cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications. Lancet. 1999;353:717-9.

Higashi MK, Veenstra DL, Kondo LM. Association between CYP2C9 genetic variants and anticoagulation-related outcomes during warfarin therapy. JAMA.. 2002;287:1690-8.

Majerus PW, Broze GJ, Miletich JP, Tollefsen DM. Anticoagulant, thrombolytic, and antiplatelet drugs. Goodman & Gilman's the pharmacological basis of therapeutics. 1996:1341-59.

Mannucci PM. Genetic control of anticoagulation. Lancet. 1999;353:688-9.

O'Reilly RA, Aggeler PM, Hoag MS, Leong LS, Kropatkin ML. Hereditary transmission of exceptional resistance to coumarin anticoagulant drugs: The first reported kindred. N Engl J Med.. 1964;271:809-15.

Penning-van Beest FJ, Geleijnse JM, van Meegen E, Vermeer C, Rosendaal FR, Stricker BH. Lifestyle and diet as risk factors for overanticoagulation. J Clin Epidemiol.. 2002;55:411-7.

Loeliger EA. Laboratory control optimal therapeutic ranges and therapeutic quality control in oral anticoagulants. Acta Haematol.. 1985;74:125-31.

Thomazini I A, Maffei FH, Yuan FC, Zannini JM, Lastória S, Noguerira FL. Terapêutica anticoagulante oral a longo prazo em trombose venosa profunda: é possível em pacientes de baixo nível socioeconômico nos paises em desenvolvimento?. Rev Ibero Americana Trombose e Hemostasia. 1995;8:201-5.

McInnes GT, Helenglass G. The performance of clinics for outpatient control of anticoagulation. J R Coll Physicians Lond.. 1987;21:42-5.

Ángeles Fernandez M. Gestión del tratamiento anticoagulante oral: unidad centralizada. Hematologica. 2001;86(^s2):117.

Berrettini M, Agnelli G. Management of oral anticoagulant in Italy. Semin Thromb Hemost.. 1999;25:27-31.

Poli D, Antonucci E, Lombardi A. Low rate of bleeding and thrombotic complications of oral anticoagulant therapy independent of age in the real: practice of an anticoagulation clinic. Blood Coagul Fibrinolysis.. 2003;14:269-75.

Levine MN, Raskob G, Beyth RJ, Kearon C, Schulman S. Hemorrhagic complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:287S-310S.

Kucher N, Connolly S, Beckman JA. International normalized ratio increase before warfarin: associated hemorrhage: brief and subtle. Arch Intern Med.. 2004;164:2176-9.

Harenberg J, Hoffmann U, Huhle G, Winkler M, Bayerl C. Cutaneous reactions to anticoagulants: recognition and management. Am J Clin Dermatol.. 2001;2:69-75.

Ad-El DD, Meirovitz A, Weinberg A. Warfarin skin necrosis: local and systemic factors. Br J Plast Surg.. 2000;53:624-6.

Buller HR, Sohne M, Middeldorp S. Treatment of venous thromboembolism. J Thromb Haemost.. 2005;3:1554-60.

Timi JRR, Moraes LM, Góes Junior DCA, Martins M, Moreira RCR, Abrão E. Riscos do uso do anticoagulante oral após embolectomia arterial. Rev Bras Med.. 1988;45:316-7.

Maffei FHA, Thomazini IA, Yuan FC. Acompanhamento da terapêutica anticoagulante em ambulatório especializado. Cir Vasc Ang.. 1988;4:7-13.

Lourenço DM, Morelli VM, Vignal CV. Tratamento da superdosagem de anticoagulantes orais. Arq Bras Cardiol.. 1998;70:9-13.

Rhodes S, Green ES, Bond S. Bleeding complications of oral anticoagulant therapy: a prospective audit. Br J Haematol.. 2004;1(^s125):57.

Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med.. 2003;139:893-900.

van der Heijden JF, Hutten BA, Büller HR, Prins MH. Vitamin K antagonists or low-molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism (Cochrane Review). The Cochrane Library. 2006;3:CD001367.

Hutten BA Prins MH. Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism (Cochrane Review). The Cochrane Library. 2006.

Palareti G, Leali N, Coccheri S. Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT) Italian Study on Complications of Oral Anticoagulant Therapy. Lancet. 1996;348:423-8.

Mohr JP, Thompson JL, Lazar RM. A comparison of warfarin and aspirin for prevention of recurrent ischemic stroke. N Engl J Med.. 2001;345:1444-51.

van Walraven C, Hart RG, Singer DE. Oral anticoagulants vs. aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA.. 2002;288:2441-8.

Kretschmer G, Herbst F, Prager M. A decade of oral anticoagulant treatment to maintain autologous vein grafts for femoropopliteal atherosclerosis. Arch Surg.. 1992;127:1112-5.

