Rheumatic mitral valve disease with atrial fibrillation or a history of systemic embolism Three weeks before four weeks after conversion (1C+) Persistent or paroxysmal atrial fibrillation §
Two episodes of objectively documented events: indefinite (1A) In patients with a deficiency of antithrombin or proteins C or S, gene mutation for factor V Leiden or prothrombin 2010, homocystinemia, or high factor VIII levels: six to 12 months (1A) indefinite (2C) In patients with antiphospholipid antibody or who have two or more thrombophilic conditions: 12 months (1C+) indefinite (2C) In patients with cancer: LMWH for three to six months, then warfarin indefinitely (1C) Venous thromboembolic disease and pulmonary embolism 2ĭeep venous thrombosis of the leg or pulmonary embolism †įirst episode secondary to reversible risk factor(s): three months (1A)įirst episode idiopathic: six to 12 months (1A) consider indefinite use (2A) Therapeutic INR goal * (recommendation grade if noted)ĭuration of therapy (recommendation grade if noted) Trimethoprim/sulfamethoxazole (Bactrim, Septra)Įnteral feeds with high vitamin K contentįoods with high vitamin K content, such as broccoli, brussel sprouts, cabbage, collard greens, raw endive, kale, bib leaf and red leaf lettuce, mayonnaise, mustard greens, parsley, spinach, raw swiss chard, raw turnip greens, watercress Warfarin and heparin are restarted postoperatively once hemostasis has been achieved. When determining whether to use bridge therapy, the risk of bleeding should be balanced against the risk of thromboembolism.īefore invasive procedures, patients at high risk for thromboembolization should stop warfarin therapy four to five days preoperatively and start LMWH or unfractionated heparin two to three days before surgery. Outpatient LMWH is as safe and effective as inpatient unfractionated heparin for treatment of venous thromboembolism in most patients.įor treatment of acute deep venous thrombosis and pulmonary embolism, warfarin should be started with unfractionated heparin or LMWH for at least five days and until a therapeutic International Normalized Ratio (2.5 ± 0.5) is achieved.įor patients at higher risk of thromboembolism, invasive procedures requiring the interruption of anticoagulation therapy can be managed on an outpatient basis with LMWH.
Warfarin (Coumadin) therapy should be initiated using validated 5-mg and 10-mg nomograms. Patients at higher risk of thromboembolization should stop warfarin therapy four to five days before surgery and start LMWH or unfractionated heparin two to three days before surgery. When invasive procedures require the interruption of oral anticoagulation therapy, recommendations for bridge therapy are determined by balancing the risk of bleeding against the risk of thromboembolism. Because patients with venous thromboembolism and cancer who have been treated with LMWH have a survival advantage that extends beyond their venous thromboembolism treatment, the ACCP recommends beginning their therapy with three to six months of LMWH. The ACCP recommends starting warfarin with unfractionated heparin or LMWH for at least five days and continuing until a therapeutic INR is achieved. Use of outpatient low-molecular-weight heparin (LMWH) is as safe and effective as inpatient unfractionated heparin for treatment of venous thromboembolism. For patients with atrial fibrillation, the INR is maintained at 2.5 ± 0.5 indefinitely for most patients with mechanical valves, the recommended INR is 3.0 ± 0.5 indefinitely. Therapy for venous thromboembolism includes an INR of 2.5 ± 0.5, with the length of therapy determined by associated conditions. The ACCP guidelines recommend short-term warfarin therapy, with the goal of maintaining an International Normalized Ratio (INR) of 2.5 ± 0.5, after major orthopedic surgery. The Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy provides guidelines for outpatient management of anticoagulation therapy.
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