A 28-year-old woman with known antiphospholipid syndrome had a cerebral venous sinus thrombosis 6 months ago. She is currently on warfarin with INR 2.5. She is now being considered for elective surgery. Which anticoagulation strategy is most appropriate for her perioperative bridging?
- A Switch to direct oral anticoagulants (rivaroxaban) perioperatively
- B Bridge with therapeutic low-molecular-weight heparin (LMWH) ✓
- C Stop warfarin 5 days before surgery with no bridging
- D Continue warfarin at sub-therapeutic INR 1.5–2.0 throughout surgery
Correct answer: B. Bridge with therapeutic low-molecular-weight heparin (LMWH)
Explanation
APS with arterial thrombosis (cerebral venous thrombosis) is high-risk for perioperative thromboembolism. ISTH guidelines recommend therapeutic LMWH bridging when warfarin is held for surgery. DOACs are not recommended in triple-positive APS or arterial APS thrombosis based on the TRAPS trial showing inferior outcomes with rivaroxaban compared to warfarin. Sub-therapeutic INR continuation is not accepted perioperative practice for high-risk thrombotic conditions.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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