HomertonUniversityHospital NHS Foundation Trust
Anticoagulant Clinic Referral
To book an initial appointment:
  • Complete referral form and send or fax to Anticoagulant Department on 020-8510-5743
  • Phone Anticoagulant Department on Ext. 5764 to confirm date and time of appointment (within 48hours of discharge)
  • Give patient information about appointment
  • Clinics: a.m. -Monday, Tuesday, Thursday p.m. - Wednesday, Friday
  • If transport required it is the responsibility of the ward staff or referring team to arrange

Surname:
Forename:
M / F:
Date of Birth:
Hospital No: / Consultant:
Referring Doctor:
Bleep No:
Ward / Dept :
Date of Referral :
Reason(s) for Anticoagulation
If acute VTE, was it: first episode Recurrent
And: post-op pregnancy/OCP/non surgical transient risk factors  spontaneous 
Others please specify ______
Proposed Duration of Therapy (see overleaf)
6/52  13/52  26/52  long-term  / Proposed Target INR (see overleaf)
2.5  3.0  3.5  4.0 
Medical History
Bleeding disorder
Hypertension
Liver/renal dysfunction
Epilepsy
Frequent falls
Excess alcohol
Cancer
Peptic ulcer
CVA/TIA / Medication
If taking aspirin or clopidogrel should these be discontinued?
YesNo
ANTICOAGULANT THERAPY AND TEST RESULTS (at least 5 INRs required)
DATEINRWARFARIN (mg)

Indications for Oral Anticoagulation

INDICATIONS / TARGET INR / DURATION
Isolated calf vein thrombosis / 2.5 (2.0-3.0) / 6 weeks
First episode proximal DVT / PE provoked by e.g. surgery / 2.5 (2.0-3.0) / At least 13 weeks
First episode proximal DVT / PE provoked by transient non-surgical factors (e.g. OCP, post pregnancy, plaster cast) / 2.5 (2.0-3.0) / 26 weeks
Unprovoked first episode proximal DVT / PE / 2.5 (2.0-3.0) / Consider 1 year*
DVT / PE and continued risk factors / 2.5 (2.0-3.0) / Consider long term
Recurrent DVT / PE off warfarin / 2.5 (2.0-3.0) / Consider long term
Recurrent DVT / PE on warfarin / 3.5 (3.0-4.0) / Long term
Pregnancy and Cancer-associated VTE / Use therapeutic LMWH / 6 months
Atrial fibrillation / 2.5 (2.0-3.0) / Long term
Elective cardioversion / 3.0 (2.5-3.5)pre-
2.5 (2.0-3.0)post- / >3 weeks pre
4 weeks post
Tissue prosthetic valve / graft / 2.5 (2.0-3.0) / 13 weeks
Mural thrombus / 2.5 (2.0-3.0) / 13 weeks; consult Cardiology
Cardiomyopathy / 2.5 (2.0-3.0) / Long term
Thromboembolic stroke / 2.5 (2.0-3.0) / Long term
Mechanical prosthetic valve / graft
Depends on prosthesis thrombogenicity** and the presence of patient risk factors^ which would raise the target INR.
(Discuss with cardiothoracic team) / **Low: 2.5 (2.0-3.0)
**Medium: 3.0 (2.5-3.5)
**High: 3.5 (3.0-4.0)
^Low: 3.0 (2.5-3.5)
^Medium: 3.5 (3.0-4.0)
^High: 4.0 (3.5-4.5) / Long term
Antiphospholipid syndrome: venous and arterial events / 2.5 (2.0-3.0) / Long term

*Patients with unprovoked proximal DVT / PE should be considered for long term anticoagulation, taking into account information that may help predict risk of recurrence and risk of bleeding in the individual patient.

^ mitral/tricuspid/pulmonary position, previous arterial thromboembolism, AF, LA diameter >50mm, mitral stenosis, LVEF <35%, L atrial dense spontaneous echo contrast.