No Win Scenario
A very nice woman, who'd been my patient for several years, died two weeks ago. I feel frustrated about this particular case, so will give a few of the details to see if anybody has suggestions.
Let's start by reviewing the statistics for stroke and atrial fibrillation. The stroke rate for patients with atrial fibrillation, who do not use anticoagulants, is six percent per year (so the statistics say).
This patient of mine had had atrial fibrillation for several years, but was doing well on Coumadin - an anticoagulant - until she started passing massive amounts of blood in her urine and turned up in the emergency room. She was admitted, and workup showed a large tumor on her kidney. We had to stop her Coumadin due to the bleeding. She was discharged, I got her in to see the urologist who was willing to operate, and I was in the midst of making arrangements to have her evaluated by Cardiology when she had a stroke. It was a bad one. She never really woke up from it, and died a week later.
This stroke happened within
two weeks of her discontinuation of the blood thinner. This is the second such case I have seen; I had another patient who developed lower GI bleeding on Coumadin and who had a stroke within a week of discontinuing the drug. Now, for full disclosure, both these patients were over 80 years of age, so their stroke risk was much higher than the average risk I quoted. Still, what do you do when a patient develops life-threatening symptoms on Coumadin but you know their risk of stroke is astronomical?
I still don't have an answer.
posted by Dr. Alice at #
