Anticoagulation Before Elective Forefoot Surgery
A 71-year-old woman on warfarin for atrial fibrillation (CHA2DS2-VASc 5, prior stroke) is scheduled for elective bunionectomy and hammertoe correction. Her INR is 2.6. She also takes aspirin 81 mg, metoprolol, and atorvastatin. Cardiology has not been consulted. She reports easy bruising and one episode of melena 2 months ago that resolved without workup. She is anxious about stopping her blood thinner and asks whether she can just continue it.
1. Should warfarin be interrupted for this elective procedure, and what is the perioperative plan?
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For elective forefoot surgery, warfarin interruption is generally not required for minor procedures with low bleeding risk, but this is not a minor-risk patient: prior stroke, CHA2SVASc 5, and recent melena. The safest course is to involve cardiology and GI before scheduling. If warfarin is continued, the INR should be within therapeutic range and hemostasis carefully obtained. If interruption is chosen, bridge with LMWH based on thrombotic risk and bleeding risk. The melena requires evaluation (endoscopy, H. pylori, anemia workup) before elective surgery because of bleeding risk.
2. How does the melena change the preoperative evaluation, and what would you do?
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Melena indicates possible GI bleeding; even if resolved, it warrants CBC, iron studies, and endoscopy. Elective surgery should be deferred until the source is identified and, if needed, treated. If anemia is present, correct it before surgery. This also informs whether antiplatelet therapy should continue. Document a shared decision with the patient, cardiology, and GI.
3. What is the appropriate management of her aspirin and anticoagulation on the day of surgery if the procedure proceeds?
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Aspirin is generally continued for secondary prevention in a patient with prior stroke, given the low bleeding risk of forefoot surgery. Warfarin management depends on the plan: if continued, check INR on the day of surgery; if interrupted, follow a bridging protocol. Coordinate with anesthesia and cardiology. Local hemostasis, tourniquet use, and careful wound closure reduce bleeding. Postoperative VTE and bleeding risk must be reassessed before discharge.