Table 3

Risk stratification for discontinuation of warfarin therapy with respect to the requirement for heparin bridging

High risk of thromboembolismLow risk of thromboembolism
Prosthetic metal heart valve in mitral or aortic* positionXenograft heart valve
Prosthetic heart valve and atrial fibrillation
Atrial fibrillation and mitral stenosis
Atrial fibrillation with previous stroke or transient ischaemic attack+3 or more of:
Congestive cardiac failure
Age>75 years
Diabetes mellitus
Atrial fibrillation without high-risk factors
(CHADS2 <4)
Atrial fibrillation and previous stroke or transient ischaemic attack within 3 months
<3 months after venous thromboembolism‡>3 months after venous thromboembolism
Previous venous thromboembolism on warfarin, and target INR now 3.5
  • Thrombophilia syndromes do not usually require heparin bridging, but individual cases should be discussed with a haematologist.

  • *Heparin bridging for a metal aortic valve is recommended by European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines 2017,33 but this varies between international guidelines31 32 and local guidance should be established in conjunction with cardiology or cardiothoracic services.

  • †Blood pressure>140/90 mm Hg or on antihypertensive medication.

  • ‡The majority of patients are now on direct oral anticoagulants for venous thromboembolism and bridging is not appropriate. Consider deferring a high-risk procedure beyond 3 months therapy in this high-risk group for thromboembolism.

  • INR, international normalised ratio.