Anticoag Bridge

septe m ber
2012
Anticoagulation Bridging
GUIDELINES AND DECISION TREE
BEFORE Procedure
AFTER Procedure
ALL PATIENTS
ALL PATIENTS
7-10 days before procedure

Note the patients INR target range:

Use the Bridging Tree (page 2) to:
. Order INR if needed.
Classify the BLEEDING RISK of the procedure

Classify the patients THROMBOEMBOLISM RISK
PATIENTS WHO REQUIRE BRIDGING

STARTING 1 DAY AFTER THE PROCEDURE
PATIENTS WHO REQUIRE BRIDGING
MODERATE patient thromboembolism risk

MODERATE procedure bleeding risk
7-10 days before procedure
Platelets:
7 days
before
6 days
5 days
4 days
3 days
2 days
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Take your
regular dose
Regular weekly of warfarin
dose:
If INr is
2.9 or less,
take your
regular dose
of warfarin
No
warfarin
No
warfarin
No
warfarin
No
warfarin
No
enoxaparin
No
enoxaparin
WArfArIN
(Coumadin)
mg/week Check your

PT/INr
before
before
No
enoxaparin
before
No
warfarin
The doctor
performing your
procedure may ask
you to have your
PT/INr checked this
morning. Ordering
and checking test
results will be their
responsibility.
If INr is
3.0 or more:
Do Not take
warfarin
enoxaparin at enoxaparin at
enoxaparin at
AM
PM
mg
1 day
Date:
Day: S M Tu
W Th F S
LOVENOX
No
enoxaparin
before
LOVENOX
Dose:
before
LOVENOX
eNOxAPArIN
(Lovenox)
before
AM*
*The last dose

of enoxaparin
and
PM
must be at least
24 hours before
surgery.
The above information is not a substitute for professional medical advice. Please talk with your healthcare provider if you have any questions or concerns.
2012 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 COAG001 - 09/12
*50276*
Med Ed 50276
3 days before procedure
Take your
regular dose
of warfarin
no
enoxaparin
Dose:
5 days
after
6 day
after
7 days
after
after
Date:
Day: S M Tu
W Th F S
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
P
Check your
PT/inr
mg
aSK YOUr
SUrGeOn
WHen YOU
SHOULD STarT
enOxaParin*
enoxaparin
no
enoxaparin
enoxaparin
AM
no
enoxaparin
no
enoxaparin
no
enoxaparin
AM
and
enoxaparin
and
PM
PM
at least 24
hours afTer
surgery
PM
*Do NoT take enoxaparin unless your surgeon tells you to. Your surgeon may consider the risk of bleeding after your procedure
to be too high to safely use enoxaparin. Follow your surgeons instructions regarding if and when to start enoxaparin.
2012 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 COaG002 - 09/12
*50276*
Med Ed 50276
Warfarin (Coumadin) and Lovenox

anticoagulation Bridging instructions
Bridging instructions
afTEr your procedure
HiGH patient risk of blood clot (thromboembolism)

