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Dr. Bourge, the ACCP consensus included several
recommendations on anticoagulation therapy for PAH patients:
1. Patients with IPAH should receive anticoagulation with
warfarin. Level of evidence: fair; benefit: intermediate;
grade of recommendation: B. 2. In patients with PAH occurring
in association with other underlying processes, such as
scleroderma or congenital heart disease, anticoagulation
should be considered. Level of evidence: expert opinion;
benefit: small/weak; recommendation: E/C. With regard
to your current practice of anticoagulation in these patients,
do you prescribe anticoagulants in all patients with idiopathic
PAH in the absence of contraindications?
Unless there is a strong contraindication, we routinely
give anticoagulants
all patients with PAH. There is fair to good anecdotal
evidence to support this practice.
Do you prescribe anticoagulants for patients with
CREST/scleroderma?
If not, would you use anticoagulants in a patient with
scleroderma and very severe PAH requiring intravenous
epoprostenol?
We consider those patients with CREST/scleroderma as at
the same risk for thrombosis in situ as all patients with
PAH, and generally use the same criteria for anticoagulation.
The evidence to support this practice is not as strong,
however.
How about patients with congenital heart disease
and pulmonary
hypertension?
One cannot lump all patients with congenital heart disease
together. If there is a repaired shunt and pulmonary hypertension,
then we tend to do so, unless there is a contraindication
such as recurrent hemoptysis. If there is an unrepaired
shunt, then it depends on the pulmonary arterial pressure
and other comorbid problems (there are not many data in
this population however).
What is your target/range INR? Does it depend on
the patient?
We aim for an INR of 2.0 to 2.5, unless there is a comorbid
problem with a recommendation for a higher INR (such as
atrial fibrillation).
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