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Teachable Moment
November 25, 2019

Bridging Anticoagulation Therapy: A Teachable Moment

Author Affiliations
  • 1Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
JAMA Intern Med. 2020;180(2):311-312. doi:10.1001/jamainternmed.2019.5934

A 76-year-old man who had nonischemic cardiomyopathy with an ejection fraction of 30%, chronic obstructive pulmonary disease (COPD) being managed with 3-liter flow home oxygen, and paroxysmal atrial fibrillation (AF) being managed with warfarin therapy presented to the emergency department after developing lightheadedness, fatigue, and a large bruise on his right buttocks after a mechanical fall at home.

The previous week, the patient had been hospitalized with a COPD exacerbation, reporting coughing up some scant blood-tinged sputum at home. Warfarin treatment was discontinued at admission as a precaution. He had no further blood-tinged sputum throughout the hospitalization, and his hemoglobin level remained stable. At discharge, his international normalized ratio (INR) was 1.24; hemoglobin level was 12.1 g/dL; and he was ambulatory without assistance. His CHA2DS2-VASc score was 4 (2 points for age, 1 point for hypertension, 1 point for heart failure), and he had no history of ischemic stroke or major bleeding episodes. The patient was offered treatment with a direct oral anticoagulant but elected to resume warfarin owing to familiarity and comfort with it. He was discharged home with the existing dose of warfarin. In the setting of a subtherapeutic INR, a 5-day regimen of enoxaparin therapy was also prescribed as a bridging anticoagulant. Follow-up in the anticoagulation clinic was scheduled for 1 week after discharge.

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