Key result
Higher baseline INR was significantly associated with slow normalization of prothrombin time after stopping warfarin, with an odds ratio of 0.27 for achieving normal hemostasis per unit increase.
Cohort (n=202)
No
Baseline INR is an independent predictor of slow normalization of prothrombin time after stopping warfarin before surgery, though its positive predictive value is low.
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May not yet alter perioperative warfarin management due to low PPV; leaves open prospective validation of INR-guided timing.
BACKGROUND: Anticoagulation with warfarin should be stopped 4-6 days before invasive procedures to avoid bleeding complications. Despite this routine, some patients still have high International Normalized Ratio (INR) values on the day of surgery and the procedure may be cancelled. We sought to identify easily available clinical characteristics that may influence the rate of normalization of prothrombin time when warfarin is stopped before surgery or invasive procedures. METHODS: Clinical data were collected retrospectively from consecutive cases from two cohorts, who stopped warfarin 6 days before surgery. An INR value of 1.6 or higher on the day of surgery or requirement for reversal with vitamin K the day before surgery were criteria for slow return (S) to normal INR. RESULTS: Of 202 patients, 14 (7%) were classified as S. Eight of the S-patients required reversal with vitamin K one day before surgery and in another case surgery was cancelled due to high INR. Baseline INR was the only variable significantly associated with classification as S in stepwise logistic regression analysis (p = 0.003). The odds ratio for being in the normal group was 0.27 (95% confidence interval 0.12-0.62) for each unit baseline INR increased. The positive predictive value of baseline INR with a cut off at > 3.0 was only 15% and for INR > 3.5 it was 33%. CONCLUSION: Baseline INR, but not the size of the maintenance dose, is associated with the rate of normalization of prothrombin time after stopping warfarin, but it has limited utility as predictor in clinical practice. Whenever normal hemostasis is considered crucial for the safety, the INR should be checked again before the invasive procedure.
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Schulman et al. (2008) conducted a cohort in Patients on long-term warfarin therapy requiring temporary cessation for surgery or invasive procedures (n=202). Baseline INR vs. Lower baseline INR was evaluated on Slow normalization of prothrombin time (INR ≥ 1.6 on day of surgery or requiring vitamin K reversal) (OR 0.27, 95% CI 0.12-0.62, p=0.003). Higher baseline INR was significantly associated with slow normalization of prothrombin time after stopping warfarin, with an odds ratio of 0.27 for achieving normal hemostasis per unit increase.
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