Peri Operative Anticoagulation in Non valvular AF

To bridge or Not to bridge these patients with LMWH is always the question asked. Although interruption of warfarin is thought to expose patients to a low risk of arterial thromboembolism, such events can have devastating consequences: valve thrombosis is associated with a 15% mortality rate, and an embolic stroke is associated with a 70% rate of major neurologic deficit or death.

Attempting to mitigate this risk by administering a short-acting anticoagulant, typically low-molecular-weight heparin (LMWH), shortly before or after surgery as “bridging anticoagulation” can expose patients to serious bleeding complications.
To walk this fine line between the twin risks of thromboembolism and bleeding requires an approach to perioperative anticoagulation that is sensible and, when possible, based on evidence.

A sensible approach entails first estimating a patient’s risk of thromboembolism, which will help determine whether bridging can be justified on the basis of empiric considerations (as clinical trials addressing this issue have not yet been done). After estimating the patient’s risk, the clinician should next consider the risk of bleeding associated with the surgery and tailor postoperative anticoagulation to minimize this risk. An assessment of postoperative hemostasis is essential, as it can modify reinitiation of postoperative anticoagulation. Finally, after anticoagulant treatment is resumed, ongoing vigilance for bleeding and thromboembolism is needed, especially during the first 1 to 2 weeks after surgery when most of these adverse events occur.
Read the article published in Mayo Clinic Proceedings.......