Current trends in the preoperative management of patients receiving warfarin for anticoagulation
Keywords:
Perioperative Period, Anticoagulants, Heparin, Thrombosis
Abstract
Introduction: The perioperative management of patients receiving chronic treatment with warfarin and scheduled for invasive, elective or emergency procedures is a difficult and frequently arising problem in clinical practice. The lack of clear management guidelines and the indiscriminate use of the temporary replacement with unfractionated heparin creates delays, increases costs and unnecessarily prolongs the length of hospital stay.
Objectives: To review current trends and their supporting evidence of temporary replacement ("bridging") during the pre-operative period, emphasizing the use of low-molecular-weight heparins on an outpatient basis.
Methodology: PubMed search of evidence-based management guidelines, expert consensus and original trials.
Results: Three evidence-based clinical practice guidelines, together with multiple narrative expert reviews, four of them recently published, were identified. Clinical trials found in the surgical setting were purely observational. Although there are comparative studies, none of them apply to the surgical setting.
Discussion: Management evidence is limited and expert consensus guidelines are inconsistent.
Conclusions: There is suggestive, though non-conclusive evidence supporting the use of low-molecular-weight heparins for temporary replacement ("bridging") of pre-operative anticoagulation on an outpatient basis. There is a need to conduct well-designed comparative studies in the perioperative setting. Guidelines for anticoagulation management in elective and emergency cases are proposed on the basis of the information available, expressed in the form of a simple and innovative graphic algorithm applicable to the Colombian situation.
References
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2.Friberg J, Gislason GH, Gadsb0ll N, et al. Temporal trends in the prescription of vitamin K antagonists in patients with atrial fibrillation. J Intern Med. 2006;259:173-8.
3.McKenna R. Abnormal coagulation in the postoperative period contributing to excessive bleeding. Med Clin North Am. 2001;85:1277-310.
4. Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med. 2003;139:893-900.
5. Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med. 2003;163:901-8.
6. Gladstone DJ, Bui E, Fang J, et al. Potentially preventable strokes in high-risk patients with atrial fibrillation who are not adequately anticoagulated. Stroke. 2009;40:235-40.
7. Rincón PG. Anticoagulación y anestesia, caso clínico. Rev. Colomb. anestesiol. 1987;15:291-6.
8. Valencia W, Husbands JS. Tromboembolismo venoso postoperatorio: grave riesgo prevenible. Rev Colomb Anestesiol. 2010;38:499-507.
9. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133 (6 Suppl):S299-339.
10. Spyropoulos AC, Douketis JD. Guidelines for antithrombotic therapy: periprocedural management of antithrombotic therapy and use of bridging anticoagulation. Int Angiol. 2008;27: 333-43.
11. Bonow RO, Carabello BA, Chatterjee K, et al. American Col-lege of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol. 2008;52:1-142.
12. Spyropoulos AC. To bridge or not to bridge: that is the question. The argument FOR bridging therapy in patients on oral anticoagulants requiring temporary interruption for elective procedures. J Thromb Thrombolysis. 2010;29:192-8.
13. Jaff MR. Chronically anticoagulated patients who need surgery: can low-molecular-weight heparins really be used to "bridge" patients instead of intravenous unfractionated heparin? Catheter Cardiovasc Interv. 2009;74 Suppl 1:S17-21.
14. Douketis JD, Bakhsh E. Perioperative management of antithrombotic therapy. Pol Arch Med Wewn. 2008;118:201-8.
15. O'Donnell M, Kearon C. Perioperative management of oral anticoagulation. Cardiol Clin. 2008;26:299-309.
16. Douketis JD, Johnson JA, Turpie AG. Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen. Arch Intern Med. 2004;164: 1319-26.
17. Jeske AH, Suchko GD. Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment. J Am Dent Assoc. 2003;134:1492-7.
18. Bacci C, Maglione M, Favero L, et al. Management of dental extraction in patients undergoing anticoagulant treatment. Results from a large, multicentre, prospective, case-control study. Thromb Haemost. 2010;104:972-5.
