Journal of thrombosis and thrombolysis
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J. Thromb. Thrombolysis · Feb 2006
ReviewPerioperative management of oral anticoagulation: when and how to bridge.
The management of patients on oral anticoagulation (OAC) who need to undergo surgery or invasive procedures is problematic. "Bridging" the subtherapeutic periods with either intravenous unfractionated heparin or subcutaneous treatment-dose low-molecular-weight heparin (LMWH) decreases the amount of time patients are not anticoagulated but may increase the risk of postoperative bleeding and is costly. The available literature does not provide sufficient information to allow clinicians to choose an optimal perioperative strategy. Recent studies primarily have examined the perioperative use of LMWH, and have found arterial thromboembolic rates of 0.4-1.5%. ⋯ For most patients at low or moderate stroke risk, bridging will be unnecessary and may be harmful. Bridging is recommended for patients who have a high annual risk of stroke and thus have a more appreciable perioperative stroke risk. Postoperative anticoagulation must be used cautiously and patients monitored closely after major surgery due to the risk of postoperative major bleeding.
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J. Thromb. Thrombolysis · Feb 2006
ReviewManaging oral anticoagulation requires expert experience and clinical evidence.
The management of patients on chronic oral anticoagulant therapy, namely Vitamin K antagonists such as warfarin, is often associated with difficult and challenging issues for the healthcare practitioner. Many of these issues, such as warfarin failure or resistance, the optimal warfarin initiation dose, the optimal target International Normalized Ratio in antiphospholipid syndrome, the optimal monitoring frequency and use of point-of-care monitoring, the management of oral anticoagulation during invasive procedures, and the management of over-anticoagulation, have not been evaluated in rigorously-designed clinical trials. The latest American College of Chest Physician recommendations concerning these issues are Grade 2C, the weakest recommendations available. It remains up to the experience and expertise of the individual practitioner along with whatever clinical evidence is available in a particular healthcare environment-especially one associated with an anticoagulant management service-to implement management strategies with respect to these issues in patients on oral anticoagulation.