Abstract
BackgroundAnticoagulation with warfarin should be stopped 4–6 days before invasive procedures to avoid bleeding complications. Despite this routine, some patients still have high International Normalized Ratio (INR) values on the day of surgery and the procedure may be cancelled. We sought to identify easily available clinical characteristics that may influence the rate of normalization of prothrombin time when warfarin is stopped before surgery or invasive procedures.MethodsClinical data were collected retrospectively from consecutive cases from two cohorts, who stopped warfarin 6 days before surgery. An INR value of 1.6 or higher on the day of surgery or requirement for reversal with vitamin K the day before surgery were criteria for slow return (S) to normal INR.ResultsOf 202 patients, 14 (7%) were classified as S. Eight of the S-patients required reversal with vitamin K one day before surgery and in another case surgery was cancelled due to high INR. Baseline INR was the only variable significantly associated with classification as S in stepwise logistic regression analysis (p = 0.003). The odds ratio for being in the normal group was 0.27 (95% confidence interval 0.12–0.62) for each unit baseline INR increased. The positive predictive value of baseline INR with a cut off at > 3.0 was only 15% and for INR > 3.5 it was 33%.ConclusionBaseline INR, but not the size of the maintenance dose, is associated with the rate of normalization of prothrombin time after stopping warfarin, but it has limited utility as predictor in clinical practice. Whenever normal hemostasis is considered crucial for the safety, the INR should be checked again before the invasive procedure.
Highlights
Anticoagulation with warfarin should be stopped 4–6 days before invasive procedures to avoid bleeding complications
The normalization of the prothrombin time, expressed as International Normalized Ratio (INR) as an indicator of re-establishment of normal hemostasis depends on the clearance of the vitamin K antagonists (VKA) and on the capacity of the liver to synthesize the coagulation factors II, VII, IX and X
Study design In this study we retrospectively reviewed the data from two sources, both consisting of patients seen by the Thrombosis Service at Hamilton Health Sciences preoperatively for bridging of anticoagulation in association with surgery or invasive procedures
Summary
Anticoagulation with warfarin should be stopped 4–6 days before invasive procedures to avoid bleeding complications Despite this routine, some patients still have high International Normalized Ratio (INR) values on the day of surgery and the procedure may be cancelled. The normalization of the prothrombin time, expressed as International Normalized Ratio (INR) as an indicator of re-establishment of normal hemostasis depends on the clearance of the VKA and on the capacity of the liver to synthesize the coagulation factors II, VII, IX and X. The latter is contingent on the availability of vitamin K
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