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Warfarin 4th Ed
Warfarin 4th Ed
Oxford Radcliffe Hospitals, Oxford, 2Addenbrookes Hospital, Cambridge, 3Glasgow Royal Infirmary, Glasgow, 4Aberdeen Royal
Infirmary, Aberdeen, and 5Royal Hallamshire Hospital, Sheffield, UK
Recommendation
doi:10.1111/j.1365-2141.2011.08753.x
Guideline
Recommendation
Recommendation
Recommendations
Patients with AF who require warfarin for the prevention
of cardio-embolic should have an INR target of 25 (1A).
1.4 Cardioversion
Patients who develop AF and are considered for cardioversion require anticoagulation prior to and after the event.
Patients undergoing elective cardioversion should be anticoagulated with warfarin for at least 3 weeks prior to and
4 weeks post cardioversion if sinus rhythm is achieved and
sustained. The target INR for this indication is 25. One
study has suggested that there is a critical difference in
2
Recommendations
Guideline
between different degrees of anticoagulation there is often a
lack of clarity about time spent in range and so these are
effectively intention to treat observations.
Where patients would appear to possibly benefit from a higher
INR but there are features to suggest that the risk of anticoagulant-related bleeding is high, then this needs to be borne in
mind when advising on optimal treatment for the patient. In
situations where an embolic event occurs during on target
anticoagulation, elevation of the INR target or addition of antiplatelet drugs should be considered (Vahanian et al, 2007; Salem
et al, 2008). We suggest the following, which is based on the
European Society of Cardiology guidelines (Vahanian et al,
2007). We have restricted the highest recommended target INR
to 35 as we do not feel that there is evidence for increased efficacy
of higher levels offsetting the increased risk of bleeding.
Recommendations
The recommended target INRs for mechanical heart valves
are given in Table I.
Prosthesis
Thrombogenicity*
INR target
No patient
risk factors
INR target
Patient-related
risk factors
Low
Medium
High
25
30
35
30
35
35
Recommendations
Patients with intermittent claudication should not routinely be treated with anticoagulants (1A).
Patients who suffer acute arterial embolism and proceed to
embolectomy should be considered for long-term anticoagulation with warfarin with an INR target of 25 (2C).
Recommendations
Guideline
the first 36 months). Thereafter, continued anticoagulation
may be recommended to prevent late recurrence. The benefit
of anticoagulation continues only for as long as therapy is
continued (Agnelli et al, 2001, 2003; Pinede et al, 2001; Ost
et al, 2005; Schulman et al, 2006; Campbell et al, 2007)
therefore continued anticoagulation effectively equates to
long-term treatment.
Recommendations
Recommendations
Guideline
patients who do not require rapid anticoagulation, a slowloading regimen is safe and achieves therapeutic anticoagulation in the majority of patients within 34 weeks.
Recommendation
For outpatients who do not require rapid anticoagulation
a slow-loading regimen is safe and achieves therapeutic
anticoagulation in the majority of patients within
34 weeks (2C).
4. Peri-operative anticoagulation
3. Initiation of treatment
3.1 Rapid induction regimens for patients with acute
thrombosis
Patients with acute thrombosis should have parenteral anticoagulation, for example with UFH, LMWH or fondaparinux,
until oral anticoagulation with warfarin is established. In these
patients the time to stable anticoagulation is an important
factor. Heneghan et al (2010) systematically reviewed the
literature on the most effective methods for initiating warfarin.
Overall, they found no evidence to suggest a 10 mg loading
dose is superior to 5 mg. In the elderly, lower initiation doses
or age-adjusted doses may be more appropriate (Roberts et al,
1999; Gedge et al, 2000). In these studies, significantly fewer
patients on an age-adjusted regimen had high out-of-range
INRs, compared to standard dosing. There is insufficient
evidence to warrant genotype-guided initiation. Although it
has been shown that genetic testing can predict the maintenance dose, for initiation, information from previous dosing
rapidly becomes more important (Ferder et al, 2010) and
response to a standard dosing algorithm can accurately predict
maintenance dose without genotyping (Lazo-Langner et al,
2009; Le Gal et al, 2010).
Recommendations
Guideline
Logistically, warfarin should not be taken for 5 d before
surgery and, if possible, the INR should be determined the day
before surgery to allow the administration of oral vitamin K if
the INR is 15, so reducing the risk of cancellation. In patients
who are receiving pre-operative bridging with LMWH the last
dose should be at least 24 h before surgery and some
recommend that the last dose is halved for high risk surgery
(Douketis et al, 2008). The INR should be checked on the day
of surgery and warfarin can be resumed, at the normal
maintenance dose, the evening of surgery or the next day if
there is adequate haemostasis (Douketis et al, 2008).