Johnson WC, Williford WO. Department of Veterans Affairs Cooperative Study #362: Benefits, morbidity, and mortality associated with long-term administration of oral anticoagulant therapy to patients with peripheral arterial bypass procedures: a prospective randomized study. J Vasc Surg.. 2002;35:413-21.

Tangelder MJ, Algra A, Lawson JA, Hennekes S, Eikelboom BC. Optimal oral anticoagulant intensity to prevent secondary ischemic and hemorrhagic events in patients after infrainguinal bypass graft surgery: Dutch BOA Study Group. J Vasc Surg.. 2001;33:522-7.

Santos FC, Menegon FTF, Thomazini-Santos IA, Gianini M, Lastória S, Maffei FHA. Terapia anticoagulante a longo prazo em doença arterial periférica. J Vasc Bras.. 2003;2:228.

Fihn SD, McDonell M, Martin D. Risk factors for complications of chronic anticoagulation: A multicenter study. Warfarin Optimized Outpatient Follow-up Study Group. Ann Intern Med.. 1993;118:511-20.

Landefeld C S, Beyth RJ. Anticoagulant-Related Bleeding: clinical epidemiology, prediction, and prevention. Am J Med.. 1993;95:315-28.

Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:483S-512S.

Harrington RA, Becker RC, Ezekowitz M. Antithrombotic therapy for coronary artery disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:513S-48S.

Salem DN, Stein PD, Al-Ahmad A. Antithrombotic therapy in valvular heart disease-native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:457S-82S.

Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ. Antithrombotic Therapy in Atrial Fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:429S-56S.

Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med.. 1994;120:897-902.

Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet. 1993;342:1255-62.

Cannegieter SC, Rosendaal FR, Wintzen AR, van der Meer FJ, Vandenbroucke JP, Briet E. Optimal oral anticoagulant therapy in patients with mechanical heart valves. N Engl J Med.. 1995;333:11-7.

Hull R, Hirsh J, Jay R. Different intensities of oral anticoagulant therapy in the treatment of proximal-vein thrombosis. N Engl J Med.. 1982;307:1676-81.

Crowther MA, Ginsberg JS, Julian J. A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with antiphospholipid antibody syndrome. N Engl J Med.. 2003;349:1133-8.

Torn M, Van der Meer FJ, Rosendaal FR. Lowering the intensity of oral anticoagulant therapy: effects on the risk of hemorrhage and thromboembolism. Arch Intern Med.. 2004;164:668-73.

Coon WW, Willis PW. Hemorrhagic complications of anticoagulant therapy. Arch Intern Med.. 1974;133:386-92.

Davis FB, Estruch MT, Samson-Corvera EB, Voigt GC, Tobin JD. Management of anticoagulation in outpatients: experience with an anticoagulation service in a municipal hospital setting. Arch Intern Med.. 1977;137:197-202.

Palareti G, Hirsh J, Legnani C. Oral anticoagulation treatment in the elderly. Arch Intern Med.. 2000;160:470-8.

Van der Meer FJ, Rosendaal FR, Vandenbroucke JP, Briet E. Bleeding complications in oral anticoagulant therapy: analysis of risk factors. Arch Intern Med.. 1993;153:1557-62.

Risks of long-term oral anticoagulant therapy in elderly patients after myocardial infarction: Second report of the Sixty Plus Reinfarction Study Research Group. Lancet. 1982;1:64-8.

Wickramasinghe LS, Basu SK, Bansal SK. Long-term oral anticoagulant therapy in elderly patients. Age Ageing.. 1988;17:388-96.

Joglekar M, Mohanaruban K, Bayer AJ, Pathy MS. Can old people on oral anticoagulants be safely managed as out-patients?. Postgrad Med J.. 1988;64:775-7.

Errichetti AM, Holden A, Ansell J. Management of oral anticoagulant therapy: experience with an anticoagulation clinic. Arch Intern Med.. 1984;144:1966-8.

Petty GW, Lennihan L, Mohr JP. Complications of long-term anticoagulation. Ann Neurol.. 1988;23:570-4.

Bleeding during antithrombotic therapy in patients with atrial fibrillation: The Stroke Prevention in Atrial Fibrillation Investigators. Arch Intern Med.. 1996;156:409-16.

Pini M, Aiello S, Manotti C. Low molecular weight heparin versus warfarin in the prevention of recurrences after deep vein thrombosis. Thromb Haemost. 1994;72:191-7.

Das SK, Cohen AT, Edmondson RA, Melissari E, Kakkar VV. Low-molecular-weight heparin versus warfarin in the prevention of recurrent venous thromboembolism: a randomized trial. World J Surg.. 1996;20:521-6.

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