Cardiovascular Critical Care I
Risk Factor Assessment
Score
Total Patient
Score
Bleeds/100 Patient-Yr
of Warfarin
HAS-BLED
Hypertension
Abnormal renal or liver function (1 point each)
Stroke
Bleeding
Labile INRs
Elderly (> 65 yr)
Drugs or alcohol (1 point each)
1 or 2
1 or 2
Any score
1.13
1.02
1.88
3.74
8.70
12.5
0a
1.56
HEMOR2RHAGES
Hepatic or renal disease
Ethanol abuse
Malignancy
Older age
Reduced platelet count or function
Rebleeding risk
Hypertension (uncontrolled)
Anemia
Genetic factors
Excessive fall risk
Stroke
≥ 5
Any score
1.9
2.5
5.3
8.4
10.4
12.3
4.9
aScores ˃ 5 were too rare to determine risk, but are likely ˃ 10%. AF = atrial fibrillation.
In the critically ill patient, parenteral anticoagulation with unfractionated heparin or low-molecular-
weight heparin may be more favorable if the benefit of anticoagulation exceeds the risk of bleeding.
Unfractionated heparin infusions would be favored more than low-molecular-weight heparin in
renal failure (CrCl less than 30 mL/minute/1.73 m2).
For anticoagulation of most critically ill patients, oral anticoagulation may be less favorable or even
detrimental compared with parenteral anticoagulation.
Elimination of DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) is significantly
affected in renal compromise. An additional consideration in the critical care setting is the
feasibility of reversal in the event of an acute bleed or need for an invasive procedure. Novel
antidotes continue to be studied and approved (idarucizumab, andexanet); however, clinical
experience with reversibility in these settings is evolving. Finally, the aforementioned DOACs
are not devoid of relevant drug-drug interactions, particularly when given in combination with
strong CYP and/or P-glycoprotein inhibitors/inducers.
ii.
Warfarin is challenging due to issues with malnutrition, drug interactions, and unpredictable
dose response in the critically ill patient. Complications with this agent are more predictably
managed than are complications with other oral anticoagulants if a patient requires an invasive
procedure or develops an acute bleed, but warfarin use is still not without risk.
For patients with AF/flutter for 48 hours or more (or if undetermined) without therapeutic
anticoagulation, absence of thrombus on the left side of the heart should be confirmed by
transesophageal ECHO before pharmacologic or direct current cardioversion.
If AF/flutter for more than 48 hours or an unknown duration that requires direct current or
pharmacologic cardioversion for hemodynamic instability, anticoagulation should be initiated as
soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated