Withdrawal of warfarin prior to a surgical procedure: time to follow the guidelines?
OBJECTIVE
Patients with cardiogenic sources of embolism may be at increased risk of cerebral infarction when anticoagulation therapy is suspended for surgical procedures. The purpose of this study was to determine frequency of cardioembolic cerebral infarction during periprocedural warfarin withdrawal.


METHODS
Retrospective analysis of prospective cerebral infarction registry data from two tertiary medical centers.


RESULTS
Over a 12-month period, 14 cases of cardioembolic cerebral infarction occurring during the period of warfarin withdrawal for a medical procedure were observed, accounting for 7.1% of the 197 cardioembolic cerebral infarctions encountered. Across all patients, cerebral infarctions developed an average of 5.4 days after the last dose of warfarin (range 3-8). Among the 14 patients (8 males and 6 females) with warfarin cessation-related infarcts, age ranged from 54 to 91 years. Each had been on chronic anticoagulation with warfarin for more than 1 year. Retrospective analysis suggested that all these cerebral infarctions had been potentially preventable. In each case, either the planned procedure did not require discontinuation of warfarin or, when withdrawal was required, no bridging, parenteral anticoagulation was provided to lessen the risk during the warfarin-free period.


CONCLUSIONS
Patients at high risk of cardioembolic cerebral infarction may benefit from more intensive management strategies to reduce cerebral infarction risk during periprocedural periods.
Akopov
Sergey E
SE
Division of Neurology, Cedars-Sinai Medical Center Los Angeles, CA 90048, USA.
Suzuki
Shuichi
S
Fredieu
Andre
A
Kidwell
Chelsea S
CS
Saver
Jeffrey L
JL
Cohen
Stanley N
SN
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage* / Q000627:therapeutic use; D002544:Cerebral Infarction / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology*; D003327:Coronary Disease / Q000150:complications*; D004334:Drug Administration Schedule; D004617:Embolism / Q000150:complications*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011300:Preoperative Care; D012042:Registries; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014859:Warfarin / Q000008:administration & dosage* / Q000627:therapeutic use
D000925:Anticoagulants; D014859:Warfarin