Perioperative Management of Anticoagulation

Anticoagulation therapy is used in primary and secondary prevention of deep vein thrombosis (DVT), pulmonary embolism, myocardial infarctions, and stroke. For individuals with atrial fibrillation (AF), who have a known risk, it can be a recommended lifelong therapy. The following module discusses the risks associated with interrupting anticoagulation therapy during the perioperative period, focusing on individuals with AF, mechanical valves, or a history of DVT. Information on how to evaluate the risks of clotting and determining the best strategy for perioperative anticoagulation is provided. In addition, methods for stopping warfarin therapy and bridging heparin or low-molecular weight heparin in perioperative patients are also reviewed.

To provide hospitalists with up-to-date information regarding the management of patients on anticoagulation therapy during the perioperative period.

This activity is designed for hospitalists. No prerequisites required.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. After completing the module, the participant should be able to:

1. Appreciate the risk of interrupting anticoagulation in patients with atrial fibrillation, mechanical valves, or a history of deep venous thrombosis/pulmonary embolism.
2. Understand how to balance the risk of interrupting anticoagulation against the risk of perioperative bleeding from heparin bridging therapy.
3. Learn when to stop warfarin and when to administer bridging heparin in perioperative patients.
4. Review the current data on the use of low-molecular weight heparin as bridging therapy in the perioperative period in anticoagulated patients.

Accreditation Statement: The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement: The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)^™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Release date: July 1, 2007 Expiration date: July 1, 2009

Estimated time to complete activity: 1 hour

Full Disclosure Policy Affecting CME Activities: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The presenting faculty reported the following:

^*Dr Delong is Fellow, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
^†Dr Streiff is Assistant Professor, Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Conflict of Interest: Dr Delong reports having no significant financial or advisory relationships with corporate organizations related to this activity; Dr Streiff reports serving as a consultant for Eisai, Inc; receiving honoraria from GlaxoSmithKline and Sanofi-Aventis; and serving on the speakers’ bureau for Sanof-Aventis.

Off-Label Product Discussion: The use of low-molecular weight heparin (LMWH) for prophylactic anticoagulation in individuals with mechanical heart valves is discussed in this module. LMWH is not approved by the US Food and Drug Administration for anticoagulation of mechanical heart valves.

Address correspondence to: Melissa Delong, MD, Fellow, Division of General Internal Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Room 8078, Baltimore, MD 21287. E-mail: .

The following is an interactive educational module designed to help you gauge your basic knowledge of the topic and then direct you to areas you may need to focus on. It consists of 3 sections: an unaccredited pre-test, a study program, and a CME post-test. All 3 sections must be completed to receive CME credit.