Warfarin IE

prophylaxis


.
..
warfarin aspirin
1. non-valvular AF
risk CHA2DS2-VASc score1

Risk factor Sco

re
Congestive heart 1
failure/LVEF<40%
Hypertension 1
Age 75 2
Diabetes mellitus 1
Stroke/TIA/thromboembolism 2
Vascular disease 1
(MI/PAD/aortic plaque)
Age 65-74 1
Sex (female) 1
Maximum score 9
 CHA2DS2- Reccomendate
VASc d
score antithrombotic
therapy
0 ASA 75-325 mg daily
or
No antithrombotic
therapy
1 Warfarin INR 2-3 or
ASA 75-325 mg daily
2 Warfarin INR 2-3

* Risk stroke CHA2DS2-VASc score

2. Valvular heart disease

Mitral stenosis Significant mitral
regurgitation with AF
Rheumatic MS with sinus rhythm
 thromboembolism
LA thrombus
LA diameter>5.5 .
* target INR = 2-3
3. Postoperative surgery
3.1 AF : - New-on set AF 48 .
- Chronic AF AF
30
Sinus rhythm

* target INR = 2-3

3.2 Postoperative valve surgery

Valve type, Warfa ASA (low
timing rin dose)
Mechanical valve
All position, life
long (if
atherosclerosis
or
thromboembolis
m
despite adequate
INR
and low bleeding
 risk)
Bioprosthesis valve
First 3 months
Mitral/tricuspid
Aortic
After 3 months
With other warfarin
indication
Valve repair
Mitral (first 3
months, sinus)*
Aortic
* warfarin aspirin

Target INR mechanical

prosthesis1
Patient risk factor
Prosthesis (MVR, TVR,
thrombogeni thromboembolism, AF, MS,
city LVEF <35%)
No Yes
Low
(Carbomedics,
2.5 (2-3) 3.0 (2.5-3.5)
Metronic Hall,
St Jude, ON-X)
Medium/high
3.0 (2.5-3.5)* 3.0 (2.5-3.5)*
(other)
* modification
 4.
warfarin
target INR = 2-3
4.1 cardioversion AF
4.2 venous thromboembolism
4.3 Anterior wall MI LV thrombus
LVEF <40%
Right ventricular wall abnormality
- Dilated cardiomyopathy with intra
cardiac thrombus
4.4 Embolic stroke recurrent
cerebral infraction
5. warfarin3
5.1
2-3 .
5.2 heparin
warfarin INR

6. INR monitoring
INR
2
2-3
INR
 4-6
12

INR

1.
2. 5-20%

3. INR 1.510-20%

4. vitamin K
INR



5. INR
vitamin K110.
 FFP
prothrombin complex
concentrate recombinant factor
VIIa

vitamin K112

6. INR
vitamin K1

7. INR1.5-1.95-
10%
INR

8. INR INR
2

prosthetic valve malignancy

 9. INR 1.5-23-4
INR
INR 5.0
1
INR

10%
10. INR 5.0 -9.0
2INR

20%

vitamin K1
1-2.5.
INR
vitamin K12.5-5.
INR 24
11. INR 9.0
vitamin K12.5-5.
INR

 24-48INR
vitamin K11-2.

INR

1.
2. vitamin K

3. vitamin
K warfarin
4.
metabolism
coagulation factor
5. drug interaction
6.
(-)

INR

1
 2 Paracetamol, NSAIDs,
Antibiotics
3
4
5 (, ,
)

Warfarin

Cardiovascular Drugs:Amiodarone,
propafenone,Fluvastatin, rosuvastatin,
Propranolol, Antibiotics:Erythromycin,
clarithromycin, cotrimoxazole, ciprofoxacin,
cefoperazone, metronidazole Antifungals:
Ketoconazole, itraconazole, fluconazole
Acid suppression therapy:Cimetidine,
proton-pump inhibitors ,NSAIDs
Coxibs
Warfarin

Enzyme inducers
Rifampicin, Phenytoin, Carbamezepine,
Phenobarbital, Griseofulvin

Cholestyramine, Sucralfate

target INR = 2-3
< 1.5 10-20%
1.5-1.9 5-10%
2.0-3.0 Continue same
dose
3.1-3.9 5-10%
4.0-4.9 Hold for 1 day then
10%
5.0-8.9 no Omit 1-2 doses, Vit
bleeding K1 1 mg orally
9.0 no Vit K1 5-10 mg
bleeding orally
Major Vit K1 10 mg iv
bleeding with plus FFP
any INR Repeat Vit K1 every
12 hours if needed

Vitamin E, Fish oil

Warfarin: (Gingko
biloba)
Warfarin:

-Glakay


ASA (), NSAIDs,
COX-2 inhibitor
Steroid
(Herbal), (Gingko
biloba),(Ginseng)

Warfarin
1.

2.
3.

4.

 5.

