Anticoagulation Bridging
Decision Support
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Click here for references
Oral Anticoagulants
What oral anticoagulant does the patient take?
Warfarin (Coumadin®, others)
Dabigatran (Pradaxa®)
Rivaroxaban (Xarelto®)
Is surgery or procedure elective or
emergent?
Elective
Emergent
Thromboembolism Risk
• This risk classification is an initial guide for decisionmaking that should be adapted to individual patient
circumstances. If you are unsure of your patient’s risk
of thromboembolism, continue with decision support
here.
• If you already know your patient’s risk of
thromboembolism, choose management plan below:
– High Thromboembolic Risk Perioperative Bridging
– Moderate Thromboembolic Risk Perioperative Bridging
– Low Thromboembolic Risk – no bridging therapy
Is patient having any of the following (very low
bleeding risk procedures):
1) Dental extraction?
2) Cataract extraction/IOL?
3) Upper GI endoscopy?
4) Carpal Tunnel Release?
5) Needle Breast Biopsy?
6) Cutaneous procedure (Mohs, excisions)?
Yes
No
HIGH RISK: Does patient have any of the following?
1) Any mitral valve prosthesis?
2) Caged-ball or tilting disc valve prosthesis? (Types
of Mechanical Valves)
3) Stroke, TIA, or VTE in last 3 months?
4) Stroke or TIA with mechanical valve in last 6
months?
5) Severe thrombophilia? (examples)
6) CHADS2 score of 5 or 6 with atrial fibrillation?
(CHADS2 Scoring Tool)
7) Rheumatic valvular heart disease with atrial
fibrillation?
Yes
No
MODERATE RISK: Does patient have any of the
following?
1) Bileaflet aortic valve prosthesis with at least one
risk factor? (risk factors)
2) CHADS2 score of 3 or 4 with atrial fibrillation?
3) Prior thromboembolism with atrial fibrillation
during interruption of warfarin?
4) VTE within past 3-12 months?
5) Recurrent VTE?
6) Active cancer (treated within 6 months or
palliative)?
7) Non-severe thrombophilia? (examples)
Yes
No
Patient does not meet criteria for moderate or
high risk of thromboembolism.
Consider no bridging therapy during
interruption of warfarin unless patient’s history
indicates otherwise.
Exit
No need to stop warfarin before
surgery or procedure.
Exit
Types of Mechanical Valves
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Valve Type
Valve Name(s)
Bileaflet
St. Jude; CarboMedics; ATS Open Pivot;
On-X; Conform-X
Tilting Disc (single leaflet)
Bjork-Shiley (now discontinued); Medtronic
Hall; Omnicarbon; Monostrut
Caged-Ball
Starr-Edwards (only one FDA approved)
Bioprosthetic (does not require
anticoagulation)
Carpentier-Edwards (porcine); Hancock II
and Mosaic (both by Medtronic, porcine);
Edwards Prima Plus, Medtronic Freestyle,
and Toronto SPV (by St. Jude) are
pericardial porcine valves.
Prosthetic Heart Valves. Author: Eric M Kardon, MD, FACEP, Attending Emergency Physician, Georgia
Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center.
CHADS2 Scoring Tool
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Characteristic
Points
Recent CHF exacerbation
1
Hypertension (treated or untreated)
1
Age > 75 years
1
Diabetes
1
Prior Stroke or TIA
2
Examples of Severe Thrombophilia
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•
•
•
•
•
Protein C Deficiency
Protein S Deficiency
Antithrombin Deficiency
Antiphospholipid Syndrome
Multiple abnormalities
Risk Factors
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•
•
•
•
•
•
Atrial fibrillation
Prior stroke or TIA
Hypertension
Diabetes
Congestive heart failure
Age > 75
Examples of Non-severe Thrombophilia
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• Heterozygous factor V Leiden mutation
• Factor II (prothrombin) mutation
Patient is at HIGH risk for thromboembolism
Consider bridging patient with therapeutic
enoxaparin if bleeding risk acceptable.
