A 79-year-old woman is referred for perioperative evaluation prior to cataract surgery. Medical history is significant for hypertension, heart failure, mild intermittent asthma, gout, and nonvalvular atrial fibrillation for which she takes warfarin. Medications also include lisinopril, furosemide, carvedilol, and amlodipine. The patient has no history of stroke. Two weeks ago, the INR was 2.5.
Blood pressure is 130/82 mm Hg and pulse is 84/min and irregular. Jugular venous pressure is normal and the lungs are clear to auscultation. The patient has a grade 2/6 systolic ejection murmur at the right upper sternal border without radiation. Pedal edema is not present.
What is the best way to manage this patient's anticoagulation?

Question

A 79-year-old woman is referred for perioperative evaluation prior to cataract surgery.  Medical history is significant for hypertension, heart failure, mild intermittent asthma, gout, and nonvalvular atrial fibrillation for which she takes warfarin.  Medications also include lisinopril, furosemide, carvedilol, and amlodipine.  The patient has no history of stroke.  Two weeks ago, the INR was 2.5.
Blood pressure is 130/82 mm Hg and pulse is 84/min and irregular.  Jugular venous pressure is normal and the lungs are clear to auscultation.  The patient has a grade 2/6 systolic ejection murmur at the right upper sternal border without radiation.  Pedal edema is not present.
What is the best way to manage this patient's anticoagulation?

Quizplus · Accepted Answer

11ec193a_9731_e634_853d_0be59d2f5ecc_MD0002_00 Management of perioperative anticoagulation with warfarin requires consideration of the surgical risk of bleeding weighed against the perioperative thrombotic risk if anticoagulation is stopped: perioperative thrombotic risk Low-bleeding-risk surgeries or procedures (eg, cataract surgery, central venous catheter removal) do not typically require adjustment or interruption in the warfarin regimen, regardless of thrombotic risk.High-bleeding-risk surgeries (eg, joint replacement) require a temporary interruption in anticoagulation. For patients at very high thrombotic risk (eg, CHA₂DS₂-Vasc score ≥6), the interruption in anticoagulation should be accompanied by perioperative bridging (eg, low-molecular-weight heparin, unfractionated heparin) (Choice B). Low-bleeding-risk surgeries or procedures (eg, cataract surgery, central venous catheter removal) do not typically require adjustment or interruption in the warfarin regimen, regardless of thrombotic risk. Low-bleeding-risk surgeries or procedures (eg, cataract surgery, central venous catheter removal) do not typically require adjustment or interruption in the warfarin regimen, regardless of thrombotic risk. High-bleeding-risk surgeries (eg, joint replacement) require a temporary interruption in anticoagulation. For patients at very high thrombotic risk (eg, CHA₂DS₂-Vasc score ≥6), the interruption in anticoagulation should be accompanied by perioperative bridging (eg, low-molecular-weight heparin, unfractionated heparin) (Choice B). High-bleeding-risk surgeries (eg, joint replacement) require a temporary interruption in anticoagulation. For patients at very high thrombotic risk (eg, CHA₂DS₂-Vasc score ≥6), the interruption in anticoagulation should be accompanied by perioperative bridging (eg, low-molecular-weight heparin, unfractionated heparin) (Choice B). This patient with atrial fibrillation and a CHA₂DS₂-Vasc score of 5 is at high perioperative thrombotic risk but is undergoing a low-bleeding-risk surgery (cataract); therefore, continuation of warfarin is appropriate. Temporary interruption of warfarin without perioperative bridging would have been appropriate if she had been undergoing a high-bleeding-risk surgery (Choice C). CHA₂DS₂-Vasc (Choices D and E) Neither permanent discontinuation of warfarin nor temporary reduction in the target INR is a viable strategy for managing perioperative bleeding and thrombotic risk in this patient requiring warfarin for atrial fibrillation. Educational objective: Management of perioperative anticoagulation with warfarin involves balancing the bleeding risk of surgery with the thrombotic risk of stopping anticoagulation. Low-bleeding-risk surgeries or procedures (eg, cataract surgery) typically require no adjustment or interruption in the warfarin regimen. High-bleeding-risk surgeries (eg, joint replacement) require a temporary interruption in anticoagulation; the interruption should be accompanied by bridging (eg, low-molecular-weight heparin, unfractionated heparin) in patients at very high thrombotic risk. __________ References: Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22315257)

A 79-Year-Old Woman Is Referred for Perioperative Evaluation Prior to Cataract