6.
7.
8.
Warfarin

9.1 Perioperative thromboembolism risk

Risk Mechanical Atrial VTE
valve fibrillation
High Mitral CHADS2 score VTE within 3
prosthesis of 5-6 mo
Other than Stroke/TIA Severe
bileaflets within 3 mo thrombophili
prosthesis Rheumatic a
Stroke/TIA valvular PC/PS/AT
within 6 mo heart def, anti-
disease
phospholipid
Ab
Mode Bileaflets CHADS2 score VTE within 3-
rate aortic of 3-4 12 mo
prosthesis Other
with any of thrombophili
AF, post- a
stroke/TIA, factor V/II
 HT, DM, mutation
CHF, Recurrent
age >75 y VTE
Active cancer
Low Bileaflets CHADS2 score VTE >12 mo
aortic of 0-2 w/o other
prosthesis w/o risk factor*
w/o risk* stroke/TIA
Risk factor* PC/PS/AT=Protein C, Protein
S, Anti Thrombin
PC/PS/AT def, anti-phospholipid
Ab
VTE = venous
thromboembolism , w/o = without
9.2 High perioperative bleeding risk
surgery
9.2.1 Coronary artery bypass or
heart valve replacement surgery
9.2.2 Intracranial or spinal surgery
9.2.3 Major vascular surgery (eg,
aortic aneurysm repair,
peripheral artery bypass)
9.2.4 Major orthopedic surgery (eg,
hip or knee replacement)
9.2.5 Reconstructive plastic
surgery
9.2.6 Major cancer surgery
9.2.7 Prostate and bladder surgery
9.2.8 Other procedures
9.2.8.1 Colonic polyp resection
9.2.8.2 Prostate or kidney biopsy
 9.2.8.3 Pacemaker or
implantable cardioverter-
defibrillator (ICD) implant
9.3 Bridging dose regimens
9.3.1 Therapeutic-dose heparin
bridging regimen
SC enoxaparin 1 mg/kg bid or 1.5
mg/kg od
IV UFH to attain aPTT ratio 1.5-2
9.3.2 Prophylactic-dose heparin
regimen
SC enoxaparin 30 mg bid or 40
mg od
SC UFH 5000-7000 IU bid
9.4 warfarin
bridging

9.4.1 warfarin
5
INR <1.5
INR 1.5-1.8
9.4.2 warfarin 12-
24
9.4.3 INR
>1.5 oral vitamin K 1
.
 9.4.4
thromboembolism
bridging anticoagulation
9.4.5
thromboembolism bridging
anticoagulation
9.4.6
thromboembolism

9.4.7 minor
dental procedure warfarin
oral prothrombotic agent
warfarin 2-3
9.4.8 minor
dermatologic procedure
warfarin optimizing
local hemostasis
9.4.9 cataract
surgery warfarin

9.5 bridging
anticoagulation
9.5.1 therapeutic-dose iv
UFH bridging
 9.5.1.1 UFH 4-6

9.5.1.2 UFH 48-72
high-bleeding-
risk surgery 24
non-high-
bleeding-risk surgery

bolus
9.5.2 therapeutic-dose SC
LMWH bridging
9.5.2.1 LMWH
24
9.5.2.2 LMWH 48-72
high-bleeding-
risk surgery 24
non-high-
bleeding-risk surgery

10
mechanical heart
valves3
10.1 adjusted-dose bid LMWH
manufacturer's
peak anti-Xa LMWH SC 4

10.2 adjusted-dose UFH
SC 12
mid-interval aPTT 2
anti-Xa heparin 0.35-0.70 U/mL

10.3 UFH LMWH 13
warfarin
UFH LMWH
10.4 warfarin

10.5 warfarin
10.6 thromboembolism
prosthesis

mitral thromboembolism
warfarin
 UFH LMWH
aspirin 75-100 .

11 Infective endocarditis prophylaxis4

11.1 infective endocarditis

antibiotic prophylaxis


prosthetic valve prosthetic
material
infective endocarditis
congenital heart disease

Complex cyanotic heart disease
residual defects
palliative shunts
conduits prostheses
complete repair

prosthetic material
percutaneous technique 6


residual defects
prosthetic material device
percutaneous technique
11.2 infective
endocarditis
antibiotic prophylaxis
Dental procedures
manipulation gingival
periapical region
perforation oral
mucosa ( root canal
procedures)
11.3 IE prophylaxis
Dental procedures

prosthodontic
orthodontic
appliances/braces
lips
oral mucosa
Respiratory tract,
gastrointestinal,
genitourinary, dermatological
musculoskeletal
 procedures active
infection
11.4 Recommended prophylaxis for
dental procedures
Single dose 30-60 min before
procedure
Situatio Antibiotic Adults Children
n
No Amoxicillin 2 g po or 50 mg/kg
penicillin or ampicillin iv po or iv
allergy Cefazolin 2 g po or 50 mg/kg
Ceftriaxone iv po or iv
1 g po or 50 mg/kg
iv po or iv
Penicillin Clindamycin 600 mg 20 mg/kg
allergy po or iv po or iv

Reference
1. 2012 ESC Guidelines: Management of
Valvular Heart Disease
2. 2005 ACCP Guidelines: Prevention and
Management of Postoperative Atrial
Fibrillation After Cardiac Surgery
3. 2012 ACCP Guidelines: Antithrombotic
Therapy and Prevention of Thrombosis
4. 2009 ESC Guidelines: Prevention,
Diagnosis, and Treatment of Infective
Endocarditis
5.

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