This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (17)  • Contact me when this article is cited  Related Content  • Related letters  • Similar articles in this journal  Topic Collections  • Thrombolysis  • Venous Thromboembolism  • Cardiovascular System  • Surgery  • Blood/ Coagulation  • Alert me on articles by topic  Social Bookmarking   What's this?

David A. Garcia, MD; Susan Regan, PhD; Lori E. Henault, MPH; Ashish Upadhyay, MD; Jaclyn Baker, MD; Mohamed Othman, MD; Elaine M. Hylek, MD, MPH

Arch Intern Med. 2008;168(1):63-69.

Background  Significant uncertainty surrounds the treatment of patients who must discontinue warfarin sodium therapy before an invasive procedure. In part, the uncertainty results from the lack of published information about the risk of thromboembolism associated with short-term warfarin therapy interruption. We aimed to assess the frequency of thromboembolism and bleeding within a large cohort of patients whose warfarin therapy was temporarily withheld for an outpatient invasive procedure.

Methods  This prospective, observational cohort study was performed at 101 sites (primarily community-based physician office practices) in the United States. Enrollment was conducted from April 4, 2000, to March 6, 2002. The main outcome measures were thromboembolism or clinically significant hemorrhage within 30 days of warfarin therapy interruption.

Results  A total of 1293 episodes of warfarin therapy interruption in 1024 individuals were included. The mean (SD) patient age was 71.9 (10.6) years; 438 (42.8%) were female. The most common indications for anticoagulant therapy were atrial fibrillation (n = 550), venous thromboembolism (n = 144), and mechanical heart valve (n = 132). The most common procedures were colonoscopy and oral and ophthalmic surgery. Perioperative heparin or low-molecular-weight heparin was used in only 8.3% of cases overall. Seven patients (0.7%; 95% confidence interval [CI], 0.3%-1.4%) experienced postprocedure thromboembolism within 30 days. None of the 7 patients who experienced thromboembolism received periprocedural bridging therapy. Six patients (0.6%; 95% CI, 0.2%-1.3%) experienced major bleeding, whereas an additional 17 patients (1.7%; 95% CI, 1.0%-2.6%) experienced a clinically significant, nonmajor bleeding episode. Of these 23 patients who had bleeding episodes, 14 received periprocedural heparin or low-molecular-weight heparin. The duration of warfarin therapy interruption was variable; however, more than 80% of patients had warfarin therapy withheld for 5 days or fewer.

Conclusions  For many patients receiving long-term anticoagulation who need to undergo a minor outpatient intervention, a brief (5 days) periprocedural interruption of warfarin therapy is associated with a low risk of thromboembolism. The risk of clinically significant bleeding, even among outpatients undergoing minor procedures, should be weighed against the thromboembolic risk of an individual patient before the administration of bridging anticoagulant therapy.

Author Affiliations: Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque (Drs Garcia and Othman); and Department of Medicine, General Medicine Unit, Massachusetts General Hospital (Dr Regan), Department of Medicine, Research Unit–Section of General Internal Medicine, Boston University School of Medicine (Drs Baker and Hylek and Ms Henault), and Department of Medicine, Caritas St Elizabeth's Medical Center, Tufts University School of Medicine (Dr Upadhyay), Boston.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

RELATED LETTERS

Periodontal Surgery for Patients Receiving Anticoagulant Therapy
Sharon Elad and Mordechai Findler
Arch Intern Med. 2008;168(15):1719.
EXTRACT | FULL TEXT  

Factors in Warfarin Therapy Discontinuation
Christopher John Boos and Howard J. Marshall
Arch Intern Med. 2008;168(17):1932.
EXTRACT | FULL TEXT  

Factors in Warfarin Therapy Discontinuation—Reply
David Garcia and Elaine Hylek
Arch Intern Med. 2008;168(17):1933.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Standardized Low-Molecular-Weight Heparin Bridging Regimen in Outpatients on Oral Anticoagulants Undergoing Invasive Procedure or Surgery: An Inception Cohort Management Study
Pengo et al.
Circulation 2009;119:2920-2927.
ABSTRACT | FULL TEXT  

Preparation for pacemaker or implantable cardiac defibrillator implants in patients with high risk of thrombo-embolic events: oral anticoagulation or bridging with intravenous heparin? A prospective randomized trial
Tolosana et al.
Eur Heart J 2009;0:ehp194v2-ehp194.
ABSTRACT | FULL TEXT  

Warfarin Therapy Adjustment for Oral Surgery Is an Unnecessary Risk
Bayne and Brennan
Arch Intern Med 2008;168:1932-1932.
FULL TEXT  

Factors in Warfarin Therapy Discontinuation
Boos and Marshall
Arch Intern Med 2008;168:1932-1932.
FULL TEXT  

Periodontal Surgery for Patients Receiving Anticoagulant Therapy
Elad and Findler
Arch Intern Med 2008;168:1719-1719.
FULL TEXT  

The Perioperative Management of Antithrombotic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Douketis et al.
Chest 2008;133:299S-339S.
ABSTRACT | FULL TEXT  

Warfarin: To Stop or Not to Stop?
Journal Watch Dermatology 2008;2008:3-3.
FULL TEXT  

Bridging Anticoagulation
JWatch Oncology and Hematology 2008;2008:2-2.
FULL TEXT