Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach

Abstract

Case 1: A 69-year-old woman with chronic atrial fibrillation and hypertension requires a dental restoration procedure that will need local anesthetic injections. Case 2: A 77-year-old, 100-kg man with chronic atrial fibrillation, stable coronary artery disease, hypertension, and a previous transient ischemic attack that occurred 2 years ago after warfarin interruption for colon polypectomy now requires colon resection for stage I adenocarcinoma of the bowel.

Konsensus-Statement – Schlaganfallprophylaxe bei nicht-valvulärem Vorhofflimmern unter besonderer Berücksichtigung der direkten oralen Antikoagulanzien

“…Für das oft auch als "Bridging" bezeichnete perioperative Management von mit VKA antikoagulierten Patienten gibt es Leitlinien, auf die in diesem Zusammenhang nicht näher eingegangen wird [19,20].…”

Perioperative management of patients on chronic antithrombotic therapy

“…A suggested approach for stratifying thromboembolic risk according to the indication for anticoagulation is provided in Table 3. 1,[12][13][14] For patients with atrial fibrillation, the CHADS 2 score (see definition and scoring in Table 3), although not prospectively validated for use in the perioperative setting, typically is used for stratification. 13 For patients with venous thromboembolism, important considerations include the timing of the most recent thromboembolic event 15 and the presence (or absence) of underlying prothrombotic risk factors.…”

“…Certain procedures, such as implantation of a pacemaker or cardioverter/ defibrillator, or intracranial or spinal surgery, may not intrinsically exhibit an increased risk of hemorrhage, but even a small amount of excess bleeding in these confined locations can be associated with an adverse outcome. 12 Perioperative management of patients on chronic vitamin K antagonist therapy…”

“…In general, interruption of warfarin is not required for minor dental procedures, including tooth extractions and endodontal procedures. 12 Continuing warfarin with concomitant administration of a prohemostatic agent (eg, an antifibrinolytic agent, such as tranexamic acid or aminocaproic acid used as a mouthwash before and after the dental work), or interrupting warfarin for only 2-3 days, resulting in an INR that is slightly subtherapeutic at the time of the procedure, are reasonable management strategies. 1 Similarly, interruption of warfarin therapy generally is not necessary for patients undergoing minor skin excisions, such as treatment of basal and squamous cell skin cancers and actinic keratosis.…”

“…12 In 1 prospective cohort study in which all patients received enoxaparin 1.5 mg/kg daily, beginning within 12-24 hours after surgery, major bleeding occurred in 8 of 40 patients undergoing major surgery (20%) and 1 of 148 patients undergoing minor surgery (0.7%). 30 In other studies that allowed more flexibility in either the timing of when postoperative anticoagulation was initiated, or the initial dose administered, the authors reported a lower incidence of major bleeding (Ͻ 5%).…”