When Can Your Trauma Patient Stop Taking Warfarin?
I admit it. I read trauma and surgery literature, not medical literature. Imagine my surprise when a fellow physician (internist) told me that there is an objective system for helping us figure out whether anticoagulation is needed for atrial fibrillation. “CHADS2” he said. Am I the last trauma surgeon on earth to hear about this?
CHADS2 is a validated scoring system for predicting stroke risk in people with atrial fibrillation. There are 5 components as follows:
- C – congestive heart failure – 1 point
- H – hypertension (treated or untreated) – 1 point
- A – age >= 75 – 1 point
- D – diabetes mellitus – 1 point
- S2 – history of stroke or TIA – 2 points
Stroke risk is directly correlated to the number of points scored. So based on that the recommendations are:
- Score = 0: low risk, no therapy needed or just take aspirin
- Score = 1: moderate risk, aspirin or oral anticoagulant
- Score >= 2: moderate to high risk, take oral anticoagulant
Bottom line: Evaluate every trauma patient on anticoagulation to see if they really need to keep taking it. If it’s for a one-time episode of DVT or PE that happened years ago, they should be able to stop. If it’s for a-fib, check their CHADS2 score and work with their primary care provider to see if they could take aspirin or nothing. Factor in a history of frequent falls or car crashes as well.
Reference: Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 110 (16): 2287–92, 2004.
OnSurg thanks collaborative partner Dr Michael McGonigal. Dr McGonigal tweets at @RegionsTrauma