hem 2 - pacemaker

[ArchivalUser]

A 46-year-old woman (G0P0) is evaluated for follow-up monitoring of pulmonary emboli that developed 13 months ago. The thrombotic event was unprovoked, and anticoagulation was discontinued after 6 months of therapy. The family history is negative for thrombosis.

Genetic analysis performed 3 weeks after the discontinuation of warfarin therapy indicated that she is heterozygous for the factor V Leiden mutation. Five weeks after therapy was discontinued, the patient experienced left lower-extremity pain and swelling in the absence of transient risk factors. A nonocclusive thrombus in the popliteal vein was shown on ultrasonography for which she underwent anticoagulation therapy with low-molecular-weight heparin followed by warfarin for 6 months.

Which of the following is the most appropriate management of this patient's thrombophilic disorder?

A Long-term warfarin at a target INR of 2 to 3
B Long-term warfarin at a target INR of 1.5 to 2
C Discontinuation of warfarin
D Daily aspirin therapy

[ArchivalUser]

A Long-term warfarin at a target INR of 2 to 3

[ArchivalUser]

i pick A

[ArchivalUser]

A)
Key Points

* The risk for recurrent venous thrombosis in patients with the factor V Leiden mutation is not greater than that in those without an underlying thrombophilic abnormality.
* Patients at high risk for recurrent thrombosis should receive long-term anticoagulation therapy with warfarin.

Although heterozygosity for the factor V Leiden mutation is a risk factor for the development of an initial episode of venous thrombosis, the risk for recurrent venous thrombosis in such a patient is not greater than that in those without an underlying thrombophilic abnormality. Given that she developed two unprovoked venous thrombotic events over a relatively short period and the absence of risk factors that increase her risk for bleeding during warfarin therapy, this patient should receive long-term warfarin therapy at a target INR of 2 to 3. Although a target INR of 1.5 to 2 has been shown to have efficacy in preventing recurrent venous thrombosis, it is not as efficacious as a target INR of 2 to 3, and the risk for major bleeding is similar for the two target INR ranges. Discontinuing warfarin therapy would not be appropriate because of her high risk for recurrent thrombosis. Aspirin has not been shown to have efficacy in the secondary prevention of venous thromboembolism.

[ArchivalUser]

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