19. Eisen GM, Baron TH, Dominitz JA, et al. American Society for Gastrointestinal Endoscopy. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc. 2002;55:775-9.
20. Hirschman DR, Morby LJ. A study of the safety of continued anticoagulation for cataract surgery patients. Nurs Forum.2006;41:30-7.
21. Katz J, Feldman MA, Bass EB, et al. Study of Medical Testing for Cataract Surgery Team. Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology. 2003;110:1784-8.
22. Kallio H, Paloheimo M, Maunuksela EL. Haemorrhage and risk factors associated with retrobulbar/peribulbar block: a pro-spective study in 1383 patients. Br J Anaesth. 2000;85:708-11.
23. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35:64-101.
24. Syed S, Adams BB, Liao W, et al. A prospective assessment of bleeding and international normalized ratio in warfarin-anticoagulated patients having cutaneous surgery. J Am Acad Dermatol. 2004;51:955-7.
25. Sorbi D, Norton I, Conio M, et al. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc. 2000;51:690-6.
26. Ihezue CU, Smart J, Dewbury KC, et al. Biopsy of the prostate guided by transrectal ultrasound: relation between warfarin use and incidence of bleeding complications. Clin Radiol. 2005;60:459-63.
27. Wiegand UK, LeJeune D, Boguschewski F, et al. Pocket hematoma after pacemaker or implantable cardioverter defibrillator surgery: influence of patient morbidity, operation strategy, and perioperative antiplatelet/anticoagulation therapy. Chest.2004;126:1177-86.
28. Couillard P, Poppe AY, Coutts SB. Predicting recurrent stroke after minor stroke and transient ischemic attack. Expert Rev Cardiovasc Ther. 2009;7:1273-81.
29. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285: 2864-70.
30. Salem DN, Stein PD, Al-Ahmad A, et al. Antithrombotic therapy in valvular heart disease--native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126 (3 Suppl):S457-82.
31. Heit JA, Mohr DN, Silverstein MD, et al. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Arch Intern Med. 2000;160:761-8.
32. Büller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest.2004;126 (3 Suppl):S401-28.
33. Longstreth WT Jr, Bernick C, Fitzpatrick A, et al. Frequency and predictors of stroke death in 5,888 participants in the Cardiovascular Health Study. Neurology. 2001;56:368-75.
34. Hermans C, Claeys D. Review of the rebound phenomenon in new anticoagulant treatments. Curr Med Res Opin. 2006;22:471-81.
35. Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med. 1997;336:1506-11.
36. Dunn AS, Wisnivesky J, Ho W, et al. Perioperative management of patients on oral anticoagulants: a decision analysis. Med Decis Making. 2005;25:387-97.
37. Hann CL, Streiff MB. The role of vena caval filters in the management of venous thromboembolism. Blood Rev. 2005;19:179-202.
38. Amadeus Investigators, Bousser MG, Bouthier J, et al. Comparison of idraparinux with vitamin K antagonists for prevention of thromboembolism in patients with atrial fibrillation: a randomised, open-label, non-inferiority trial. Lancet. 2008;371:315-21.
39. Kalafut MA, Gandhi R, Kidwell CS, et al. Safety and cost of low-molecular-weight heparin as bridging anticoagulant therapy in subacute cerebral ischemia. Stroke. 2000;31:2563-8.
40. Shapira Y, Sagie A, Battler A. Low-molecular-weight heparin for the treatment of patients with mechanical heart valves. Clin Cardiol. 2002;25:323-7.
