Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Coagulants (clotting factors) are proteins produced by the liver. Clotting
factors are responsible for "cementing" clumps of platelets together to form
a stronger and larger clot. Anti-coagulants such as intravenous or subcutaneous
heparin, subcutaneous low molecular weight heparin, and oral warfarin
(Coumadin), prevent the formation of blood clots either by inhibiting the
production of clotting factors or by interfering with the action of the clotting
factors.
Heparin. Heparin prevents
the formation and growth of blood clots by inhibiting the action of clotting factors that
cement the clumps of platelets together. Heparin is given either intravenously
or as a subcutaneous (under the skin) injection.
Heparin commonly is given intravenously, usually with aspirin, anti-platelet
agents, or fibrinolytic (clot-dissolving) medications for treating heart attacks. Intravenous heparin
is given (usually with aspirin or an anti-platelet agent) to patients with heart
attacks who are undergoing PTCA with or without stenting. Heparin also is given
to patients who are at risk of developing blood clots within the chambers (atria
and ventricles) of the heart. (For example, patients with atrial fibrillation
can develop blood clots in the atria. Patients with large heart attacks and major
damage to the heart muscle also can develop blood clots in the ventricles.)
Heparin's anti-coagulant effect is fast acting (beginning shortly after the
start of the infusion) and dose-related (greater with higher doses). The
duration of heparin treatment for heart attacks is approximately 48 hours.
Heparin's major side effect is bleeding, and the
most serious bleeding complication is intracranial hemorrhage (bleeding into the brain).
The risk of bleeding is higher with higher doses. Thus, patients
receiving heparin will undergo frequent blood testing to measure APPT levels. The APPT
level is a measure of the degree of anti-coagulation. The goal is to
keep the patient's APPT level in a safe range and to avoid abnormally high
APPT levels that signify excessive anti-coagulation and a greater risk of
bleeding. If there is bleeding, heparin has the advantage of having a short duration
of action and its anti-coagulant effects disappears rapidly
after stopping the intravenous infusion.
Low molecular weight heparin. Low molecular weight heparins such as
enoxaparin (Lovenox) and dalteparin (Fragmin),
are sub-fractions of heparin with longer-lasting effects than heparin. They can be given every
12-24 hours as subcutaneous injections (like insulin). Studies have shown
enoxaparin and dalteparin to be equivalent to intravenous heparin in patients with
many conditions such as heart attacks, unstable angina, and blood clots in the
veins or arteries of the lungs. The effects of low molecular weight heparins
generally wear off after 6-12 hours. They are not used in place of intravenous heparin in
patients undergoing PTCA or stenting.
Warfarin. Warfarin (Coumadin)
prevents the formation of blood clots by inhibiting the production of clotting factors by the
liver. Warfarin must be taken orally and is slow acting; it can
take days to achieve an adequate anti-coagulant effect. Warfarin's anti-coagulant effect is dose-related, that
is, its effect is greater with larger doses.
Because of its
slow onset of action, Coumadin is not commonly used immediately for the treatment
of heart attacks. Instead, it is used orally on a long-term basis in selected
patients after heart attacks to prevent blood clots. For example, patients with
atrial fibrillation or patients with major damage to ventricular muscle will
take warfarin daily on a long-term basis to prevent blood clots in
the atria and ventricles, respectively. Warfarin also is commonly used to prevent blood
clots in veins of the legs in patients who are likely to develop them.
The risk with warfarin is abnormal bleeding, and the risk of bleeding is higher with higher doses.
Thus, patients on warfarin should have their blood tested frequently (often
weekly) to measure their prothrombin time and INR. Like APPT, the prothrombin
time and INR measure the degree of anti-coagulation. The goal of treatment
is to keep the prothrombin time and INR in a safe range, avoiding excessively
high prothrombin time and INR levels that indicate too much anti-coagulation and
a greater risk of bleeding. The effects of warfarin may be increased or
decreased greatly by many other medications or foods, and it is crucial to review
these medications and foods with the doctor.
Warfarin has a long duration of action, and its anti-coagulation effect can last several days after it is
stopped. Therefore, transfusions of clotting factors and/or vitamin K (to stimulate the
liver to produce the clotting factors depleted by treatment with warfarin) must be
given to reverse the anti-coagulation in the event of serious bleeding.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
Cholesterol is naturally produced by the body, and is a building block for cell membranes and hormones. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol, conversely, high-density lipoprotein (HDL) cholesterol is the "good" cholesterol. High cholesterol treatment includes lifestyle changes (diet and exercise), and medications such as statins, bile acid resins, and fibric acid derivatives.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
Heart failure is caused by many conditions including coronary artery disease, heart attack, cardiomyopathy, and conditions that overwork the heart. Symptoms of heart failure include congested lungs, fluid and water retention, dizziness, fatigue and weakness, and rapid or irregular heartbeats.
Heart disease, particularly coronary artery disease is the leading cause of heart attacks. Women are more likely to die from a heart attack than men. High cholesterol, high blood pressure, obesity, and high triglycerides are contributors to heart disease. Some of the common symptoms of a heart attack in women include chest pain, shortness of breath, nausea, feeling faint or woozy, and more. Heart disease can be prevented by lifestyle changes and controlling high blood pressure, cholesterol, weight, and diseases such as diabetes.
Heart attacks are the major causes of unexpected, sudden death among men and women. A heart attack is also a significant cause of heart failure. Learn the risk factors for heart attack such as high blood pressure, diabetes, and other heart conditions. Lowering your risk factor, lifestyle changes, and in some cases medication are the most effective way of preventing a heart attack.
Fabry disease (Fabry's disease, alpha-galactosidase-A) is a genetic disorder with symptoms such as burning sensations in the hands, small-raised reddish-purplish blemishes on the skin, fever, decreases sweating, and GI difficulties. Fabry disease patients are at increased risk of heart attack, heart disease, kidney failure, and stroke. Symptoms of Fabry disease can be treated with medication.
A heart attack is a layperson's term for a sudden blockage of a coronary artery. This photo essay inlcudes graphics, pictures, and illustrations of diseased heart tissue and the mechanisms that lead to coronary artery disease, and possible heart attack.
Biologic rhythms, or biorhythms, are how our bodies respond to the regular phases of the sun, moon, and seasons. A medical chronobiologist studies how the "body clock" or biorhythms affect diseases and how the body clock responds to treatment of diseases and conditions at different times of the day.
Cholesterol occurs naturally in the body. High blood cholesterol levels increase a person's risk of developing heart disease, heart attacks, strokes, TIAs, and more. In addition to medication (fibrates, statins, bile acid sequestrants, and niacin), lifestyle changes can be made to lower blood cholesterol levels
Vitamins and exercise can lower your risk for heart attack and heart disease. Folic acid, vitamins, and homocysteine levels are interconnected and affect your risk for heart disease or heart attack. Antioxidants and exercise also play a key role in heart attack and heart disease prevention. Lower your risk factors for heart disease and heart attack by lowering cholesterol, lowering blood pressure, diabetes prevention, and smoking cesssation.
Smoking increases the risk of heart disease in women and men. Nicotine in cigarettes decrease oxygen to the heart, increases blood pressure, blood clots, and damages coronary arteries. Learn how to quit smoking today, to prolong your life.
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