Should Anticoagulants Be Discontinued Before a Bronchoscopy?

Laura S. Lehman, PharmD, BCPS, CACP

Disclosures

June 09, 2008

Question

In patients on chronic anticoagulation because of atrial fibrillation, should the anticoagulant therapy be discontinued before undergoing a bronchoscopic procedure with biopsy?

Response from Laura S. Lehman, PharmD, BCPS, CACP
Clinical Coordinator, Department of Pharmacy, Carroll Hospital Center, Westminster, Maryland

According to the American Association for Respiratory Care guidelines for bronchoscopy, "coagulopathy or bleeding diathesis that cannot be corrected" is an absolute contraindication to bronchoscopy.[1] One could interpret this statement to mean that active anticoagulation is also a contraindication to bronchoscopy.

In contrast, the British Thoracic Society advises that patients stop oral anticoagulants at least 3 days before a bronchoscopy if a biopsy is anticipated; alternatively, the anticoagulation may be reversed with vitamin K supplementation.[2] If anticoagulation absolutely must be maintained, the patient's International Normalized Ratio (INR) should be below 2.5, and heparin should be initiated.[2] Unfortunately, this second recommendation by the British Thoracic Society does not clarify the role of heparin in this situation, and it does not discuss the bleeding risk with an INR above 2.5.

The American College of Chest Physicians also provides specific recommendations for withholding warfarin prior to invasive procedures, advising that 4 doses be withheld before a scheduled surgery.[3] These guidelines also describe the potential risk for thrombotic events in the absence of anticoagulation for various conditions to identify which patients may need "bridge" therapy with heparin or low molecular weight heparin while the patient's INR is subtherapeutic, both before and after the procedure. The annualized risk of withholding anticoagulation in patients with atrial fibrillation ranges from 1% to 12%, depending on concomitant risk factors.[3]

Taking all of these guidelines into consideration, it is recommended that patients with atrial fibrillation who are considered at low risk for a thromboembolic event during short-term interruption of warfarin therapy should withhold 3 to 4 doses of warfarin prior to a bronchoscopy that may entail biopsy. Patients considered at higher risk for stroke should be considered for bridge therapy with heparin or low molecular weight heparin, according to the procedure described in the American College of Chest Physicians guidelines.

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Response from Laura S. Lehman, PharmD, BCPS, CACP

 

Laura S. Lehman, PharmD, BCPS, CACP
Clinical Coordinator, Department of Pharmacy, Carroll Hospital Center, Westminster, Maryland

According to the American Association for Respiratory Care guidelines for bronchoscopy, "coagulopathy or bleeding diathesis that cannot be corrected" is an absolute contraindication to bronchoscopy.[1] One could interpret this statement to mean that active anticoagulation is also a contraindication to bronchoscopy.

In contrast, the British Thoracic Society advises that patients stop oral anticoagulants at least 3 days before a bronchoscopy if a biopsy is anticipated; alternatively, the anticoagulation may be reversed with vitamin K supplementation.[2] If anticoagulation absolutely must be maintained, the patient's International Normalized Ratio (INR) should be below 2.5, and heparin should be initiated.[2] Unfortunately, this second recommendation by the British Thoracic Society does not clarify the role of heparin in this situation, and it does not discuss the bleeding risk with an INR above 2.5.

The American College of Chest Physicians also provides specific recommendations for withholding warfarin prior to invasive procedures, advising that 4 doses be withheld before a scheduled surgery.[3] These guidelines also describe the potential risk for thrombotic events in the absence of anticoagulation for various conditions to identify which patients may need "bridge" therapy with heparin or low molecular weight heparin while the patient's INR is subtherapeutic, both before and after the procedure. The annualized risk of withholding anticoagulation in patients with atrial fibrillation ranges from 1% to 12%, depending on concomitant risk factors.[3]

Taking all of these guidelines into consideration, it is recommended that patients with atrial fibrillation who are considered at low risk for a thromboembolic event during short-term interruption of warfarin therapy should withhold 3 to 4 doses of warfarin prior to a bronchoscopy that may entail biopsy. Patients considered at higher risk for stroke should be considered for bridge therapy with heparin or low molecular weight heparin, according to the procedure described in the American College of Chest Physicians guidelines.

Discuss this article

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