Warfarin Management Before Hip Replacement Surgery

Preoperative Management

The American College of Cardiology recommends stopping warfarin 4 to 5 days before hip replacement surgery to allow the INR to return to normal (1.2) at the time of the procedure 1, 2
For low-risk patients, including those with atrial fibrillation without history of stroke, stop warfarin 4-5 days before surgery and allow INR to fall to normal or near normal (1.3-1.5) by the time of surgery 1, 2, 5
For moderate-risk patients, including those with history of venous thromboembolism within 3-6 months, stop warfarin 4-5 days before surgery and administer prophylactic doses of heparin (5000 U) or LMWH (3000 U) subcutaneously every 12 hours starting 2 days before procedure 1, 2
For high-risk patients, including those with recent thromboembolic events (within 3 months), stop warfarin 4-5 days before surgery with close INR monitoring and administer therapeutic doses of heparin (15,000 U every 12 hours subcutaneously) or LMWH (100 U/kg every 12 hours) when INR falls below therapeutic range 2, 4

The American Geriatrics Society recommends classifying patients as low-risk, moderate-risk, or high-risk based on their thromboembolism risk, with low-risk patients including those with atrial fibrillation without history of stroke, and high-risk patients including those with recent thromboembolic events (within 3 months) 3, 4

The American College of Cardiology suggests administering vitamin K 2.5 mg orally 2 days before procedure to reduce the period off warfarin to 2 days for patients who need more rapid reversal of anticoagulation 1, 2

The American Geriatrics Society recommends resuming warfarin 12-24 hours after surgery when adequate hemostasis is achieved, and using lower leg compression devices in addition to anticoagulation for patients undergoing hip arthroplasty 7
The preferred method of prophylaxis for elective hip replacement is LMWH rather than adjusted-dose warfarin 7

Elderly patients (>75 years) require lower warfarin doses and may have higher bleeding risk 5
Patients with renal insufficiency may have prolonged LMWH half-life, requiring dose adjustment 4
Inadequate bridging therapy for high-risk patients can lead to thromboembolic events 2, 4