41. Ortel TL, Hasselblad V. A double blind randomized control trial of post-operative low molecular weight heparin bridging therapy versus placebo bridging therapy for patients who are at high risk for arterial thromboembolism (PERIOP-2). Canadian Institutes of Health Research (CIHR) [internet]. 2011 [citado: 10 de febrero de 2011]. Disponible en: URL: http://www.clinicaltrials.gov/ct2/show/NCT00432796?term=periop&rank=1
42. Ortel TL, Hasselblad V. Effectiveness of bridging anticoagulation for surgery (The BRIDGE Study). National Heart, Lung, and Blood Institute (NHLBI) [internet]. 2009 [citado: 10 de febrero de 2011]. Disponible en: URL : http://www.clinicaltrials.gov/ct2/show/NCT00786474?term=bridge&rank=26
43. Spyropoulos AC, Turpie AG, Dunn AS, et al. Clinical outcomes with unfractionated heparin or low-molecular-weight heparin as bridging therapy in patients on longterm oral anticoagulants: the REGIMEN registry. J Thromb Haemost.2006;4:1246-52.
44. Spyropoulos AC, Turpie AG, Dunn AS, et al. Perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin in patients with mechanical prosthetic heart valves on long-term oral anticoagulants (from the REGIMEN Registry). Am J Cardiol. 2008;102:883-9.
45. Ansell J, Hirsh J, Hylek E, et al. American College of Chest Physicians. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133 (6 Suppl):S160-98.
46. Hylek EM, Regan S, Go AS, et al. Clinical predictors of pro-longed delay in return of the international normalized ratio to within the therapeutic range after excessive anticoagulation with warfarin. Ann Intern Med. 2001;135:393-400.
47. Couturaud F, Julian JA, Kearon C. Low molecular weight heparin administered once versus twice daily in patients with venous thromboembolism: a meta-analysis. Thromb Haemost. 2001;86:980-4.
48. Woods K, Douketis JD, Kathirgamanathan K, et al. Low-dose oral vitamin K to normalize the international normalized ratio prior to surgery in patients who require temporary interruption of warfarin. J Thromb Thrombolysis. 2007;24:93-7.
49. Lubetsky A, Yonath H, Olchovsky D, et al. Comparison of oral vs intravenous phytonadione (vitamin K1) in patients with excessive anticoagulation: a prospective randomized controlled study. Arch Intern Med. 2003;163:2469-73.
50. Spence RK. Clinical use of plasma and plasma fractions. Best Pract Res Clin Haematol. 2006;19:83-96.
51. Leissinger CA, Blatt PM, Hoots WK, et al. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. Am J Hematol. 2008;83:137-43.
52. Demeyere R, Gillardin S, Arnout J, et al. Comparison of fresh frozen plasma and prothrombin complex concentrate for the reversal of oral anticoagulants in patients undergoing cardiopulmonary bypass surgery: a randomized study. Vox Sang.2010;99:251-60.
2.Friberg J, Gislason GH, Gadsb0ll N, et al. Temporal trends in the prescription of vitamin K antagonists in patients with atrial fibrillation. J Intern Med. 2006;259:173-8.
3.McKenna R. Abnormal coagulation in the postoperative period contributing to excessive bleeding. Med Clin North Am. 2001;85:1277-310.
4. Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med. 2003;139:893-900.
5. Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med. 2003;163:901-8.
6. Gladstone DJ, Bui E, Fang J, et al. Potentially preventable strokes in high-risk patients with atrial fibrillation who are not adequately anticoagulated. Stroke. 2009;40:235-40.
7. Rincón PG. Anticoagulación y anestesia, caso clínico. Rev. Colomb. anestesiol. 1987;15:291-6.
8. Valencia W, Husbands JS. Tromboembolismo venoso postoperatorio: grave riesgo prevenible. Rev Colomb Anestesiol. 2010;38:499-507.
9. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133 (6 Suppl):S299-339.
10. Spyropoulos AC, Douketis JD. Guidelines for antithrombotic therapy: periprocedural management of antithrombotic therapy and use of bridging anticoagulation. Int Angiol. 2008;27: 333-43.
11. Bonow RO, Carabello BA, Chatterjee K, et al. American Col-lege of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol. 2008;52:1-142.
12. Spyropoulos AC. To bridge or not to bridge: that is the question. The argument FOR bridging therapy in patients on oral anticoagulants requiring temporary interruption for elective procedures. J Thromb Thrombolysis. 2010;29:192-8.
