A 63-year-old man with a history of aortic valve regurgitation and St. Jude AVR comes to your office for anticoagulation recommendations prior to colonoscopy. He is chronically anticoagulated with warfarin with a goal INR of 2.5. His EF is 35% by echocardiogram.
Which of the following do you recommend?
a. Stop his warfarin 10 days prior to the colonoscopy and restart the day after the procedure
b. Stop his warfarin 3 days prior to the colonoscopy, admit him to the hospital prior to the procedure for heparinization. He should remain in the hospital until the INR is above 2.0
c. Stop his warfarin now, begin full dose aspirin (325 mg) and perform the colonoscopy in 7 days
d. Admit directly to the hospital for 10 mg of vitamin K. Once his INR is _1.7, proceed with the colonoscopy. Keep him in hospital until his INR is higher than 2.0
e. Continue warfarin, but reduce the dose such that the goal INR is now 2.0 and proceed to colonoscopy.
Answer b:
According to the ACC guidelines, those patients with a bileaflet mechanical AVR with no risk factors (ie, AF, previous thromboembolism, LV dysfunction, hypercoagulable conditions, older generation thrombogenic valves, mechanical tricuspid valves, or more than one mechanical valve) should stop their warfarin 48 to 72 hrs before the procedure (so the INR falls to _1.5) and restarted within 24 hrs after the procedure.
Heparin is usually unnecessary. In those patients at high risk of thrombosis (defined as those with any mechanical MV replacement, or a mechanical AVR with any risk factor), therapeutic doses of IV UFH should be started when the INR falls below 2.0 (typically 48 hrs before surgery), stopped 4 to 6 hrs before the procedure, restarted as early after surgery as bleeding stability allows, and continued until the INR is again therapeutic with warfarin therapy. This patient has a mechanical AVR and reduced LV function; therefore, admitting the patient for heparin bridging before and after the procedure is necessary.
Which of the following do you recommend?
a. Stop his warfarin 10 days prior to the colonoscopy and restart the day after the procedure
b. Stop his warfarin 3 days prior to the colonoscopy, admit him to the hospital prior to the procedure for heparinization. He should remain in the hospital until the INR is above 2.0
c. Stop his warfarin now, begin full dose aspirin (325 mg) and perform the colonoscopy in 7 days
d. Admit directly to the hospital for 10 mg of vitamin K. Once his INR is _1.7, proceed with the colonoscopy. Keep him in hospital until his INR is higher than 2.0
e. Continue warfarin, but reduce the dose such that the goal INR is now 2.0 and proceed to colonoscopy.
Answer b:
According to the ACC guidelines, those patients with a bileaflet mechanical AVR with no risk factors (ie, AF, previous thromboembolism, LV dysfunction, hypercoagulable conditions, older generation thrombogenic valves, mechanical tricuspid valves, or more than one mechanical valve) should stop their warfarin 48 to 72 hrs before the procedure (so the INR falls to _1.5) and restarted within 24 hrs after the procedure.
Heparin is usually unnecessary. In those patients at high risk of thrombosis (defined as those with any mechanical MV replacement, or a mechanical AVR with any risk factor), therapeutic doses of IV UFH should be started when the INR falls below 2.0 (typically 48 hrs before surgery), stopped 4 to 6 hrs before the procedure, restarted as early after surgery as bleeding stability allows, and continued until the INR is again therapeutic with warfarin therapy. This patient has a mechanical AVR and reduced LV function; therefore, admitting the patient for heparin bridging before and after the procedure is necessary.