Name:
MODEraTE bleeding risk of procedure
MRN/MMI:
Diagnosis:
Procedure:
Procedure date:
DEar PaTiEnT: Before your procedure, you stopped taking warfarin (Coumadin) and had injections of enoxaparin (Lovenox)
instead. AFTER your procedure, you will go back to taking warfarin and and will also take enoxaparin temporarily. See below for
day-by-day instructions. Please follow your surgeons instructions if they are different from those below. restart warfarin and/or
enoxaparin only when your surgeon says its okay.
aTTEnTiOn SUrGEOn: The instructions below are tailored for patients with HiGH risk of thromboembolism and MODEraTE
bleeding risk from their procedure. Please review these post-operative patient anticoagulation instructions and approve or modify
them based on your patients hemodynamic stability.
Day of
procedure
Date:
Day: S M Tu
W Th F S
Warfarin
(Coumadin)
Regular weekly
dose:
mg/week
EnOxaParin
(Lovenox)*
iMPOrTanT:
Before restarting
warfarin, confirm
these instructions
with the physician
who performed your
procedure.
Take 2 times
your regular
daily dose (up to
10 mg maximum)
in the evening at
least 12 hours after
your procedure.
no
enoxaparin
Dose:
1 day
mg
2 days
3 days
4 days
5 days
6 days
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
after
after
Date:
Day: S M Tu
W Th F S
Take your
regular dose
of warfarin
aSK YOUr
SUrGEOn
WHEn YOU
SHOULD STarT
EnOxaParin*
Enoxaparin
after
Take your
regular dose
of warfarin
after
Take your
regular dose
of warfarin
Enoxaparin
Enoxaparin
at
AM
at
AM
and
PM
and
PM
after
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
Get PT/inr
Await instructions
about continuing
enoxaparin
Get PT/inr
Await instructions
about continuing
enoxaparin
Get PT/inr
Await instructions
about continuing
enoxaparin
no enoxaparin
Enoxaparin
PM
at least 24
hours afTEr
surgery
after
Take your
regular dose
of warfarin
no enoxaparin
Enoxaparin
no enoxaparin
Enoxaparin
at
AM
at
AM
at
and
PM
and
PM
and
AM
PM
*Do NOT take enoxaparin unless your surgeon tells you to. Your surgeon may consider the risk of bleeding after
your procedure to be too high to safely use enoxaparin. Follow your surgeons instructions regarding if and when to
start enoxaparin.
*50276*
Med Ed 50276

Anticoagulation Bridging Instructions

Warfarin: Continue warfarin at pre-procedure dose.*
Enoxaparin: No enoxaparin post-procedure.

INR: Check 7 days after the procedure.
MODERATE patient risk of blood clot (thromboembolism)

Name:
HIGH bleeding risk of procedure
MRN/MMI:
Diagnosis:
Procedure:
Procedure date:
DEAR PATIENT: Before your procedure, you stopped taking warfarin (Coumadin) and had injections of enoxaparin (Lovenox)
instead. AFTER your procedure, you will go back to taking warfarin. See below for day-by-day instructions. Please follow your
surgeons instructions if they are different from those below. Restart warfarin only when your surgeon says its okay.
ATTENTION SURGEON: The instructions below are tailored for patients with MODERATE risk of thromboembolism and HIGH bleeding
risk from their procedure. Please review these post-operative patient anticoagulation instructions and approve or modify them based on
your patients hemodynamic stability.
WARFARIN
(Coumadin)
Regular weekly
dose:
mg/week
ENOXAPARIN
(Lovenox)*
Dose:
Day of
procedure
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Take your
regular dose
of warfarin
Take your
Take your
regular dose regular dose
of warfarin
of warfarin
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
IMPORTANT:
Before restarting
warfarin, confirm
these instructions
with the physician
who performed
your procedure.
Take 2 times
your regular
daily dose (up to
10 mg maximum)
in the evening,
but at least 12
hours after your
procedure.
No
enoxaparin*
after
after
Take your
Take your
regular dose regular dose
of warfarin
of warfarin
after
after
after
after
after
P
Check your
PT/INR
No
enoxaparin
No
enoxaparin
No
enoxaparin
No
enoxaparin
No
enoxaparin
No
enoxaparin
No
enoxaparin
mg
*Do NOT take enoxaparin unless your surgeon tells you to. Your surgeon may consider the risk of bleeding after your procedure
to be too high to safely use enoxaparin. Follow your surgeons instructions regarding if and when to start enoxaparin.
2012 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 COAG003 - 09/12
*50276*
Med Ed 50276
HIGH patient thromboembolism risk

HIGH procedure bleeding risk
afTEr your procedure
HiGH patient risk of blood clot (thromboembolism)