13. Jaff MR. Chronically anticoagulated patients who need surgery: can low-molecular-weight heparins really be used to "bridge" patients instead of intravenous unfractionated heparin? Catheter Cardiovasc Interv. 2009;74 Suppl 1:S17-21.
14. Douketis JD, Bakhsh E. Perioperative management of antithrombotic therapy. Pol Arch Med Wewn. 2008;118:201-8.
15. O'Donnell M, Kearon C. Perioperative management of oral anticoagulation. Cardiol Clin. 2008;26:299-309.
16. Douketis JD, Johnson JA, Turpie AG. Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen. Arch Intern Med. 2004;164: 1319-26.
17. Jeske AH, Suchko GD. Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment. J Am Dent Assoc. 2003;134:1492-7.
18. Bacci C, Maglione M, Favero L, et al. Management of dental extraction in patients undergoing anticoagulant treatment. Results from a large, multicentre, prospective, case-control study. Thromb Haemost. 2010;104:972-5.
19. Eisen GM, Baron TH, Dominitz JA, et al. American Society for Gastrointestinal Endoscopy. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc. 2002;55:775-9.
20. Hirschman DR, Morby LJ. A study of the safety of continued anticoagulation for cataract surgery patients. Nurs Forum.2006;41:30-7.
21. Katz J, Feldman MA, Bass EB, et al. Study of Medical Testing for Cataract Surgery Team. Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology. 2003;110:1784-8.
22. Kallio H, Paloheimo M, Maunuksela EL. Haemorrhage and risk factors associated with retrobulbar/peribulbar block: a pro-spective study in 1383 patients. Br J Anaesth. 2000;85:708-11.
23. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35:64-101.
24. Syed S, Adams BB, Liao W, et al. A prospective assessment of bleeding and international normalized ratio in warfarin-anticoagulated patients having cutaneous surgery. J Am Acad Dermatol. 2004;51:955-7.
25. Sorbi D, Norton I, Conio M, et al. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc. 2000;51:690-6.
26. Ihezue CU, Smart J, Dewbury KC, et al. Biopsy of the prostate guided by transrectal ultrasound: relation between warfarin use and incidence of bleeding complications. Clin Radiol. 2005;60:459-63.
27. Wiegand UK, LeJeune D, Boguschewski F, et al. Pocket hematoma after pacemaker or implantable cardioverter defibrillator surgery: influence of patient morbidity, operation strategy, and perioperative antiplatelet/anticoagulation therapy. Chest.2004;126:1177-86.
28. Couillard P, Poppe AY, Coutts SB. Predicting recurrent stroke after minor stroke and transient ischemic attack. Expert Rev Cardiovasc Ther. 2009;7:1273-81.
29. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285: 2864-70.
30. Salem DN, Stein PD, Al-Ahmad A, et al. Antithrombotic therapy in valvular heart disease--native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126 (3 Suppl):S457-82.
31. Heit JA, Mohr DN, Silverstein MD, et al. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Arch Intern Med. 2000;160:761-8.
32. Büller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest.2004;126 (3 Suppl):S401-28.
33. Longstreth WT Jr, Bernick C, Fitzpatrick A, et al. Frequency and predictors of stroke death in 5,888 participants in the Cardiovascular Health Study. Neurology. 2001;56:368-75.
34. Hermans C, Claeys D. Review of the rebound phenomenon in new anticoagulant treatments. Curr Med Res Opin. 2006;22:471-81.
35. Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med. 1997;336:1506-11.
36. Dunn AS, Wisnivesky J, Ho W, et al. Perioperative management of patients on oral anticoagulants: a decision analysis. Med Decis Making. 2005;25:387-97.
37. Hann CL, Streiff MB. The role of vena caval filters in the management of venous thromboembolism. Blood Rev. 2005;19:179-202.
38. Amadeus Investigators, Bousser MG, Bouthier J, et al. Comparison of idraparinux with vitamin K antagonists for prevention of thromboembolism in patients with atrial fibrillation: a randomised, open-label, non-inferiority trial. Lancet. 2008;371:315-21.
