Warfarin Management

Perioperative Warfarin (Coumadin) Management  

Navigating a fine line between bleeding and thromboembolic complications

Perioperative management of the chronically anticoagulated patient is like navigating a fine line between bleeding versus thromboembolic complications.

INR

The INR is used for monitoring patients who have been stabilized on Anticoagulant Therapy.

Conventional Anticoagulation: INR = 2.0 - 3.0

High Intensity Anticoagulation: INR = 3.0 - 3.5

Any INR >5.0 is considered a CRITICAL

"Bridging” is a term used to describe the temporary use of short-acting anticoagulants (heparin or Low Molecular Weight Heparin, LMWH) during the pause of warfarin therapy.

LMWH available in the US: dalteparin (Fragmin®) and enoxaparin (Lovenox®).

CHAD SCORE

C	Congestive Heart failure	1
H	Hypertension	1
A	Age >75 years	1
D	Diabetes	1
S2	Stroke or TIA	2

SCORE

0	3%	Low
1	4%	Low
2	5%	Intermediate
3	6%	Intermediate
4	8%	High
5	12%	High
6	18%	High

CHAD-VASc SCORE

C	CHF/LV dysfunction	1
H	Hypertension	1
A2	Age ≥ 75	2
D	Diabetes mellitus	1
S2	Stroke/TIA/TE (thromboembolism)	2
V	Vascular disease - CAD, MI, PAD or aortic plaque	1
A	Age 65-74	1
Sc	Sex category - Female	1

Bridging-decision making steps

Step1:

Patient Assesment: Patient assesment is the first step in every therapy management including bridging. 

Some assessment factors include

1. Patient age

2. Surgery

3. Comorbidities

4. INR and anticoagulation data

5. Other medications

6. CHADS2 score

Step 2:

Identify the risk of clot formation.

Low risk: No need of bridging

Intermediate risk: Individualize and decide based on patient-specific factors

High-risk: Consider bridging