Consider use of heparin infusion for patients
with mechanical valve. Click here for
suggested bridging plan.
Patient is at MODERATE risk of thromboembolism
If patient is undergoing a major cardiac surgery or
carotid endarterectomy surgery, consider no
bridging therapy.
If patient is undergoing a surgery or procedure with
low risk for bleeding, consider bridging with
heparin infusion, therapeutic enoxaparin, or lowdose enoxaparin based on patient's history.
For all other patients with moderate risk, bridging
therapy should be chosen based on patient’s
history. Click here for suggested bridging plans.
Patient is at LOW risk of thromboembolism
Consider no bridging therapy during
interruption of warfarin based on patient’s
history.
Exit
High Thromboembolism Risk
Perioperative Bridging
Day
Anticoagulation Plan
Pre-op Day 5
Stop warfarin (last dose on Pre-op Day 6).
Pre-op Day 3
Start therapeutic enoxaparin bridging (1 mg/kg SC q12h) or heparin infusion
when INR < goal range.
Pre-op Day 1
Check INR, give vitamin K 1.25-2.5 mg orally if INR > 1.5. Last dose of
therapeutic enoxaparin (if using) must be > 24 hours prior to surgery.
Day of Surgery
Check INR, consider additional vitamin K if INR > 1.5. Stop heparin infusion (if
using) 4-6 hours prior to surgery. Assess hemostasis postoperatively. May
resume warfarin evening of surgery if patient taking fluids.
Post-op Day 1
Standard bleeding risk: Resume therapeutic enoxaparin or heparin infusion 24
hours after surgery if hemostasis achieved.
High bleeding risk: Consider no bridging or low-dose enoxaparin (40 mg SC
daily) 24 hours after surgery if hemostasis achieved.
Post-op Day 2
High bleeding risk: Resume therapeutic enoxaparin or heparin infusion 48-72
hours after surgery if hemostasis achieved.
Post-op Day 4+
Discontinue bridging when INR in goal range.
Exit
Moderate Thromboembolism Risk
Perioperative Bridging
Day
Anticoagulation Plan
Pre-op Day 5
Stop warfarin (last dose on Pre-op Day 6).
Pre-op Day 3
Start low-dose enoxaparin (40mg SC daily), therapeutic enoxaparin (1 mg/kg SC
q12h), or heparin infusion based on patient’s bleeding risk when INR < goal
range.
Pre-op Day 1
Check INR, give vitamin K 1.25-2.5 mg orally if INR > 1.5. Last dose of any
enoxaparin (if using) must be > 24 hours prior to surgery.
Day of Surgery
Check INR, consider additional vitamin K if INR > 1.5. Stop heparin infusion (if
using) 4-6 hours prior to surgery. Assess hemostasis postoperatively. May
resume warfarin evening of surgery if patient taking fluids.
Post-op Day 1
Standard bleeding risk: Resume low-dose enoxaparin, therapeutic enoxaparin,
or heparin infusion 24 hours after surgery if hemostasis achieved.
High bleeding risk: Consider no bridging or low-dose enoxaparin 24 hours after
surgery if hemostasis achieved.
Post-op Day 2
High bleeding risk: Continue low-dose enoxaparin (if started post-op day 1) or
resume therapeutic enoxaparin or heparin infusion 48-72 hours after surgery if
hemostasis achieved.
Post-op Day 4+
Discontinue bridging when INR in goal range.
Exit
Emergency Surgery
When rapid reversal is required for any INR:
1) Discontinue warfarin temporarily
2) Administer vitamin K1 2-5mg by slow IV
infusion**
3) Supplement with fresh frozen plasma (at least
15ml/kg)
4) Recheck INR and administer additional vitamin
K1 in 4-8 hrs, if necessary
** Intravenous vitamin K should be diluted in 50mg Dextrose 5% and
administered over 60 minutes to decrease risk of anaphylaxis.
