الفهرس 
AcknowledgementOnly 14 pages are availabe for public view
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Abstract
Among patients who undergo cardiac valve replacement, approximately 60% receive mechanical valves, and replacement of a diseased heart valve with a prosthetic valve exchanges the native disease for potential prosthesis-related complications. For those who get mechanical valves, the problem starts with regular availability of warfarin itself. Once they are on warfarin, compliance, regular follow up and regular monitoring of their coagulation profile has been a challenge because of lack of facilities in almost all public institutions, and limited access to well-equipped medical facilities. This study aimed to determine the effect of patient’s compliance, changing the time of warfarin administration during the day, administration of other medication and dietary habits of certain foods on warfarin therapeutic outcome. The current result was prospectively conducted in the period between December 2018 to May 2019 in the Outpatient Clinics of Assiut University Hospitals. The study enrolled 400 patients with prosthetic cardiac valves who were on warfarin therapy. In the current study, mean age of enrolled patients was 37.39 ± 10.07 years with range between 19 and 61 years old. Out of the studied patients; 248 (62%) patients were males and 152 (38%) patients were females. Majority (58%) of patients came from rural areas. As regard occupation of those patients, 72 (18%), 48 (12%), 132 (33%), and 16 (4%) patients were employees, farmers, housewives and students, respectively. Out of the enrolled patients; 132 (33%) patients were unemployed All patients received Warfarin at 5 P.M. Daily dose of Warfarin reached 15 mg in only 8 (2%) while it was between 11 and 14 mg in 24 (6%) patients. 188 (47%) and 180 (45%) patients received daily dose 6-10 mg and ≤ 5 mg, respectively. Majority (79%) of patients received daily dose of Warfarin at fixed time. In the present study, majority (89%) of patients were compliant on the daily dose. It was noticed that 334 (83.5%) patient took the daily dose at empty stomach, 10 (2.5%) patient takes it before meals and in the other 56 (14%) patients, the daily dose received after meals. As regarding the forgotten dose; 336 (84%), and 34 (8.5%) patients received the dose as remember, and later on, respectively. Thirty (7.5%) of the patients didn’t receive the forgotten dose at all. Compliance was 100% in those with optimal anti coagulation and those with warfarin toxicity while it was 63.3% in patients with sub optimal anti coagulation. Sixty-six (55%), 6 (5%) and 48 (40%) patients with suboptimal anticoagulation received the dose on empty stomach, before meals, and after meals, respectively. It was noticed that high percentage (21.7%) of patients with sub optimal anti coagulation never take the forgotten dose at all.
Our study found that different types of anticoagulation had no significant differences as regard baseline data with exception of patients with sub optimal anti coagulation had significant higher age (39.70 ± 9.51 years) in comparison to those with optimal anti coagulation (37.32 ± 10.05 years), and (34.40 ± 12.28 years).
Mean international normalized ratio (INR) was 2.83 ± 0.65 with range between 2.09 and 5.40. Based on level of INR; the enrolled patients were classified into; patients with optimal anti coagulation (260 (65%) patients), patients with sub optimal anti coagulation (120 (30%) patients) and patients with Warfarin toxicity (20 (5%) patients). Mean ejection fraction was 55.56 ± 4.56% with no detected abnormality in echocardiography.
As regard frequency of foods rich in vitamin K and vitamin C, the patients of our study depend on diet, it was noticed that 84 (21%), 60 (15%) and 60 (15%) patients were mainly depend on orange, cabbage and radish on their diet, respectively. Rocca was mainly present in 56 (14%). It was noticed that nearly all patients consumed the common foods with low amount of vitamin C and K. Cucumber, tomatoes, cereals and grains were consumed by all patients. It was noticed that consumption of food rich in vitamin C and vitamin K was significantly higher among patients with sub optimal anti coagulation in comparison to those with optimal anti coagulation and those with warfarin toxicity (P< 0.001).
In our study, only four patients were using oral contraception, another four patients used methimazole for thyrotoxicosis and four patients were on Carbamazepine for trigeminal neuralgia. There were four patients known to be epileptics and were on phenobarbital. All of those patients had sub optimal anti coagulation.
In our study, six (1.5%) patients were on steroid therapy for management of asthma and 5 (1.3%) patients used NSAIDs for headache. Another patient used metronidazole for diarrhea. All those patients presented with warfarin toxicity.