Which anticoagulation treatment plan(s) is/are appropriate for a 72-year-old man with a mechanical heart valve in place who takes Coumadin (warfarin) and now requires elective left colon resection?

Discontinuation of Coumadin therapy 5 days before operation with the institution of intravenous heparin as the prothrombin time normalizes

DISCUSSION: Many patients who require anticoagulation with Coumadin for underlying cardiac disease need to undergo routine general surgical procedures. The current recommendations for patients who have been on long-term Coumadin therapy is to discontinue Coumadin 5 days before an operative procedure. As the patient's prothrombin time normalizes intravenous heparin should be started. The patient should be maintained on a therapeutic dose of heparin with an activated partial thromboplastin time (aPTT) of at least 60 seconds. Heparin should then be withheld approximately 4 to 6 hours before the surgical procedure. The operation is then performed in a “heparin window,” where the level of anticoagulation can easily be titrated or totally reversed with protamine if necessary.