To Bridge or Not to Bridge? Preop Evaluation of the Patient on Coumadin

Transcription

1 To Bridge or Not to Bridge? Preop Evaluation of the Patient on Coumadin Omprakash Pansara, MD Brian Kline, MD St. Joseph s Health Family Medicine Residency Program, Syracuse, NY

2 Case 75yr old male, who presents for the pre-op evaluation for an Elective Total Right Knee Arthroplasty. He is on Coumadin for Chronic Atrial Fibrillation.

3 PMH Atrial Fibrillation HTN, HLD Systolic CHF with EF 35-40% Mild Mitral Valve and Tricuspid Valve Regurgitation Cardiomyopathy CKD III Sick Sinus Syndrome s/p Pacemaker Placement Hypothyroidism Osteoarthritis.

4 Medications Coumadin 5mg QD Coreg 3.125mg BID Lasix 40mg QD Klor 20mg QD Amlodipine 5mg QD Lisinopril 2.5mg QD Spironolactone 25mg QD Synthroid 100mcg QD Aspirin 81mg QD Tramadol 50mg TID PRN

5 PSH Pacemaker placement Cardiac Cath- No significant coronary artery blockage(1yr ago)

6 Social Former smoker. No alcohol or recreational drug use. He ambulates well with a walker. He lives in a group home.

7 Physical Exam Vitals stable. NAD. AAOX3. Regular Rhythm, I/VI Systolic Murmur. Lungs clear. ABD exam is benign. Trace leg edema. No focal neurologic deficit

8 Estimating Thrombotic Risk in A.Fib CHA 2 DS 2 -VAS C Score Risk Factor Score CHF 1 Hypertension 1 Age 75 and more 1 Diabetes 1 Stroke or TIA 2 Vascular Disease (MI,PAD, Aortic Arthrosclerosis) Age 65-74y 1 Sex Category (Female) 1 1 Score 0 0 Risk of Stroke per Year 1 1.3% (1 in 77) 2 2.2% ( 1 in 45) % (1 in 31) 4 4.0% (1 in 25) % (1 in 15) 6 9.8% (1 in 10) 7 9.6% (1 in 10) 8 6.7% (1 in 15) % (1 in 6)

9 Estimate the Risk of Major Bleeding in A.Fib (on Coumadin) HAS-BLED Score Hypertension 1 Abnormal liver/renal function Stroke 1 Bleeding 1 Labile INRs 1 E-Elderly (>65) 1 Drugs(NSAID or antiplatelet agent) /Alcohol Total 9 Score 1 point each 1 point each Score Clinically Relevant bleeding 0 7% 1% 1 8% 1% 2 11% 2% 3 16% 3% 4 15% 3% 5 or more 38% 8% Major Bleeding (Lane & Lip, 2012)

10 Lip, G., & Douketis, J. (2016)

11 Risk Stratification for Perioperative Thromboembolism Thromboemb olic Risk Atrial Fibrillation Mechanical Heart Valve Venous Thromboembo lism High Moderate Low CHA 2 DS 2 -VAS C score 6 or more Mitral Valve Prosthesis Cage-ball or tilting disc aortic valve prosthesis disk, Stroke/TIA < 6 months prior VTE <3 months pdiod Severe thrombophilia CHA 2 DS 2 -VAS C Score 4-5 Bileaflet Aortic Valve + other Risk Factor VTE > 3-12 mo prior Nonsevere thrombophilia Recurrent VTE Active Cancer CHA 2 DS 2 -VAS C 2-3 (without prior Stroke/TIA) Bileaflet Aortic Valve without other risk factor VTE > 12 month prior without other risk factors (Lip & Douketis, 2016)

12 Calculate Periprocedural Risk of Bleeding BleedMAP Score Risk Factor Prior Hx of Bleeding 1 Mechanical Mitral Valve 1 Active Cancer 1 Platelet <150K 1 (Rechenmacher & Fang, 2015)

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14 Anticoagulation Patient Related Factors OAC treatment Related Factors Concomitant Medication Use Age Inception vs OAC experience Antiplatet Drugs History of Bleeding Adherence NSAIDs Previous Stroke Intensity of anticoagulation (INR) Other medication affecting OAC intensity Anemia Time in therapeutic range Excessive alcohol intake Genetic Factors Sex Dietary intake of Vit K Management of OAC( selfmonitoring,dedicated OAC clinic, usual care) Uncontrolled Hypertension Renal Insufficiency Hepatic Dysfunction Malignancy

