1. A Patient’s Voice John’s* perspective is shared in each section. John is a 75-year-old retired surgeon with atrial fibrillation who has been taking warfarin for 10 years. John also has gout and arthritis and a stent for which he takes baby aspirin. When he initially started warfarin, it took about 8 to 12 weeks to stabilize his INR within therapeutic range, mainly through dietary adjustments. For the last 5 years, John has been using a home INR kit every 4 to 6 weeks and submits the results through an automated system to his physician. His INR has remained mostly between 2 and 3 and has never exceeded a low of 1.8 or high of 4.3. John’s atrial fibrillation and anticoagulation therapy have not significantly impacted his family or required him to change his lifestyle. *Not the patient’s real name.

2. A Patient’s Voice During atrial fibrillation, a blood clot can form in the left atrium of the heart. If a piece of the clot breaks off and travels to an artery in the brain, it can block blood flow, causing a stroke. Patients may not be aware of the different types of atrial fibrillation—educate them. Educate your patients that anticoagulation is critical, but it is just one aspect of managing atrial fibrillation. Affected portion of the brain Embolus blocks blood flow to part of the brain Internal carotid artery Common carotid artery Embolus (clot) Aorta Atrial fibrillation in the left atrium Thrombus (clot) Heart NHLBI. Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/af/signs.html. Resources and Tools

3. John’s CHADS 2 score is 1 (due to his age). Empower your patients by educating them on CHADS 2. A Patient’s Voice Resources and Tools Available at TEAManticoag.com

4. “It’s so much more important to prevent stroke than to reduce bleeds.” For John, the bleeding concern has been quite benign. As a surgeon, he was more worried about his patients bleeding. He believes his physiological makeup makes him less prone to bruising and bleeding. A Patient’s Voice Resources and Tools Available at TEAManticoag.com

5. Generic/Trade Name Identification Guide for Drugs Mentioned in Activity Generic NameTrade Name* apixabanEliquis ® clopidogrelPlavix ® dabigatran etexilatePradaxa ® diltiazemCardizem ®, Dilacor ®, Tiazac ® prasugrelEffient ® rifampinRifadin ® rivaroxabanXarelto ® ticagrelorBrilinta ® ticlopidineTiclid ® verapamilCalan ®, Verelan ®, Verelan ® PM, Isoptin ®, Isoptin ® SR, Covera-HS ® warfarinCoumadin ®, Jantoven ® *For identification purposes only; does not imply endorsement. Resources and Tools

6. Warfarin and Novel Anticoagulant Mechanisms of Action Courtesy of David Garcia, MD. XII XI IX VIII X VII V II I Fibrin Clot New Oral Xa Inhibitors Rivaroxaban Apixaban Edoxaban New Oral IIa Inhibitor Dabigatran etexilate Unfractionated Heparin Low-Molecular- Weight Heparin Warfarin Resources and Tools

7. A Patient’s Voice John’s physician offered him a new anticoagulant, but John decided to stay with warfarin because it is: Working for him (it is preventing strokes) Cost effective (he does at-home INR testing) Reversible (at his age, he is at greater bleed risk and it is harder to reverse with the newer anticoagulants) Advice for a new patient who will begin warfarin “To be successful on warfarin, the patient needs to be reliable.” “Take the medication as directed regularly, modify diet as needed to keep dosage in range, and if able and responsible, get your own INR kit for testing.” Diet and warfarin “Get the dietary thing squared away up front. Once you are rock solid with the diet, maintaining the medication is a lot easier.” “I love veggies but have reduced leafy vegetables to minimize excess vitamin K to keep INR in range.”

8. Resources and Tools Available at TEAManticoag.com

9. A Patient’s Voice John believes cost is important to discuss with patients, including: Approximate monthly cost of being on warfarin vs newer drugs Cost of INR testing in office or at home Practical ways to obtain medication (retail pharmacy vs hospital, mail order, manufacturer’s patient assistance program, etc) John travels often and lives in 3 different locations each year. He monitors his INR using a home kit. “For someone with reasonable education and background, these kits sure simplify travel time and specimen blood collection and reporting costs.” John believes reversibility is important to discuss with patients. John has never had a nosebleed while on warfarin. Visit the Anticoagulation Forum (acforum.org) to find anticoagulation clinic locations. Resources and Tools

10. A Patient’s Voice Use pamphlets, comic book-like brochures, or new apps to educate patients on strokes and anticoagulation. John believes the seriousness of a stroke is so important that if patients resist anticoagulation therapy, the physician should have them sign a release (as Dr. Flores suggests). Patient handout Resources and Tools Available at TEAManticoag.com

11. A Patient’s Voice John has not interrupted anticoagulation for dental procedures, but when John’s stent was placed, he was off warfarin for a couple days and bridged with heparin. Switching From Warfarin: How? Dabigatran Switch when INR  2 Rivaroxaban Switch when INR <3 Apixaban Switch when INR <2 Resources and Tools Available at TEAManticoag.com

12. Performance Improvement CME Activities Also Available at TEAManticoag.com

13. Proceed to Posttest and Evaluation Close the video and return to Medscape to access