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