Guidelines on oral anticoagulation with warfarin – fourth edition

Keeling, David; Baglin, Trevor; Tait, R. C.; Watson, Henry G.; Perry, David J.; Baglin, C.; Kitchen, Steve; Makris, Michael

doi:10.1111/j.1365-2141.2011.08753.x

Cited by 539 publications

(475 citation statements)

References 112 publications

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“…There is an overall consensus in favor of a bridging therapy prior to urgent cardioversion in patients with life‐threatening hemodynamic instability caused by new‐onset NVAF 8, 9, 10, 11, 12, 13. The recommendation in guidelines9, 10, 12 and summaries of product characteristics14, 15 is less clear for those with stable NVAF who do not require rapid anticoagulation.…”

Section: Introductionmentioning

confidence: 99%

Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

Bouillon¹,

Bertrand²,

Boudali³

et al. 2016

JAHA

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BackgroundSeveral studies have recently examined the risks of bleeding and of ischemic stroke and systemic embolism associated with perioperative heparin bridging anticoagulation in patients with nonvalvular atrial fibrillation. However, few studies have investigated bridging risks during vitamin K antagonist initiation in outpatient settings.Methods and ResultsA retrospective cohort study was conducted on individuals starting oral anticoagulation between January 2010 and November 2014 for nonvalvular atrial fibrillation managed in outpatient care and identified from French healthcare insurance. Bleeding and ischemic stroke and systemic embolism events were identified from the hospitalization database. Adjusted hazard ratios with 95% CI were estimated using Cox models during the first and 2 following months of anticoagulation. Of 90 826 individuals, 30% had bridging therapy. A total of 318 (0.35%) cases of bleeding and 151 (0.17%) ischemic stroke and systemic embolism cases were identified during the first month of follow‐up and 231 (0.31%) and 122 (0.16%) during the 2 following months, respectively. At 1 month of follow‐up, the incidence of bleeding was higher in the bridged group compared with the nonbridged group (0.47% versus 0.30%; P<0.001), and this increased risk persisted after adjustment for covariates (hazard ratio=1.60; 95% CI, 1.28–2.01). This difference disappeared after the first month of treatment (0.93; 0.70–1.23). No significant difference in the occurrence of ischemic stroke and systemic embolism was observed either at 1 month of follow‐up or later.ConclusionsAt vitamin K antagonist initiation for nonvalvular atrial fibrillation managed in ambulatory settings, bridging therapy is associated with a higher risk of bleeding and a similar risk of arterial thromboembolism compared with no bridging therapy.

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Section: Introductionmentioning

confidence: 99%

Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

Bouillon¹,

Bertrand²,

Boudali³

et al. 2016

JAHA

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“…4 For urgent surgical procedures that can be delayed for six to 12 hr, the anticoagulant effect of warfarin can be effectively overcome with vitamin K 1 10 mg iv. 13,14 Intravenous administration of vitamin K 1 is reported to cause anaphylaxis in three in every 100,000 patients and is recommended to be given by slow infusion at a maximal rate of 1 mgÁmin -114, 15 It is unclear if this reaction is due to the vehicle, a polyethoxylated castor oil, or the vitamin itself. Vitamin K 1 should not be given subcutaneously due to the potential for an unpredictable and delayed response, and intramuscular injection is not recommended due to the risk of intramuscular hematoma in anticoagulated patients.…”

Section: Warfarinmentioning

confidence: 99%

“…12 L'administration orale de vitamine K 1 est l'option préférée afin de renverser l'anticoagulation à la warfarine d'intensité légère à modérée (RIN élevé, mais \ 3,0) en l'absence de saignement majeur et si l'interventions chirurgicale peut être retardées de 24-36 h. 4 Dans le cas d'interventions chirurgicales urgentes qui ne peuvent qu'être retardées de six à 12 h, l'effet anticoagulant de la warfarine peut être neutralisé de façon efficace avec 10 mg iv de vitamine K 1 . 13,14 Il a été rapporté que l'administration intraveineuse de vitamine K 1 provoquait une réaction anaphylactique chez trois patients sur 100 000, et on recommande donc de l'administrer lentement à un débit maximal de 1 mgÁmin -1 . 14,15 Nous ne savons pas si une telle réaction est attribuable à l'huile de ricin polyéthoxylée présente dans la formulation, ou à la vitamine même.…”

