A patient on warfarin for atrial fibrillation (INR 2.4) requires urgent elective surgery. The surgery will be performed in 48 hours. The most appropriate management is:
- A Stop warfarin 5 days before surgery with bridging therapy using low-molecular-weight heparin in patients with high stroke risk ✓
- B Stop warfarin now and check INR immediately before surgery; proceed if INR is ≤1.5
- C Administer IV vitamin K 10 mg immediately to reverse warfarin
- D Continue warfarin and proceed with surgery when INR is 2.0-3.0
Explanation
For elective surgery requiring an INR ≤1.5 (most surgeries), warfarin should be stopped 5 days preoperatively (allowing 5 half-lives for elimination and factor replenishment). For patients at high thromboembolic risk (CHA2DS2-VASc score ≥5, recent VTE <3 months, mechanical heart valves), bridging anticoagulation with therapeutic LMWH is administered during the warfarin-free period, stopped 24 hours before surgery, and restarted postoperatively. Low thromboembolic risk patients do not require bridging (BRIDGE trial showed no benefit and higher bleeding risk with bridging in low-risk AF). IV vitamin K 10 mg is used for urgent reversal (bleeding), not elective bridging.
Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.
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Written and medically reviewed by the StethoPrep medical team.