Interruption of warfarin for low-risk procedures
Foote A, Haymart B, Kong X, Ali M, Kaatz S, Kline-Rogers E, Kozlowski J, Alexandris-Souphis T, Froehlich JB, and Barnes GD. Interruption of warfarin for low-risk procedures. J Thromb Thrombolysis 2019; 47(4):607.
J Thromb Thrombolysis
Introduction: Although the latest American College of Cardiology consensus statement recommends against warfarin interruption for low-risk procedures, many providers elect to interrupt warfarin for certain patients. Our objective was to determine the frequency of this interruption and evaluate its effect on INR control and occurrence of adverse events during the post-procedural timespan. Methods: The prevalence of low-risk procedure interruption was calculated in warfarin-treated patients in the Michigan Anticoagula-tion Quality Improvement Initiative (MAQI$sup$2$/sup$) database. Low-risk procedures included GI endoscopy, cardiac catheterization, dental procedures, dermatological procedures, cataract removal, and procedures lasting = 1 h. Bleeding and thrombotic events within a 30-day period following the procedure were identified. Bleeding events included any bleed resulting in ED visit, ISTH major bleed, and ISTH non-major bleed. Thrombotic events included stroke, TIA, or VTE. Patients bridged with LMWH were excluded from the analysis. Results: Of 11,257 patients, 905 (8.04%) underwent at least one low-risk procedure with warfarin interruption (7.2 per 100 pt-yr) with a median length of interruption of 5 days. It took interrupted patients a median of 44 days and 4 INRs to re-stabilize (have two consecutive in range INRs). Non-major bleeds, major bleeds, and thrombotic events during the 30-day post-procedure period were 4.7, 2.1, and 0.9%, respectively. Conclusions: Our findings suggest that warfarin interruption for low-risk procedures is fairly common and may contribute to adverse events, perhaps secondary to a prolonged INR re-stabilization period. For these reasons, the need for warfarin interruption for low-risk procedures must be assessed responsibly to minimize patient risk.