Catheter ablation of atrial fibrillation is currently being performed more and more without the interruption of vitamin-K antagonists. Concerning coronary angiograms and coronary intervention, is your approach the same or do you suspend these agents aiming to achieve a lower INR value?
I don't make cardiac interventions in patients with vitamin-K antagonist. The drug is discontinuated and Hepain IV is started. The procedure is performed with low level INR.
Lower than 2.0, but preferably lower than 1.5. In emergency setting we have done interventions with INR ~3.0, but note that our preferred approach is transradial, so compression hemostasis is achieved quite easily.
INR of 2 is acceptable for cardiac surgical procedures, unless the patient is also on aspirin, than lower values of INR are desireable.
I agree with the above comments. Interestingly none suggest re-evaluating with the CHADSVASC score. If the patient is at risk of an event, then INR around 2 as this allows patients to be discharged home quickly. If they are Heparinised then re-establishing warfarin or other anti-coagulant will take longer and potentially keep the patient in hospital a bit longer (always an issue with pressure on beds and resources).
Beyond CHADVASC HAS-BLED SCORE is also support for interventions with INR 2 or more
2.1 is my target value if atrial fibrillation and device implantation.
In my Cath Lab we perform femoral interventions with INR 2 for at leats 1 month is mandatory, when patient is admitted to the hospital we stop warfarin and start IV heparin and we perfor ablation under heparin protection.
We will perform Right heart Catheterisation with INR 3 or lower. The danger of discontuing anticoagulation in our population of outpatient PAH and HF patients outweighs small risk of bleed. We regularly audit our complication rates, and have found no association between warfarinisation at this level and bleeding complications. We perform 300-400 RHCs (mostly RIJ) per year and routinely use Ultrasound guidance and flouroscopy.
Is not necessary stop the anticoagulation. The warfarin is stoped and Heparin IV to keep the patient with adequated anticoagulation and protected
Under 2.5 for ablation; my experience for device implantation is under 3.0 (ICD under 2.0), almost no hematoma but I use a strong compressive / pressure dressing (hematoma may occur in obese women due to the difficulty of a really pressure dressing)
I am not sure whether you are focusing on AF ablation or you hae a broader question of antithrmobotic management during cardiac interventions. As said above, this may vary according to institutional practices. AHA has posted in 2012 AHA/ASA Science Advisory on Oral Antithrombotic Agents for the Prevention of Stroke in Nonvalvular Atrial Fibrillation at http://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_443092.pdf, in addition to Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol. 2006;48:e149-e246. You may want to also check 2011 Clinical Practice Guide on Anticoagulant Dosing...posted at www.hematology.org/practice/guidelines/7243.aspx; and Point-of-care guide to anticoagulation therapy at www.theheart.org/.../pointofcare-guide-to-anticoagulation-therapy.do. If you are intersted in pursuing it "little further" in 2011 NHLBI convened a Working Group on Guided Antithrombotic Therapy: Current Status and Future Research Directions a summary of which is posted at http://www.nhlbi.nih.gov/meetings/workshops/antithrombotic.htm
I recommend to check INR on the day of invasive procedure. Always discuss with your anesthesiologist what the INR should be before invasive procedure. An INR
There are a number of answers advising an INR of 2 or less and some add that IV heparin begins on admission, another suggests a longer stay in hospital on Heparin until the INR returns to the patients normal target.
None of the answers show a confidence in the patients own ability to take responsibility for their own healthcare. On cessation of Warfarin at home the patient can start on subcutaneous Low Molecular Weight Heparin (LMWH) until the night before the procedure and restart as soon as the surgeon recommends. If the procedure would normally have a 48 hour, or less, stay in hospital for observation and recuperation then the patient can self monitor the INR and inject LMWH at home.
I realise that some patients will be totally incapable of self medication at home, but many would be quite happy (and capable) of home treating and freeing up a bed. To suggest cessation with no regard for bridging with Heparin could be extremely dangerous for many patients, depending on the condition that requires the use of anticoagulation.
For device implantation (pacemakers, defibs etc.) we use < 3.5. I wouldn't want to comment on angiography/angioplasty or other procedures.
I use the following: diagnostic femoral angiogram INR < 1.5, diagnostic radial angiogram INR
For device and EP I will usually be happy with INR upto 3, (or 3.5 for selected low risk cases). For the rare cases where I have to convert to arterial without warning (acute VT or rarely AV node ablation), I have always used Angioseal if the INR>1.5.
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