ABSTRACT
When orally anticoagulated patients need to have surgery, the goals of management
are to minimize the risks of thromboembolism and of bleeding from the invasive procedure.
Some invasive procedures can be performed while patients are fully or partially anticoagulated
because bleeding is rare and/or easily controlled. When it is necessary to reverse
oral anticoagulant therapy it should be interrupted for as short a time as possible,
usually 4 or 5 days. Intravenous unfractionated heparin or therapeutic-dose subcutaneous
low-molecular-weight heparin (LMWH) can be given as “bridging therapy” to reduce the
risk of thromboembolism while oral anticoagulation is interrupted. However, the risks
and benefits of bridging therapy are uncertain. Bridging therapy, particularly with
LMWH, may not be very effective at preventing embolism in patients with atrial fibrillation
or mechanical heart valves, and it may be associated with bleeding. My preference
is to minimize the time that patients are off oral anticoagulant therapy, generally
restarting warfarin the day of surgery; reserve bridging therapy for those at highest
risk of thromboembolism; and to use “prophylactic” rather than “therapeutic” doses
of heparin after major surgery. As major surgery markedly increases the risk of venous
thromboembolism, postoperative bridging therapy should be considered for patients
without an inferior vena caval filter that have had proximal deep vein thrombosis
or pulmonary embolism during the previous month.
KEYWORDS
Anticoagulation - surgery - bridging therapy - perioperative