39. Kalafut MA, Gandhi R, Kidwell CS, et al. Safety and cost of low-molecular-weight heparin as bridging anticoagulant therapy in subacute cerebral ischemia. Stroke. 2000;31:2563-8.
40. Shapira Y, Sagie A, Battler A. Low-molecular-weight heparin for the treatment of patients with mechanical heart valves. Clin Cardiol. 2002;25:323-7.
41. Ortel TL, Hasselblad V. A double blind randomized control trial of post-operative low molecular weight heparin bridging therapy versus placebo bridging therapy for patients who are at high risk for arterial thromboembolism (PERIOP-2). Canadian Institutes of Health Research (CIHR) [internet]. 2011 [citado: 10 de febrero de 2011]. Disponible en: URL: http://www.clinicaltrials.gov/ct2/show/NCT00432796?term=periop&rank=1
42. Ortel TL, Hasselblad V. Effectiveness of bridging anticoagulation for surgery (The BRIDGE Study). National Heart, Lung, and Blood Institute (NHLBI) [internet]. 2009 [citado: 10 de febrero de 2011]. Disponible en: URL : http://www.clinicaltrials.gov/ct2/show/NCT00786474?term=bridge&rank=26
43. Spyropoulos AC, Turpie AG, Dunn AS, et al. Clinical outcomes with unfractionated heparin or low-molecular-weight heparin as bridging therapy in patients on longterm oral anticoagulants: the REGIMEN registry. J Thromb Haemost.2006;4:1246-52.
44. Spyropoulos AC, Turpie AG, Dunn AS, et al. Perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin in patients with mechanical prosthetic heart valves on long-term oral anticoagulants (from the REGIMEN Registry). Am J Cardiol. 2008;102:883-9.
45. Ansell J, Hirsh J, Hylek E, et al. American College of Chest Physicians. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133 (6 Suppl):S160-98.
46. Hylek EM, Regan S, Go AS, et al. Clinical predictors of pro-longed delay in return of the international normalized ratio to within the therapeutic range after excessive anticoagulation with warfarin. Ann Intern Med. 2001;135:393-400.
47. Couturaud F, Julian JA, Kearon C. Low molecular weight heparin administered once versus twice daily in patients with venous thromboembolism: a meta-analysis. Thromb Haemost. 2001;86:980-4.
48. Woods K, Douketis JD, Kathirgamanathan K, et al. Low-dose oral vitamin K to normalize the international normalized ratio prior to surgery in patients who require temporary interruption of warfarin. J Thromb Thrombolysis. 2007;24:93-7.
49. Lubetsky A, Yonath H, Olchovsky D, et al. Comparison of oral vs intravenous phytonadione (vitamin K1) in patients with excessive anticoagulation: a prospective randomized controlled study. Arch Intern Med. 2003;163:2469-73.
50. Spence RK. Clinical use of plasma and plasma fractions. Best Pract Res Clin Haematol. 2006;19:83-96.
51. Leissinger CA, Blatt PM, Hoots WK, et al. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. Am J Hematol. 2008;83:137-43.
52. Demeyere R, Gillardin S, Arnout J, et al. Comparison of fresh frozen plasma and prothrombin complex concentrate for the reversal of oral anticoagulants in patients undergoing cardiopulmonary bypass surgery: a randomized study. Vox Sang.2010;99:251-60.
How to Cite
1.
Alvarado Arteaga IM. Current trends in the preoperative management of patients receiving warfarin for anticoagulation. Colomb. J. Anesthesiol. [Internet]. 2012 Jan. 1 [cited 2024 Apr. 29];40(1):52-9. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/866
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2012-01-01
How to Cite
1.
Alvarado Arteaga IM. Current trends in the preoperative management of patients receiving warfarin for anticoagulation. Colomb. J. Anesthesiol. [Internet]. 2012 Jan. 1 [cited 2024 Apr. 29];40(1):52-9. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/866
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