Name:
HiGH bleeding risk of procedure
MRN/MMI:
Diagnosis:
Procedure:
Procedure date:
DEar PaTiEnT: Before your procedure, you stopped taking warfarin (Coumadin) and had injections of enoxaparin (Lovenox)
instead. AFTER your procedure, you will go back to taking warfarin and may take enoxaparin only as instructed by your surgeon.
See below for day-by-day instructions. Please show these instructions to your surgeon. follow your surgeons instructions if they
are different from those below. restart warfarin and take enoxaparin only when your surgeon says its okay.
aTTEnTiOn SUrGEOn: The instructions below are tailored for patients with HiGH risk of thromboembolism and HiGH bleeding
risk from their procedure. Please review these post-operative patient anticoagulation instructions and approve or modify them
based on your patients hemodynamic stability. Enoxaparin should be started (if at all) no sooner than 72 hours after the
procedure, and only after adequate surgical hemeostasis has been achieved.
Warfarin
(Coumadin)
Regular weekly
dose:
mg/week
EnOxaParin
(Lovenox)*
Dose:
mg
Day of
procedure
1 day
2 days
3 days
4 days
5 days
6 days
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
Date:
Day: S M Tu
W Th F S
after
after
after
after
after
after
iMPOrTanT:
Before restarting
warfarin, confirm
these instructions
with the physician
who performed
your procedure.
Take 2 times
your regular
daily dose (up to
10 mg maximum)
in the evening at
least 12 hours after
your procedure.
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
no
enoxaparin
no
enoxaparin
no
enoxaparin
aSK YOUr
SUrGEOn if YOU
SHOULD STarT
EnOxaParin*
Get PT/inr
Await instructions
about continuing
enoxaparin
Get PT/inr
Await instructions
about continuing
enoxaparin
Get PT/inr
Await instructions
about continuing
enoxaparin
Enoxaparin
at
AM
and
PM
no enoxaparin
no enoxaparin no enoxaparin
Enoxaparin
Enoxaparin
Enoxaparin
at
AM
at
AM
at
and
PM
and
PM
and
LOVENOX


Enoxaparin: No enoxaparin post-procedure OR, if the
patient is hemodynamically stable and at the discretion of
the physician performing the procedure, consider enoxaparin
beginning at least 72 hours after the procedure and
continuing until the INR falls into goal range.

INR: Check 4 to 6 days after the procedure.
LOVENOX
2012 Intermountain Healthcare. All rights reserved.
Take your
regular dose
of warfarin
LOVENOX
NOTE: At the discretion of the physician performing the procedure, it may be appropriate
to check the INR the day before the procedure. If the INR is greater than 1.5, Vitamin K
1-2 mg orally may be indicated. Order and follow up of the INR is the responsibility of the
physician performing the procedure.
Take your
regular dose
of warfarin
Take your
regular dose
of warfarin
LOVENOX

Begin bridge therapy. Also refer to Intermountains Heparin,
Low-Molecular Weight (enoxaparin) for monitoring guidelines:
3 days before the procedure: Give an evening dose of
enoxaparin subcutaneously at 1 mg/kg of actual body weight.
2 days before the procedure: Give enoxaparin subcutaneously
every 12 hours at 1 mg/kg of actual body weight. Give the last
dose of enoxaprin no later than 24 hours prior to the procedure.
Date:
Date:
Day: S M Tu Day: S M Tu
W Th F S
W Th F S
Take your
regular dose
of warfarin
iMPOrTanT:
Before restarting
warfarin, confirm
these instructions
with your surgeon.
Take 2 times
your regular
daily dose (up to
10 mg maximum)
in the evening, but
at least 12 hours
after your procedure.
Bridging Instructions
AFTER your procedure
INR:
risks. Your healthcare provider should review these carefully with you. Be sure to ask questions if you do not understand.
Share these instructions with the doctor who will perform your procedure. Bridging may be different for each person.
The doctor who will do the procedure might make changes to these instructions. If they are changed, follow his or her
instructions instead.
Date:
Day: S M Tu
W Th F S
after
LOVENOX
GFR:
stopped temporarily. To decrease the chance of blood clots while you are off your warfarin, another medication called
enoxaparin (Lovenox) may be given as a shot (injection) instead.
What do I need to do? Your bridging instructions for BEFORE and AFTER your procedure are tailored to your specific
4 days
Date:
Day: S M Tu
W Th F S
after
LOVENOX
Creatinine:
What is bridging? Bridging is the period of time surrounding a medical procedure when warfarin (Coumadin) is
3 days
Date:
Day: S M Tu
W Th F S
after
MODERATE patient thromboembolism risk

