Volume 182 - Issue 7
Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis
Author: David J Blacker
Med J Aust 2005; 182 (7): 365-368. || doi: 10.5694/j.1326-5377.2005.tb06741.x
Published online: 4 April 2005
Published online: 4 April 2005
To the Editor: The recent position statement by the Warfarin Reversal Consensus Group provides clear and concise guidelines for a number of clinical scenarios related to the use of warfarin. 1 Unfortunately, it makes the general statement about the periprocedural management of warfarin in patients with atrial fibrillation (AF), “clinical experience suggests that bridging therapy is not required” [page 496]. Clinicians caring for patients with large ischaemic stroke in these circumstances may beg to differ.
Although studies of bridging therapy in patients with AF in the periprocedural period are lacking, there are data which suggest that there is a considerably higher risk of thromboembolism during this period than would be expected by simply calculating the risk for several days off anticoagulation therapy.2-4 My own study of such patients undergoing endoscopy found a stroke risk of up to 3% in those at high risk.2 Many of these strokes were severe. The prothrombotic periprocedural environment may be a factor here, although advanced age and vascular risk factors may also contribute. The outstanding risk factor, however, is a previous history of stroke,2 and this is also a major risk factor for perioperative stroke in patients without AF.5 I would suggest careful, individualised assessment of all patients, and judicious bridging therapy where possible for patients with AF who have a past history of stroke.
References
- Baker RI, Coughlin PB, Gallus AS, et al. Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis. Med J Aust 2004; 181: 492-497. <eMJA full text>
- Blacker DJ, Wijdicks EF, McClelland RL. Stroke risk in anticoagulated patients with atrial fibrillation undergoing endoscopy. Neurology 2003; 61: 964-968. i1085674
- Dunn A, Turpie A. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med 2003; 163: 901-908.
- Kearon C, Hirsh J. Current concepts: management of anticoagulation before and after elective surgery. N Engl J Med 1997; 336: 1506-1511. i1085677
- Blacker DJ, Flemming KD, Link MJ, Brown RD. The preoperative cerebrovascular consultation: common cerebrovascular questions before general or cardiac surgery. Mayo Clin Proc 2004; 79: 223-229. i1085679