Dunn proposed perioperative management of a patient taking an oral anticoagulant. These recommendations can reduce adverse effects and complications. The author is from Mount Sinai Medical Center in New York City.
Patient selection: on an oral anticoagulant
Parameters:
(1) annual risk of stroke without anticoagulation
(2) risk of bleeding associated with the procedure
(3) patient's strong preference for bridging
Annual Risk of Stroke
Risk of Bleeding
Patient Wants Bridging
Strategy
low (< 4%)
low
NA
no bridging
low (< 4%)
high
NA
no bridging
moderate (4-8%)
low
no
no bridging
moderate (4-8%)
low
yes
bridge preoperatively
moderate (4-8%)
high
NA
bridge preoperatively
high (> 8%)
low
NA
bridge
high (> 8%)
high
NA
bridge
where:
• A low risk for stroke corresponds to atrial fibrillation with <= 2 risk factors for stroke.
• A moderate risk for stroke corresponds to a bileaflet mechanical atrial valve replacement.
• A high risk for stroke corresponds to a mechanical mitral valve replacement.
A person who is undergoing a minor procedure may not need to stop the oral anticoagulants. If there is some risk of bleeding associated with the procedure, then anticoagulants may be stopped a few days prior to surgery (many patients are subtherapeutic after 2 days without therapy).
Preoperative bridging:
(1) Stop oral anticoagulants 4 days prior to surgery.
(2) Start heparin (usually low molecular weight heparin at a therapeutic dose) 2 days prior to surgery.
(3) If the patient cannot take heparin then another parenteral anticoagulant is used.
Patients should be restarted on oral anticoagulants in the evening after the procedure provided hemostasis is adequate.
Postoperative bridging:
(1) Start heparin (usually low molecular weight heparin at a therapeutic dose) 12-24 hours after surgery if there is no excessive bleeding.
(2) Postoperative bridging may significantly increase the risk of major bleeding.
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