15 Slomski, A. (2015)

16 Comparing Periprocedural rate of Thromboembolism vs Bleeding (Rechenmacher & Fang, 2015)

17 Procedure Amenable to Uninterrupted Therapeutic Warfarin Endoscopy Biopsies Endovascular Interventions Cardiac Electrophysiological studies and ablations Cardiac device implantation (pacemaker, defibrillators, loop recorders) Cataract Surgery Dermatologic Surgery Dental Extractions Epidural anesthetics and likely other interventional pain management techniques Minor noncardiac surgeries Total knee arthroplasty* Arthroscopic surgery

18 JAMA Intern Med. 2015;175(7): doi: /jamainternmed

19 (Rechenmacher & Fang, 2015)

20 (Rechenmacher & Fang, 2015)

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22 Perioperative Management of NOAC Renal function High Bleeding Risk Low Bleeding Risk High Bleeding Risk Low Bleeding Risk Dabigatran CrCl>50 Hold D- 3d Rivaroxaban Apixaban CrCl Hold D- 5d CrCl 30 or better Hold D- 3d Hold D- 2d Hold D- 3d Hold D- 2d Resume 48hr to 72hr after the surgery Resume 24hr after the surgery Edoxaban

23 Plan: His BleedMAP Score is 0. Pt s CHADS2 -VAS c Score and HAS-BLED Score are 4 and 3, respectively. This puts him for a moderate risk for perioperative thromboembolism. Currently, there is no proper guideline about patient at the moderate risk for thromboembolism. Considering his cardiomyopathy and his over all health condition, this patient was recommended to have preop and post op bridging with LMWH.

24 Teaching Points Oral anticoagulant should not be held for the low bleeding risk procedures. Patients at the greatest risk for thromboembolism without excessive bleeding risk should be considered for bridging. For moderate/intermediate risk for thromboembolism cases, use clinical judgment based on patient-specific and surgery-specific risks. Resist the temptation of bridging the patients at the low risk for thromboembolism. Remember, bleeding is more common than clotting when we bridge. Based on the recent studies, bridging nearly tripled the risks of bleeding and did not provide any significant benefit in preventing MI, thromboembolism, or death. (Slomski, 2015)

25 Teaching Points Various strategies exists about pre op and post op bridging for the patient on Coumadin (warfarin). Low molecular weight heparin(lmwh) or heparin is used for the bridging. LMWH is preferred over heparin if renal function allows. Patients on Novel Oral Anticoagulants (NOAC) usually don t need bridging, unless they are very high risk for developing thrombosis. Most NOACs need to be held 2-3 days prior to the procedure, based on the risks of the bleeding of the procedure. If renal function is worse, i.e. CrCl <50, then dabigatran needs to be held 3-5 days before the procedure based on the risks of bleeding with the procedure. Keep the patients informed and allow them to participate in the decision-making process.

26 References Rechenmacher, S. J., & Fang, J. C. (2015). Bridging anticoagulation. Journal of the American College of Cardiology, 66(12), doi: /j.jacc Slomski, A. (2015). Bridging anticoagulation offers no Perioperative benefit. JAMA, 314(8), 762. doi: /jama Lane, D. A., & Lip, G. Y. H. (2012). Use of the CHA2DS2-VASc and HAS- BLED scores to aid decision making for Thromboprophylaxis in Nonvalvular Atrial fibrillation. Circulation, 126(7), doi: /circulationaha Lip, G., & Douketis, J. (2016, November 30). Perioperative management of patients receiving anticoagulants. Retrieved January 29, 2017, from UpToDate, Clark NP, Witt DM, Davies LE, Saito EM, McCool KH, Douketis JD, Metz KR, Delate T. Bleeding, Recurrent Venous Thromboembolism, and Mortality Risks During Warfarin Interruption for Invasive Procedures. JAMA Intern Med. 2015;175(7): Brotman doi: /jamainternmed DJ, Streiff MB. Overuse of Bridging Anticoagulation for Patients With Venous ThromboembolismFirst, Do No Harm. JAMA Intern Med. 2015;175(7): doi: /jamainternmed