What is the recommended anticoagulation management for patients with atrial fibrillation on warfarin (Coumadin) undergoing hernia repair?

From the Guidelines

For patients with atrial fibrillation on warfarin undergoing hernia repair, bridging anticoagulation with heparin is generally not recommended, except for those with a very high thromboembolic risk, as the bleeding risk outweighs the thromboembolic risk, according to the 2019 AHA/ACC/HRS focused update 1. The management of anticoagulation in these patients involves temporarily discontinuing warfarin before surgery and resuming it after surgery if hemostasis is adequate. Key considerations include:

• The risk of thromboembolism, which can be assessed using tools like the CHA2DS2-VASc score
• The risk of bleeding, which can be significant with bridging anticoagulation
• The type of surgery being performed, with hernia repair generally considered to be a low-risk procedure
• The patient's individual characteristics, such as their overall health and medical history As noted in the 2019 guidelines, the Warfarin Therapy for an Elective Invasive Procedure or Surgery study found that absence of bridging was noninferior to bridging with low-molecular-weight heparin for prevention of arterial thromboembolism and decreased the risk of bleeding 1. Therefore, for most patients with atrial fibrillation on warfarin undergoing hernia repair, the recommended approach is to discontinue warfarin 5 days before surgery and resume it 12-24 hours after surgery if hemostasis is adequate, without bridging anticoagulation, unless the patient has a very high thromboembolic risk, as determined by their individual clinical characteristics and medical history.

From the Research

Anticoagulation Management for Patients with Atrial Fibrillation on Warfarin Undergoing Hernia Repair

• The British guidelines recommend that patients with atrial fibrillation on warfarin who need to undergo elective surgery, such as hernia repair, should have their warfarin stopped 5 days before the procedure 2.
• A study published in the New England Journal of Medicine found that forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding in patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure 3.
• Another study published in the journal Hernia found that patients can safely undergo inguinal hernia repair while on warfarin as long as the INR is less than 3 4.
• The CHA2DS2-VASc score is used to assess the risk of stroke in patients with atrial fibrillation, and a score of 1 or higher indicates a higher risk of stroke 5.
• However, the decision to use heparin bridging in the perioperative period should be made on a case-by-case basis, taking into account the individual patient's risk factors and the type of surgery being performed.

Perioperative Bridging Anticoagulation

• The use of perioperative bridging anticoagulation with low-molecular-weight heparin or unfractionated heparin is not routinely recommended for patients with atrial fibrillation on warfarin who are undergoing elective surgery, such as hernia repair 3, 2.
• However, bridging anticoagulation may be considered for patients who are at high risk of thromboembolic events, such as those with a history of stroke or transient ischemic attack, or those with a high CHA2DS2-VASc score 5, 6.

Recommendations

• Patients with atrial fibrillation on warfarin who need to undergo elective hernia repair should have their warfarin stopped 5 days before the procedure and restarted as soon as possible after the procedure 2.
• The use of heparin bridging in the perioperative period should be considered on a case-by-case basis, taking into account the individual patient's risk factors and the type of surgery being performed 3, 5, 6.