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Risk Assessment

To determine the need for warfarin hold and bridging, assess the patient's risk of bleeding versus thromboembolism.

Risks of Bleeding

  • Anticoagulation regimen/ INR
  • Type of surgery
  • Patient age
  • Co-morbidities
  • Additional drugs

Risks of Thromboembolism

  • Low - Bridging not likely indicated:

    • AF with CHADS2 Score 0-1
    • St Jude or ATS (bileaflet) or tissue AVR with no other indication for warfarin
    • History of hemorrhagic CVA
  • Intermediate - Assess individual cases for consideration of bridging:

    • Atrial fibrillation with CHADS2 score 2-3
    • DVT/ PE in the last 3-6 months
    • Bileaflet AVR + A fib
  • High - Use or consider bridging:

    • Recent CVA (embolic/ ischemic) or TIA
    • A fib with CHADS2 4-6
    • Left-sided ablations (if INR not ≥ 2.0)
    • AF cardioversion (if INR not ≥ 2.0 for 3 weeks)
    • DVT/ PE within the last 3 months
    • Mechanical MVR
    • Older model mechanical AVR (tilting disc, ball in cage models)
    • APLA or multiple thrombophilic abnormalities

Balancing the Risks: Bleeding vs Thrombosis

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