Warfarin can be safely stopped for short periods before elective invasive procedures without bridging heparin

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Goodfellow Gems

"Warfarin can be safely stopped for short periods before elective invasive procedures without bridging heparin"

In an RCT warfarin treatment was stopped 5 days before the invasive elective procedure and was resumed within 24 hours afterwards.  Heparin SC or placebo was given from 3 days prior to surgery then for 5 to 10 days after the surgery. It was recommended that the international normalized ratio (INR) be measured 1 day before the procedure; if the INR was greater than 1.8, oral vitamin K (1.0 to 2.5 mg) was recommended and if 1.5 to 1.8, oral vitamin K was optional. Major bleeding was significantly increased from 1.3% in the non-bridging group to 3.2% in the bridging group with no thromboembolism increase.1 The highest risk patients, such as those with prior stroke or mitral stenosis, while eligible, represented a small minority and this limits generalizability.2 Anticoagulation was interrupted for procedures predominantly of low bleeding risk such as colonoscopy or ambulatory surgery. This study will be useful for primary care clinicians doing office surgery. Clinical judgement is still recommended.

References:

  1. Douketis JD et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation June 22 New England Journal of Medicine.
    http://www.nejm.org/doi/full/10.1056/NEJMoa1501035

  2. BA Steinberg. Interruption of all anticoagulation is non-inferior to the use of short-term parenteral bridging in patients with atrial fibrillation undergoing invasive procedures. Evidence Based Medicine 10.1136/ebmed-2015-110263

Gems are chosen by the Goodfellow director Dr. Bruce Arroll to be either practice changing or practice maintaining. The information is educational and not clinical advice.


As published in NZ Doctor 30/09/2015