Section: La Warfarineunclassified

Reversal of warfarin anticoagulation for urgent surgical procedures

Curtis

Schweitzer

Vlymen

2015

Can J Anesth/J Can Anesth

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Purpose Patients treated with warfarin for therapeutic anticoagulation present a challenge for the perioperative management of urgent and emergent surgery. Anticoagulation must be reversed prior to most surgical procedures to prevent intraoperative bleeding. The purpose of this module is to review the options for urgent reversal of warfarin anticoagulation and the indications for each reversal agent. Selection of the appropriate agent is important to reduce unnecessary complications of treatment and to achieve optimal reversal of anticoagulation. Principal findings When urgent surgery is required for patients taking warfarin, intravenous vitamin K 1 should be used for procedures that can be delayed for six to 12 hr. Vitamin K 1 results in the activation of existing clotting factors rather than requiring the synthesis of new proteins, which allows for its relatively rapid onset of action. Intravenous vitamin K 1 acts more quickly than oral administration, with reversal of anticoagulation occurring within six to 12 hr vs 18-24 hr, respectively. If surgery cannot be delayed, prothrombin complex concentrates (PCCs) should be given, and intravenous vitamin K 1 should be infused concurrently to ensure sustained reversal of anticoagulation. The duration of action of both PCCs and plasma is six hours due to the short half-life of factor VII. Prothrombin complex concentrates contain small amounts of heparin and are contraindicated in patients with heparin-induced thrombocytopenia. Plasma should be used only if PCCs are unavailable or are contraindicated. Conclusion Reversal of warfarin anticoagulation can be achieved in a safe and timely manner when the appropriate agent is selected and administered correctly. Objectives of this Continuing Professional Development (CPD) module:After reading this module, the reader should be able to: 1. Identify the options for emergency reversal of warfarin anticoagulation; 2. Describe the dose, onset, and duration of action of agents that reverse warfarin anticoagulation; 3. List potential complications and contraindications of agents that reverse warfarin anticoagulation; 4. Choose the optimal agent for emergency reversal of warfarin anticoagulation, considering the timing of the operation and the risks and benefits of each agent.Despite increasing use of novel agents, warfarin remains the most widely prescribed oral anticoagulant in clinical use. A recent analysis of prescribing trends following regulatory approval for the newer agents showed that warfarin still accounted for over 75% of all the oral anticoagulants used. 1 Warfarin is indicated to reduce the risk of thromboembolic events in patients with atrial fibrillation, mechanical heart valves, and deep venous thrombosis, among other indications. Therefore, as the population ages, the use of anticoagulants, including warfarin, is projected to increase substantially.Patients treated with warfarin for therapeutic anticoagulation present a challenge for the perioperative management of urgent and emergent surgery. In order to...

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“…In response to the recently updated guidance for anticoagulation with warfarin (Keeling et al, 2011), we were disappointed to note that there was no consideration given to the issue of left ventricular thrombus and anticoagulation. This is a not uncommonly encountered scenario, and one for which little robust evidence exists to assist with the management.…”

Section: Comment On Guidelines On Oral Anticoagulation With Warfarin4mentioning

confidence: 99%

Comment on Guidelines on oral anticoagulation with warfarin – 4th edition

Gosai¹,

Muthusamy²

2011

Br J Haematol

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(VDR)relativetoABL1transcript,andflowcytometrytostudythe apoptotic effect of VD. VD induced apoptosis of cultured lymphocytes in P prior to remission, but not in C or in P at relapse (Fig 1B, C). Response to VD correlated with VDR expression (Fig 1C). Pepper et al (2003) demonstrated that lymphocytes from CLL patients overexpress variable levels of VDR, and that an analog of 1-25(OH) 2 D 3 , can induce apoptosis of these cells in vitro. Our observations strongly suggest that these in vitro concepts may hold true in vivo, with VD supplementation at the conventional dose. This effect seems to be related to the level of VDR expression in lymphocytes. It could be speculated that patients with higher VDR levels could have the best response to VD therapy. Our late observations in P also suggest that VD resistance may also develop. A clinical trial is now needed to determine whether there is room for VD in the treatment of CLL.

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Guidelines on oral anticoagulation with warfarin – fourth edition

Cited by 539 publications

References 112 publications

Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

Short‐Term Risk of Bleeding During Heparin Bridging at Initiation of Vitamin K Antagonist Therapy in More Than 90 000 Patients With Nonvalvular Atrial Fibrillation Managed in Outpatient Care

Reversal of warfarin anticoagulation for urgent surgical procedures

Comment on Guidelines on oral anticoagulation with warfarin – 4th edition

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