Warfarin

Yeah.

Along the lines of lifetime management, I think, you know, one of the big dividers obviously is Coumadin or Warfarin versus no Warfarin, right? And so I often find myself, and these are not conversations that, you know, it's a one and done.

Oftentimes you have to go back to the patient a few times and and sort of really get them to consider from all angles, you know, the risks and benefits of anticoagulation, the very real possibility of having multiple sternotomies in their lifetime, which I think is very difficult for people to wrap their heads around when they have never known anyone who's had open heart surgery before.

Um, and, and, and just the fact that, you know, bioprocesses can degenerate faster in younger patients.

Any last comments at all?

I think the last comment that I will make is that we talk a lot about the rural-urban divide, and it's about access to the TAVR itself.

But if you think about these patients who also, since we're talking about a younger age group and in a lower-risk population, the follow-up is also key, right? So I think that in rural centers where mechanical valves have existed for a long time, they might have a surgeon, they might have an INR or Coumadin clinic.

But getting these patients into TAVR clinic, getting them a TAVR isn't the last step.

And they said to me, oh, her leg is swollen because she has a deep venous thrombosis, which is a clot.

We'll put her on Coumadin.

I mean, I sued them successfully.

Nothing good comes after the word Coumadin.

Yeah, well, if you don't get rid of a clot, you can get a stroke.

See, if it detaches and becomes an embolism will come up to the lungs.

Heparin works very quickly and is often used in patients who are hospitalized.

Warfarin, on the other hand, works more slowly and requires INR monitoring.

Then we have the DOACs, like apixaban and Xarelto, which directly inhibit clotting factors and generally don't require routine INR monitoring.

One bored pearl I always remind students about, mechanical heart valves still equal warfarin.

Another question here for you.

What blood thinner is typically used if the patient has a mechanical heart valve?

Warfarin.

You got it.

And that's because of my experience with people on blood thinners, like many of you have people, you know, on blood thinners and their arms are always bruised in this way because, you know, they bleed very easy.

That's Coumadin.

or whichever thinner she was on.

I don't know which one.

So quick timeline on anticoagulants.

I'm sure folks listening in will be familiar with the product Warfarin.

So back in the 1940s, that was first developed as a bait for rodents to thin their blood and stop their clotting, ultimately killing them.

And that quickly became adopted across the U.S. and the Western Hemisphere as a rodent bait.

Yeah, I looked that up just to verify, and there's no evidence with the newer medicines.

When people are on Coumadin or Warfarin, it's the same thing.

So many things interact with that, and doctors have been used to prescribing Warfarin for years for anticoagulation.

We tell them, don't take supplements because your INR just goes up and down and up and down.

that.

And I said, I could explain to physicians how to treat blood clots because we had a drug called Coumadin and other substances.

So I thought to myself, I almost felt that I was a knight in shining armor going out to help people.

So that's what I started.

And I'll take us back to an old trial called ACTIV-W, which was in general patients with atrial fibrillation.

When warfarin was compared to essentially DAT, which was aspirin plus clopidogrel, Warfarin did better than DAPT in reducing stroke and thromboembolism, but the rate of major bleeding and the rate of intracranial bleeding was no different between Warfarin and DAPT and dual antiplatelet therapy.

So dual antiplatelet therapy, while some practitioners like to keep those patients on it after implanting a left atrial appendage occlusion, Well, you could almost say that it's like putting them on warfarin afterwards in a sort of rather crude manner.

So no surprise what we found really is in terms of the major bleed rate, it was high and it was higher than comparing to reduced dose DOA.