Anticoagulation around invasive procedures

Suggestions for Anticoagulation Management

Thromboembolic risk Renal function Bridge therapy
Low All patients
  • Last dose of warfarin on day -6 pre procedure
  • Hold warfarin day -5 through day -1
  • Consider vitamin K 2.5mg PO on day -1 pre-procedure if INR > 1.5
  • Resume warfarin 12-24 hours post-procedure at 1 to 1.5 times usual maintenance dose (decision based on post-op assessment of bleeding risk)
High or Moderate CrCl>30
  • Last dose of warfarin on day -6 pre procedure
  • Hold warfarin day -5 through day -1
  • Start LMWH on day -3 (or when INR < lower limit of range)
  • Consider vitamin K 2.5mg PO on day -1 pre-procedure if INR > 1.5
  • Initiate UFH SQ/IV or LMWH when INR falls below lower limit of therapeutic range
  • Last dose LMWH 24 hours pre-procedure (on day -1, give ½ dose LMWH if pt is receiving once-daily LMWH
  • Resume warfarin 12-24 hrs post-procedure at 1 to 1.5 times usual maintenance dose (decision based on post-procedure assessment of bleeding risk)
  • Resume LMWH 24 hrs post-procedure (or 48-72hrs for major surgery or high bleeding risk procedure) and continue until INR > lower limit of therapeutic range
CrCl<30
  • Last dose of warfarin on day -6 pre procedure
  • Hold warfarin day -5 through day -1
  • Consider vitamin K 2.5mg po or 1mg IV on day -1 pre-procedure if INR > 1.5
  • Admit on day –1 pre-procedure and begin IV UFH (70 U/kg bolus, 15 U/kg/hr infusion and adjust per inpatient protocol)
  • Stop IV UFH 6 hours pre-procedure
  • Resume warfarin 12-24 hours post-procedure at 1 to 1.5 times usual maintenance dose (decision based on post-op assessment of bleeding risk)
  • Resume UFH 24hrs post-procedure (or 48-72hrs for major surgery or high bleeding risk procedure) and continue until INR > lower limit of therapeutic range