Category: Advancing Modules

Benefits of anticoagulation explained

Benefits of anticoagulation for 100 stroke patients

  • Without anticoagulation 25 might have a stroke during 1st year
  • With anticoagulation only 10 have a stroke ( i.e. a 60% relative risk reduction: 25-10/25 x100% = 60%). Some of these 10 may have a haemorrhagic stroke due to the anticoagulation
  • Of the 25 who would have had a stroke, 15 avoid a stroke due to taking anticoagulation
  • 85 did not have a stroke
  • Treat 100 patients with anticoagulants for a year and benefit 15
  • Treat about 6 patients in atrial fibrillation for a year with anticoagulation and prevent one of them having a stroke ( i.e. number needed to treat = 6)
  • Each patient in atrial fibrillation has a 1 in 6 chance of benefit from taking anticoagulation for the first year after an ischaemic stroke or TIA

Anticoagulation

Introduction to anticoagulation

Please note that this Topic Loop is under review and will be updated shortly to reflect the latest National Stroke Guidelines for Stroke (RCP 2023) 

  • Anticoagulation may be indicated after an ischaemic stroke if the patient has
    • atrial fibrillation
    • prosthetic heart valves
    • recent myocardial infarction
    • deep vein thrombosis or pulmonary embolism
  • Anticoagulation reduces the risk of another stroke more than antiplatelets such as aspirin in patients with atrial fibrillation
  • Anticoagulation is associated with an increased risk of bleeding
  • Warfarin was previously the most commonly used anticoagulant. Warfarin is a vitamin K antagonist and works by inhibiting vitamin K dependent clotting factors.  Warfarin requires regular monitoring and it interacts with many other drugs that either increase or decrease its effects.  It can be reversed relatively easily if required.
  • Patients should be advised to check if any new medications interact with warfarin
  • Newer oral anticoagulants have been developed, which may replace warfarin, because they have fewer drug interactions and require less frequent blood tests. They are known as the Direct Oral Anticoagulants (DOACS).

Summary

  • Heavy alcohol intake can lead to increased stroke risk through:
    • Raised blood pressure
    • Changes in blood platelets and clotting factors
    • Atrial fibrillation
  • Competence at recognising alcohol misuse
  • Ability to identifying organisations and resources to help patients to stop excessive drinking are important

Important considerations

  • Competence at detecting alcohol misuse is important. This includes knowing what questions to ask, e.g.:
    • Has alcohol ever lead you to neglect your family or work?
    • Can you always control the amount of alcohol you drink?
  • Recognising that alcohol misuse is often associated with other drug abuse and tackling both may be needed for successfully stopping alcohol misuse and reducing stroke risk
  • Knowledge of programmes of psychological strategies available locally for support e.g. day hospital or alcohol support groups (e.g. Alcoholic Anonymous)
  • Recognising some alcoholic stroke patients may have important vitamin deficiencies

Alcohol

Introduction

There is no ‘safe’ limit of alcohol intake. The risk of developing a range of illnesses increases with any amount you drink on a regular basis.

The Chief Medical Officers’ guidelines for both men and women are:                                                                                 (this applies to adults who drink regularly i.e. most weeks)

  • To keep health risks from alcohol to a low level it is safest not to drink more than 14 units a week on a regular basis.
  • If you regularly drink as much as 14 units per week, it is best to spread your drinking evenly over 3 or more days.
  • If you have 1 or 2 heavy drinking episodes a week, you increase your risks of death from long term illness and from accidents and injuries.
  • The risk of developing a range of health problems, including cancers of the mouth, throat and breast, increases the more you drink on a regular basis.
  • If you want to cut down the amount you drink, a good way is to have several drink-free days each week.
  • If you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum.

 DOH (2016)

Other things to consider…

  • PILs: each medicine is supplied with a Patient Information Leaflet. These provide information in plain English in a style which is easy to understand.
  • Carer filled ‘dosettes’ are usually not clearly labelled, so information such as the name of the medicines, its strength or even when it has to be taken are omitted.
  • Excursions & Daycare Centres: how are medicines managed when they attend these? Are the staff provided with clearly labelled medicines?