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European Heart Journal 1991 12(7):1225-1233;
Copyright © 1991 by the European Society of Cardiology.
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© 1991 The European Society of Cardiology

Hypercoagulable state and thromboembolism following warfarin withdrawal in post-myocardial-infarction patients

L. GRIP*, M. BLOMBÄCK{dagger} and S. SCHULMAN{ddagger}

*From the Departments of Cardiology, Karolinska Hospital Stockholm, Sweden
{dagger}Internal Medicine Karolinska Hospital Stockholm, Sweden
{ddagger}Clinical Chemistry and Blood Coagulation, Karolinska Hospital Stockholm, Sweden

Received 5 November 1990; revised 14 June 1990; .

Correspondence: Lars Grip, MD, Department of Cardiology, Thoracic Clinics, Karolinska Hospital, S. 10401 Stockholm, Sweden

Abstract

Nine out of 47 (19%) patients on chronic anticoagulation with warfarin, as secondary prophylaxis after myocardial infarction, initially treated with streptokinase, had thromboembolic complications within 4 weeks after sudden (7/25) or gradual (2/22: NS) warfarin withdrawal.

The biochemical effects of warfar in withdrawal were repeatedly studied in 20 of the patients during the first 14 days following drug cessation. During the first 4 days, the levels of coagulation factors VII and IX increased more rapidly than proteins C and S. Thus, a gap was created between the factors provoking and inhibiting the coagulation process. Furthermore, plasma concentrations of fibrinopeptide A (EPA) increased, reflecting activation of the coagulation system.

These laboratory findings suggest that withdrawal of warfar in creates a transient hypercoagulable state, imposing a risk of thromboembolic events in patients given anticoagulant treatment as secondary prophylaxis following myocardial infarction.

Key Words: Rebound phenomenon • hypercoagulable state • cessation of anticoagulants • thromboembolism • vitamin-K-dependent factors • myocardial infarction


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