HIGH procedure bleeding risk
Procedure date:
Lab results: Date:
enOxaParin
(Lovenox)
2 days
Date:
Day: S M Tu
W Th F S

If INR is less than 1.8 (for target range of 2 to 3) or less than
2.2 (for target range of 2.5 to 3.5), consult the attending physician
or anticoagulation expert and consider continuing enoxaparin until INR
falls into goal range.
Diagnosis:
Procedure:
mg/week
1 day
Date:
Day: S M Tu
W Th F S
LOVENOX
MrN/MMI:
bleeding risk of procedure
Warfarin
(Coumadin)
Regular weekly
dose:
Day of
procedure
LOVENOX
Name:
MODerATe HIGH
Diagnosis:
Procedure date:
aTTenTiOn SUrGeOn: The instructions below are tailored for patients with MODeraTe risk of thromboembolism and MODeraTe
bleeding risk from their procedure. Please review these post-operative patient anticoagulation instructions and approve or modify
them based on your patients hemodynamic stability.
LOVENOX
Anticoagulation Bridging Instructions

BefOre your procedure


Enoxaparin: Administer subcutaneously every 12 hours
at 1 mg/kg of actual body weight beginning at least 24
hours after the procedure, and continuing until the
INR is checked.*
MODeraTe bleeding risk of procedure
MRN/MMI:
instead. AFTER your procedure, you will go back to taking warfarin and will also take enoxaparin temporarily. See below for dayby-day instructions. Please show these instructions to your surgeon. follow your surgeons instructions if they are different from
those below. restart warfarin and/or enoxaparin only when your surgeon says its okay.
LOVENOX
HIGH patient thromboembolism risk

MODERATE procedure bleeding risk
afTer your procedure
Dear PaTienT: Before your procedure, you stopped taking warfarin (Coumadin) and had injections of enoxaparin (Lovenox)
LOVENOX

Calculate creatinine clearance (CrCl) if not assessed in the last 30 days.
If CrCl is less than 30 mL/min (or equivalent GFR using MDRD
equation), the decision to bridge in the outpatient setting MUST be
individualized. Consider involving the patient in the decision making
process. Consult the attending physician or anticoagulation
expert for advice before bridging.
For patients in renal failure or on dialysis, bridging with
enoxaparin (Lovenox) a low-molecular-weight
heparin is CONTRAINDICATED.
If CrCl is 20 to 29 mL/min, consider inpatient intravenous
unfractionated heparin OR enoxaparin at a dose of 1 mg/kg of
actual weight ONCE A DAY, with the last dose 48 hours prior
to the procedure.
If CrCl is 30 to 59 mL/min, consider rounding the enoxaparin
dose down to the nearest 10 mg.