There are two randomized trials in progress, PERIOP-2
(clinicaltrials.gov/ct2/show/NCT00432796) and BRIDGE
(clinicaltrials.gov/ct2/show/NCT007864740), which should
help us to make decisions on peri-operative bridging. Based
on the evidence to date, we make the following recommendations:
Recommendations
Recommendation
All hospitals managing patients on warfarin should stock
a licensed four-factor prothrombin complex concentrate
(1C).
Emergency anticoagulation reversal in patients with
major bleeding should be with 2550 u/kg four-factor
prothrombin complex concentrate and 5 mg intravenous vitamin K (1B).
Recombinant factor VIIa is not recommended for
emergency anticoagulation reversal (1B).
Fresh frozen plasma produces suboptimal anticoagulation reversal and should only be used if prothrombin
complex concentrate is not available (1C).
Guideline
with the currently used micelle formulation (Makris et al,
2010).
Patients bleeding at therapeutic levels of anticoagulation
should be investigated for the source of bleeding. Haematuria
is not a feature of anticoagulation and patients with this
symptom at therapeutic levels should be investigated for
possible bladder and renal tract malignancy.
For bleeding in the oral cavity, antifibrinolytic drugs, such as
tranexamic acid mouthwash, are often very helpful. For
epistaxis, nasal packing is useful when simple measures fail.
Recommendation
Recommendation
Guideline
Recommendations
8. Management of sub-therapeutic
anticoagulation in the first month after acute
VTE
Barritt and Jordan (1960) showed that if PE is untreated it has a
high mortality in the first 14 d. When Lagerstedt et al (1985)
randomized patients with calf vein DVT to no treatment there
was a high recurrence rate over 90 d, which was particularly
marked in the first 30 d. Kearon and Hirsh (1997) estimated a
risk of recurrence of 40% in the first month after VTE if patients
are not anticoagulated. Sub-therapeutic anticoagulation is likely
to be more effective than no anticoagulation but this raises the
issue as to what should be done when a patient has a significantly
sub-therapeutic INR shortly after acute VTE. It also raises the
issue of how low an INR has to be before most clinicians would
regard it as significant; there was no clear consensus among the
writing group but opinions ranged from <15 to <17.
Recommendation
Table II. Annual rates for bleeding event (fatal or non-fatal requiring
hospital admission) following acute myocardial infarction (MI),
according to anti-thrombotic therapy [adapted from Sorensen et al
(2009), copyright (2009), with permission from Elsevier].
Antithrombotic regimen
Bleeding admission
rate (% per year)
Aspirin
Clopidogrel
Warfarin
Aspirin + clopidogrel
Aspirin + warfarin
Clopidogrel + warfarin
Aspirin + clopidogrel + warfarin
26
46
43
37
51
123
120
Recommendations
Guideline
Recommendations
Guideline
with 100150 lg vitamin K or altering the dietary intake of
vitamin K to achieve a more consistent intake of vitamin K has
been shown to reduce INR fluctuations in selected patients
with unstable INRs and to improve overall anticoagulation
control in patients with an unexplained instability of response
to warfarin (Ford et al, 2007; Rombouts et al, 2007; Sconce
et al, 2007; de Assis et al, 2009).
10
Authorship contributions
Agnelli, G., Prandoni, P., Santamaria, M.G., Bagatella, P., Iorio, A., Bazzan, M., Moia, M., Guazzaloca, G., Bertoldi, A., Tomasi, C., Scannapieco,
G. & Ageno, W. (2001) Three months versus one
year of oral anticoagulant therapy for idiopathic
deep venous thrombosis. Warfarin Optimal
Duration Italian Trial Investigators. New England
Journal of Medicine, 345, 165169.
Agnelli, G., Prandoni, P., Becattini, C., Silingardi, M.,
Taliani, M.R., Miccio, M., Imberti, D., Poggio, R.,
Ageno, W., Pogliani, E., Porro, F. & Zonzin, P.
(2003) Extended oral anticoagulant therapy after a
first episode of pulmonary embolism. Annals of
Internal Medicine, 139, 1925.
Anand, S., Yusuf, S., Xie, C., Pogue, J., Eikelboom,
J., Budaj, A., Sussex, B., Liu, L., Guzman, R.,
Cina, C., Crowell, R., Keltai, M. & Gosselin, G.
(2007) Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. New England
Journal of Medicine, 357, 217227.
Andersen, L.V., Vestergaard, P., Deichgraeber, P.,
Lindholt, J.S., Mortensen, L.S. & Frost, L. (2008)
Warfarin for the prevention of systemic embolism in patients with non-valvular atrial fibrillation: a meta-analysis. Heart (British Cardiac
Society), 94, 16071613.
de Assis, M.C., Rabelo, E.R., Avila, C.W., Polanczyk,
C.A. & Rohde, L.E. (2009) Improved oral anti-
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Recommendations
Disclaimer
While the advice and information in these guidelines is
believed to be true and accurate at the time of going to press,
neither the authors, the British Society for Haematology nor
the publishers accept any legal responsibility for the content of
these guidelines.
Guideline
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Guideline
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Guideline
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