Return to Anticoagulation Bridging
Decision Support
Exit
High Bleeding Risk Examples
• Urologic surgery and procedures consisting of TURP, bladder
resection, or tumor ablation; nephrectomy; or kidney biopsy
• Pacemaker or implantable cardioverter-defibrillator device
implantation
• Colonic polyp resction, typically of large (1-2 cm long) sessile polyps
• Surgery and procedures in highly vascular organs (kidney, liver,
spleen)
• Bowel resection
• Major surgery with extensive tissue injury (cancer surgery, joint
arthroplasty, reconstructive plastic surgery)
• Cardiac, intracranial, or spinal surgery
Return to High
Thromboembolism Risk
Perioperative Bridging
Return to Moderate
Thromboembolism Risk
Perioperative Bridging
Dabigatran “Bridging”
•
Emergent Surgery:
–
–
–
•
Stop dabigatran. If appropriate, consider delaying surgery until aPTT is normal or appropriate amount of
time has passed for drug to have cleared (see table below). INR is not a reliable indicator.
There is no reversal agent for dabigatran. Transfuse FFP, PRBC and platelets as indicated. Consider use of
recombinant factor VIIa or hemodialysis. PCC is not available at St. Mary’s Hospital.
Consider Hematology Consult.
Elective Surgery:
Creatinine
Clearance
(mL/min)
Dabigatran Half-life
(hours)
Last dose of dabigatran prior to surgery
Standard Bleeding Risk
High Bleeding Risk
> 80
13 (11-22)
24 hours
2-4 days
> 50 to ≤ 80
15 (12-34)
24 hours
2-4 days
> 30 to ≤ 50
18 (13-23)
At least 2 days (48 hours)
4 days
≤ 30*
27 (22-35)
2-5 days
> 5 days
*dabigatran is contraindicated when CrCl ≤ 30 mL/min
Restart dabigatran post-operatively when hemostasis achieved and wound is stable. Bridging anticoagulation is
not necessary due to rapid onset of dabigatran, but use of an alternate route anticoagulant (e.g. LMWH) may be
appropriate if the patient cannot take medications by mouth.
Exit
Rivaroxaban “Bridging”
• Emergent Surgery:
– Stop rivaroxaban. If appropriate, consider delaying surgery until PT (not INR) is
normal or appropriate amount of time has passed for drug to have cleared
(see below).
– There is no reversal agent for rivaroxaban. Transfuse FFP, PRBC and platelets as
indicated. Consider use of recombinant factor VIIa. Rivaroxaban is not
dialyzable. PCC is not available at St. Mary’s Hospital.
– Consider Hematology consult.
• Elective Surgery: Hold rivaroxaban for 1-2 days prior to surgery based on
elimination half-life (5-9 hours in healthy adults, 11-13 hours in elderly
adults).
Restart rivaroxaban post-operatively when hemostasis achieved, at least
6-10 hours. Bridging anticoagulation is not necessary due to rapid onset or
rivaroxaban, but use of an alternate route anticoagulant (e.g. LMWH) may
be appropriate if the patient cannot take medications by mouth.
Exit
References
Return to Anticoagulation Bridging Decision Support
• Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH,
et al. Perioperative management of antithrombotic therapy:
antithrombotic therapy and prevention of thrombosis, 9th ed: American
college of chest physicians evidence-based clinical practice guidelines.
Chest. 2012;141:e326S-e350S.
• Douketis JD. Perioperative management of patients who are receiving
warfarin therapy: an evidence-based and practical approach. Blood.
2011;117(19):5044-5049.
• Garcia DA. Update in bridging anticoagulation. J Thromb Thrombolysis.
2011;31(3):259-264.
• Lexi-comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.;
September 20, 2011.
• Guidelines for testing and perioperative management of dabigatran. New
Zealand Government PHARMAC.
• DeLoughery TG. Practical aspects of the oral new anticoagulants. Am J
Hematol. 2011;86:586-590.
Updated May 14, 2012
Katherine Rotzenberg, PharmD; Dr. Roy Kim; Dave Pauly, RPh