[Bleeding risk and perioperative management of patients anticoagulated with vitamin K antagnosists]

Marzia Angelo, Ingrid Stockner, Christian J Wiedermann
Wiener Medizinische Wochenschrift 2008, 158 (21-22): 615-20
There is little consensus on the optimal perioperative management for most patients on oral anticoagulation with vitamin K antagonists. Bridging therapy is not recommended for the majority of patients on oral anticoagulation as most are at low risk for perioperative stroke. Though most clinicians choose an aggressive perioperative strategy for patients with high thromboembolic risk (e.g., mechanical mitral valve replacement) by withholding warfarin perioperatively and the use of full-dose heparin, prophylactic dose heparin is given for lower risk cagegories (e.g., bileaflet aortic valve replacement and atrial fibrillation). The amount of increase in postoperative major bleeding when full-dose anticoagulation is administered soon after surgery is the factor in the decision with the least available data. The optimal method for returning the International Normalized Ratio (INR) to the desired range preoperatively depends upon its degree of initial elevation and whether or not clinically significant bleeding is present. Rapid reversal of excessive anticoagulation should be undertaken in patients with serious bleeding at any degree of anticoagulation. Vitamin K therapy is an effective treatment for INR prolongation in patients with vitamin K-associated coagulopathy; coagulation factor replacement is required, in addition, in patients with major bleeding or with an indication for immediate correction of their INR. Patients receiving prothrombin complex concentrate have a more rapid and more complete reversal of their anticoagulation as compared with fresh frozen plasma.

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