Descarga: Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach
Archivo: guias/varias/Warfarina manejo perioperatorio guias.pdf
The management of patients who are receiving anticoagulants and require surgery or an invasive procedure is a common clinical problem that, paradoxically, is both trivial and complex.1,2 It is trivial because stopping and resuming an anticoagulant is simple enough: wait until the anticoagulant effect wears off and resume it when there is adequate hemostasis. It is complex because of the wide range of perceived thromboembolic risks during anticoagulant interruption. Consider that in a prospective cohort study assessing warfarin interruption in 535 low- to moderate-risk patients with atrial fibrillation who interrupted warfarin and did not receive heparin bridging, the incidence of arterial thromboembolism was 0.7% (95% confidence interval [CI]: 0.2-1.9).3 The authors concluded that “… for many patients receiving warfarin who need a minor procedure, a brief (5 day) interruption of therapy isassociatedwithalowriskofthromboembolism.”Nowconsidera retrospective cohort study that estimated a risk for thrombotic events of 1 per 6219 (0.016%) during warfarin interruption in a broad spectrum of warfarin-treated patients.4 The authors concluded that “with no documented increase in severe bleeding during perioperative continuation of warfarin, these data provide a compelling argument to maintain patients on warfarin during cutaneous operations.” Thus, one group considered that a risk for thromboembolism of 0.7% associated with simply stopping and restarting warfarin was acceptable, obviating the need for heparin bridging, whereas another group thought a risk of 0.016% was too high and justified perioperative continuation of warfarin.Added to these varied perceptions of thromboembolic risk is the wide range of surgical and other invasive procedures that patients undergo and clinicians’ differing perceptions of associated bleeding risk.5,6 Overall, the perceived risk for thromboembolism will likely drive patient management,6 and if it is perceived to be greater than the risk for bleeding, this will determine whether heparin bridging is administered during warfarin interruption.
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