Protocol for breast biopsy in patients taking anticoagulant and antiplatelet therapy

Prior to biopsy ask all patients whether they are taking anticoagulant or antiplatelet therapy. If taking Warfarin obtain their latest INR.

Inform all patients of the risk of bleeding, bruising and haematoma formation – and that this risk is greater for those taking any antiplatelet or anticoagulant medication.

 

 

FNA

Core Biopsy

Vacuum Biopsy

Warfarin*
No change

INR < 4.0 ok to proceed.

INR >4.0

Stop Warfarin for 3 days

INR < 2.5 ok to proceed.

INR >2.5

Stop Warfarin for 3 days
Aspirin/ Clopidogrel **

No change

No change

No change


*WARFARIN


A recent (ideally within previous 5 days but longer if INR stable over a prolonged period) INR result should be known prior to performing the biopsy.

Stopping Warfarin

Warfarin should be stopped for 3 days.Restart Warfarin with standard dose on the day of procedure i.e. patients who take Warfarin in the morning should take their standard dose on the morning of the biopsy. This will have no effect on bleeding potential of the procedure the same day.

Patients who should not stop Warfarin:

  • Mechanical mitral prosthetic heart valves (not aortic)
  • If a patient has been advised by their Clinician that they should not be taken off anticoagulation at anytime.

In such instances and if in doubt contact the anticoagulation treatment team for advice as Heparin bridging therapy may be indicated

CLOPIDOGREL +/- ASPIRIN **


The chief therapeutic indication for clopidogrel is post coronary artery stenting. Discontinuation of antiplatelet or anticoagulant therapy carries a risk of thrombosis. The potential harm of coronary occlusion should antiplatelet therapy be stopped outweighs the relatively small increased risk of breast haematoma.

Adapted from guidelines drawn up by Dr Sally Bradley and in conjunction with Dr Trevor Baglin Consultant Haematologist, Addenbrooke’s Hospital.
Dr Peter Britton Dr Matthew Wallis Cambridge Breast Unit

Clin Radiology 2008 63;3:305-311.Management of patients taking antiplatelet or anticoagulant medication requiring invasive breast procedures: United Kingdom survey of radiologists' and surgeons' current practice M.G. Pritchard, J.N. Townend, W.A. Lester, D.W. England, O. Kearins, S.A. Bradley

Other References on Anticoagulation:

  1. AJR 2000; 174:245-249 Michelle K. Melotti and Wendie A. Berg Core Needle Breast Biopsy in Patients Undergoing Anticoagulation Therapy Academic center. No significant complications in pts on warfarin, heparin or aspirin
  2. AJR 2008; 191(4):1194-7 Somerville P, Seifert PJ, Destounis SV, Murphy PF, Young W. Anticoagulation and bleeding risk after core biopsy