Question of the Week # 333

333) A 75 year old woman with past medical history of  Type 2 Diabetes mellitus, Hypertension and Ischemic stroke presents to your office for a new patient visit. She has been under the care of another primary care physician who has retired from practice so the patient has decided to establish care with you. She has left sided residual weakness from her old cerebrovascular accident. She has no other complaints. She requests you for a refill of warfarin which she has been taking for three years . This drug was prescribed by her former physician for “stroke prevention” . Her recent echcardiogram shows an ejection fraction of 60% and a recent cardiovascular stress test was negative for ischemia. Her other medications include Metformin, Glyburide and enalapril.  Her laboratory investigations including complete blood count are normal and her  INR is 1.5. Which of the following is the most appropriate  management?

A) Increase warfarin to achieve a target INR of 2.0 to 3.0

B) Discontinue Warfarin and start Aspirin/Dipyridamole combination

C) Continue low-dose Warfarin with target INR 1.5 to 2.0

D) Add Aspirin to her current regimen

E) Add Clopidogrel to her current regimen

12 Responses

  1. A.

  2. B) Discontinue Warfarin and start Aspirin/Dipyridamole combination.

    Is’nt Warfarin indicated only if patient has atrial fibrillation?

    • But patient’s CHAD score is>0
      In that case we should continue Warfarin to prevent recurrent stroke

      • CHADS2 is used to estimate the risk of stroke in patients with atrial fibrillation right? and she is being treated for hypertension and Type 2 DM. Now i’m confused.
        Dr Red please let us know right answer.

  3. bbbbbbbbbbbbbb

  4. The question is on secondary prevention of Stroke: Anti-platelet VS. Anticoagulant which is better? Answer depends on the type of stroke: cardio-embolic stroke: warfarin > Aspirin; in non cardio embolic stroke: Aspirin > Warfarin; so now if you check the question there is no Evidence of cardio embolic stroke : i.e. NO AF; ON ECHO: NO E/O Left atrial enlargement; LV wall hypokinesis; LV thrombus; vegetation’s; Valvular heart disease; systolic dysfunction& NO E/O CAD; SO this is a non cardio embolic stroke (forget about the cause it can be cryptogenic and that is not the question; then why did the other doctor start warfarin it it is a distractor he can be wrong ignore it ) now u have to stop warfarin & start anti platelet therapy/ now which Anti platelet therapy: Aspirin / clopidogrel/ ASA+ extended release dipyridamole are all acceptable options for initial therapy and selection is individualized based on risk factor profiles & always remember CHADS2 score is for Pt’s with AF here there is no AF at all hope this helps!!!!!!!!!!

  5. bbbbb

  6. B-Discontineu warfarin and start asprin & dipyridamole combination.

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