The possible exceptions are acute myocardial infarction

In conclusion, it is clear that one single therapeutic range for coumarins will not be optimal for all indications. However, a moderate-intensity INR (2.0 to 3.0) is effective for most indications. The possible exceptions are acute myocardial infarction, in which a higher INR is likely to be superior, and the primary prevention of myocardial infarction in high-risk patients in which a lower INR is effective. In addition, a lower INR range (1.5 to 2.0) is effective in patients with venous thrombosis who have received 6 months of full-dose treatment Generic viagra canada (INR, 2.0 to 3.0), although the lower intensity is less effective than the higher intensity. Fixed-dose warfarin therapy has a reduced efficacy or none at all, depending on the indication.  myocardial infarction

The optimal intensity for patients with prosthetic heart valves remains uncertain, although there is evidence that they do not require the very high-intensity regimens that have been used in the past. Defining an appropriate range is an important step in improving patient management, but it is only the first of two steps. The second is ensuring that the targeted range is achieved. In general, our success in achieving this second goal has been poor. It is better when the INR is controlled by experienced personnel in anticoagulant clinics and by using computer-assisted dosage adjustment. Specific recommendations regarding the optimal intensity of therapy for each of these indications can be found in the articles in this supplement that deal with each indication.

Management of VKA Therapy

Utilizing the correct intensity of a coumarin anticoagulant and maintaining the patient in the therapeutic range are two of the most important determinants of its therapeutic effectiveness and safety. High-quality dose management is essential to achieve and maintain therapeutic efficacy. Attainment of this goal can be influenced by physiologic and pharmacologic factors such as interacting drugs or illnesses that affect the pharmacokinetics or pharmacodynamics of warfarin, dietary or GI factors that affect the availability of vitamin K1, or physiologic factors that affect the synthetic or metabolic fate of the vitamin K-dependent coagulation factors. Patient-specific factors such as adherence to a therapeutic plan are also important. Last, the ability of the health-care provider to make appropriate dosage and follow-up decisions can have an impact. The comprehensive management of these variables requires a knowledgeable health-care provider, an organized system of follow-up, reliable PT monitoring, and good patient communication and education.

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