Case 70 – part 1 – summary

So our patient was a 75 year old male who has a PMH of NIDDM, HTN, AF and a previous bioprosthetic AV replacement.

He is anticoagulated for AF with a CHADS2 score of 3 – which is an annual stroke risk of 5.9%. Different hospitals may use different scoring systems for anticoagulation in AF.

It is important to ensure to clarify the type of heart valve the patient has, as a metallic mitral heart valve will have a significantly greater risk than a metallic aortic valve. And different types of metallic valves have significantly different risks. A bioprosthetic valve, or heart valve repair in its self is not usually an indication for long term anticoagulation.

So in our patient who is due a femoral hernia repair we need to consider if bridging is necessary. He has a CHADS2 score of 3 and has not had a CVA/TIA. According to the BCSH perioperative management of anticoagulation and anti platelets (keeling et al) 2016 guidelines, strictly our patient does not need bridging anticoagulation. Patients with AF and a CHADS2 score of >4 or a TIA/CVA within 3 months should receive bridging anticoagulation. Anticoagulation decisions can be discussed with each patient to ensure that they are fully informed.

If patient’s with AF or other indication for bridging anticoagulation are on warfarin then the warfarin is normally stopped 5 days prior to the procedure with bridging anticoagulation – usually LMWH started when the patient is/is expected to be sub therapeutic which is usually 2 days later. Different hospitals may have different protocols, and this may be different in different circumstance which are considered greater risk e.g. metallic MVR. You should check your own hospitals protocol. 

The INR should ideally be check the day prior to surgery to ensure the INR will be suitable for the procedure and that no vitamin k is needed. 

If the patient is on OD bridging LMWH the last dose is normally 24 hours prior to surgery.

The decision regarding when to start post operative anticoagulation will need to be in conjunction with the surgical team and for some high risk of bleeding procedures the surgical team may wish for 48 hours off treatment dose anticoagulation post operatively.

Once the patient has been restated on bridging anticoagulation this should be continued until INR is back into therapeutic range unless there are bleeding concerns.

Has anyone got any questions? Would you/does your hospital do things differently? 

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