Give patient FACE-TO-FACE bridging instructions
and handouts for BEFORE and AFTER based on their risk
classifications. Instruct them to share the instructions with
the physician performing the procedure, and to follow that
physicians advice if different.
MODeraTe patient risk of blood clot (thromboembolism)

Name:
Procedure:
LOVENOX


Enoxaparin: Administer subcutaneously every 12 hours at
1 mg/kg of actual body weight (5 to 6 doses total)
beginning at least 24 hours after the procedure.*
LOVENOX

Order INR if not already done.
If INR is 3.0 or greater, the last dose of warfarin (Coumadin) is 6 days
before the procedure.
If INR is less than 3.0, the last dose of warfarin is 5 days before
the procedure.
MODerATe HIGH risk of blood clot
EVENING OF THE PROCEDURE (but at least 12 hours after)

Resume warfarin at twice the patients usual scheduled dose for
that day, up to a MAXIMUM dose of 10 mg.
AM
PM
*Do NoT start enoxaparin unless your surgeon tells you to, and no sooner than 72 hours after your procedure. Your surgeon
may consider the risk of bleeding after your procedure to be too high to safely use enoxaparin. Follow your surgeons
instructions regarding if and when to start enoxaparin.
* Decision and timing of reinstitution of anticoagulation must be individualized in

conjunction with the physician performing the procedure; anticoagulation should
occur only once hemostasis is assured.
Warfarin monitoring with INR may need to be more frequent if new medications
are started or patient condition warrants more frequent monitoring.
NOTE: For stent patients, see CV Clinical Programs Perioperative Antiplatelet
Management for Patients with Coronary Stents.
*50276*
Med Ed 50276
m a n ag e m e n t o f a n t i c o ag u l at i o n b r i d g i n g
se p t e m b e r 2 012
bridging decision tree:
Does your patient require bridging?
Note: This decision support tool is intended as a guideline for common clinical situations. It is not intended as
a substitute for clinical judgment. Individual patients or situations may require variations from this approach.
For procedures not listed, clinician judgement is required to determine whether

Classify the BLEEDING RISK of the procedure NOTE:
the bleeding risk of the procedure is LOW, MODERATE, or HIGH. If bleeding risk is
MODERATE or HIGH, proceed to Step to assess THROMBOEMBOLISM RISK.
LOW BLEEDING RISK

Simple dental extraction and
endodontic procedures

Skin biopsy/MOHS

Cataract surgery

Colonoscopy without biopsy
or polypectomy

Intracranial/spinal surgery

Aortic aneurysm repair

Peripheral artery bypass

Major vascular surgery

Thoracic surgery (CABG or mechanical
valve replacement)

Major orthopedic surgery

Reconstructive plastic surgery

Major cancer surgery
check inr
take steps
to bring
inr in
range
INR in
TARGET
RANGE?
no
HIGH BLEEDING RISK

Most urologic surgeries

Prostate surgery or biopsy

Renal or hepatic biopsy

GI polypectomy/biopsy (discuss perceived bleeding
risk with endoscopist)

Cardiac pacemaker or defibrillator implantation

Bowel resection

Special consideration for laparoscopic procedures
evaluate individually
Proceed with surgery/procedure without interrupting anticoagulation.

yes
Note: If the BLEEDING RISK of the procedure is low AND the patients
THROMBOEMBOLISM RISK is low (see below to assess), either assure therapeutic
INR with no interruption as specified here OR, for dental procedures, consider
holding warfarin for 2 to 3 days before the procedure, and resuming after the procedure.
Classify the patients THROMBOEMBOLISM (TE) RISK
NOTE: If multiple conditions apply, use the one that returns the highest thrombotic risk assessment.
Mechanical Heart Valve
Atrial Fibrillation (non-valvular)
Risk factors:
CHADS2 score:

Atrial fibrillation

CHF*

HTN

DM

Age >75

Prior CVA/TIA
LOW TE RISK

Bileaflet aortic valve posthesis AND
no risk factors
MODERATE TE RISK

Bileaflet aortic valve posthesis AND
1 or more risk factors

Prior thromboembolism during
interruption of warfarin therapy
HIGH TE RISK

Any mitral valve prothesis

Older (caged-ball or tilting disc)
aortic valve prosthesis

Recent (within 6 months) stroke or
transient ischemic attack

CHF* (1 pt)

