If the patient is undergoing a procedure that is not listed above, what is the next step?
To determine whether they are at high or low risk for thrombosis
List the type of patients defined as low risk for thrombosis?
1) those with aortic bileaflet mechanical heart valve who are in sinus rhythm and have no previous history of thromboembolism. 2) patients with atrial fibrillation having a CHAD2 score <2 without previous thromboembolism or intracranial thrombus. 3) those who have had venous thromboembolism (VTE) > 3 months previously without active cancer
List the type of patients defined as high risk for thrombosis?
while not specifically defined, high risk patients are those who do not meet low-risk criteria
*** What is the protocol for low risk for thrombosis patients as when to stop Warfarin and subsequent treatment if indicated? For high risk patients for thrombosis?
1) low risk patients can stop warfarin 5 days before surgery and do not require bridging therapy with low-molecular-weight heparin (LMWH). 2) high risk patients should discontinue warfarin 5 days before surgery and start LMWH once the INR is sub therapeutic
What is started postoperatively, but no sooner than 48 hours after the procedure?
When can the heparin be stopped?
warfarin should overlap heparin therapy for at least 5 days, or until the INR is therapeutic, whichever is longer
Are there any recommendations to shorten the warfarin discontinuation period based on thrombosis risk, or to lower the INR to < 2 as a management strategy?
What were the results of the BRIDGE (Briding Anticoagulation in Patients Who Require Temporary Interruption of of Warfarin Therapy for an Elective Invasive Procedure or Surgery) trial released in August 2015 may result in modification of 2012 recommendations noted above for a subset of patients. In this randomized, controlled trial of 1,884 patients on warfarin for atrial fibrillation were randomized to receive bridging therapy or no therapy following discontinuation of warfarin 5 days before surgery. The patients had a
CHAD2 score ranging from 0-6; 39% of patients had scores > 3, placing them in a high risk category. Follow up continued for 30 days?
they found that foregoing bridging therapy was NOT inferior to using bridging therapy and was also associate with decreased bleeding complications.
*** SUMMARY = The need for th use of low-molecular-weight heparin as a bridge during discontinuation of warfarin in the perioperative period is limited to which you of patients?
patients undergoing higher risk procedures a having elevated risks of thrombosis
*** SUMMARY = True or false? Several common elective surgical procedures do not require warfarin discontinuation?
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