HTN (1 pt)

DM (1 pt)

Age >75 (1 pt)

Prior CVA/TIA (2 pts)
History of Venous
Thromboembolism (VTE)
Risk factors:

Nonsevere thrombophilia: hetero
factor V Leiden or hetero factor II, or
prothrombin gene mutation

Severe thrombophilia:
deficiency of antithrombin, or deficiency
of protein C/S, or antiphospholipid Ab,
or multiple abnormalities
LOW TE RISK
LOW TE RISK

CHADS2 score 0 to 2 AND no prior
CVA/TIA

Single VTE more than 12 months ago
AND no other risk factors
MODERATE TE RISK
MODERATE TE RISK

CHADS2 score 3 or 4


VTE in past 3 to 12 months

Nonsevere thrombophilia

Recurrent VTE

Active cancer (rx within 6 months or
on palliative care)

HIGH TE RISK
HIGH TE RISK

CHADS2 score 5 or 6

Recent (within 3 months) stroke or
transient ischemic attack
Rheumatic valvular heart disease
ACTIONS:

Less than 3 months since VTE

Severe thrombophilia
* CHF defined as EF <35% or if EF unknown, dyspnea at rest or with mild exertion

Routine testing of thrombophilias is not recommended. Use as a risk factor only if test results are already available.
Bridging Guidelines based on above risk classifications. See page 1.

Implement
NOTE: The timing of resuming anticoagulation should be made in concert with the physician performing the procedure.
See page 1 for special instructions for patients with a creatinine clearance of 20-29 or 30-59.
2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications 801-442-2963 CPM050 - 10/12
Low TE risk:
Do not bridge.
Hold anticoagulation
for 5 to 6 days before
procedure without
bridging, and resume
after the procedure.
Moderate TE risk:
Individualize plan.
Base plan on patient
preference and BLEEDING
RISK of procedure.
See page 1 for details.
High TE risk:
Bridging is indicated.
Base plan on BLEEDING
RISK of procedure. See
page 1 for details.

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septe m ber

7-10 days before procedure

. Order INR if needed.

Classify the BLEEDING RISK of the procedure

PATIENTS WHO REQUIRE BRIDGING

PATIENTS WHO REQUIRE BRIDGING

MODERATE patient thromboembolism risk

7-10 days before procedure

mg/week Check your

*The last dose

3 days before procedure

Warfarin (Coumadin) and Lovenox

HiGH patient risk of blood clot (thromboembolism)

MODEraTE bleeding risk of procedure

Warfarin (Coumadin) and Lovenox

MODERATE patient risk of blood clot (thromboembolism)

HIGH bleeding risk of procedure

HIGH patient thromboembolism risk

HiGH patient risk of blood clot (thromboembolism)

HiGH bleeding risk of procedure

2012 Intermountain Healthcare. All rights reserved.

MODERATE patient thromboembolism risk

Lab results: Date:

bleeding risk of procedure

Anticoagulation Bridging Instructions

MODeraTe bleeding risk of procedure

HIGH patient thromboembolism risk

Warfarin (Coumadin) and Lovenox

anticoagulation Bridging instructions

MODeraTe patient risk of blood clot (thromboembolism)

MODerATe HIGH risk of blood clot

EVENING OF THE PROCEDURE (but at least 12 hours after)

* Decision and timing of reinstitution of anticoagulation must be individualized in

bridging decision tree:

Does your patient require bridging?

For procedures not listed, clinician judgement is required to determine whether

LOW BLEEDING RISK

HIGH BLEEDING RISK

Proceed with surgery/procedure without interrupting anticoagulation.

Classify the patients THROMBOEMBOLISM (TE) RISK

Atrial Fibrillation (non-valvular)

* CHF defined as EF <35% or if EF unknown, dyspnea at rest or with mild exertion

Bridging Guidelines based on above risk classifications. See page 1.

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