2017 Bryan Health Primary Care Conference. Dale Hansen MD Bryan Heart 5/20/17

Transcription

1 2017 Bryan Health Primary Care Conference Dale Hansen MD Bryan Heart 5/20/17

2 I have no financial disclosures or conflicts of interest

3 Bridging Anticoagulation Primum Non Nocere

4 67 y.o. male with mechanical mitral valve scheduled for routine colonoscopy-chronic AFib on coumadin with history of TIA 6 mos. Prev. 1) Bridge with lovenox 2) Continue coumadin and proceed with colonoscopy 3) Stop coumadin and start Noac 5 days prior to procedure 4) Cancel procedure due to risk

5 Which prosthetic valve location is at highest risk for thromboembolic complications 1) Mitral 2) Aortic 3) Tricuspid

6 Bridging Anticoagulation What do I Need to Know Which procedures Which patients How to stop/reverse How to restart Bridging with Noacs

7 35 million prescriptions per year are written for oral anticoagulants Conditions treated include atrial fibrillation, mechanical heart valves, venous or arterial thromboembolism, and ventricular assist devices 15-20% of these patients undergo an invasive procedure or surgery per year Great variation among practitioners in management

8 References 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Nonvalvular Atrial Fibrillation- J Am Coll Cardiol 2017;69: ACC Update of Guidelines of Management of Patients with Valvular Heart Disease J Am Coll Cardiol 2017;print pending

9 Definitions Bridging: The process whereby an oral anticoagulant is discontinued and replaced by a subcutaneous or intravenous anticoagulant before and/or following an invasive procedure Nonvalvular AF: Atrial fibrillation in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve or mitral valve repair

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11 Bleeding Risk Defined as major bleed within 48 hours of procedure High risk- 2-4% Low risk 0-2% Most professional societies have published consensus documents classifying risk per procedure Low risk procedures generally do not need anticoagulants held

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14 Indeterminate risk Hip/knee replacement Prostate biopsy Hysterectomy Shoulder Surgery

15 EP Procedures Bruise trial-with pacemaker or AICD insertion -lower rate of bleeding with no interruption of anticoagulants if INR <3 than stopping anticoagulants and bridging Compare-similar results with arrhythmia ablation procedures

16 Patient Related Bleed Risk Prior bleeding events with or without surgery Use of concominant antiplatelet agents Known bleeding diathesis Supratherapeutic INR Abnormal liver or renal function

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24 ALL OTHERS 1. Stop warfarin 5 days prior to procedure 2. Start UFH when INR < 2.0 or after omitting 2 3 doses - Enoxaparin 1 mg/kg every 12 hours - Last dose 24 h prior to surgery 3. Check INR 24 hours prior to procedure 4. Restart Warfarin immediately post op 5. Remember DVT Prophylaxis 6. Hold therapeutic heparin for 48 hr post op 7. Continue ASA

25 Interrupting Warfarin Check INR 7 days prior to procedure If INR >3 hold warfarin >5days If INR 1.5 to 1.9 hold warfarin 3-4 days If maintenance dose > 7.5 mg. shorter discontinuation times needed

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30 Bridging in Non-Valvular Atrial Fibrillation Thromboembolism rates are low~1% Bridging if prior ischemic stroke, TIA, or systemic embolism CHADS-VASC score of 7 or greater

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32 NO PRIOR STROKE OR EMBOLIC EVENT,CHADS-VASC SCORE <7 (AKA-ALL STARS ALIGNED) No bridging therapy needed Stop warfarin for 5 days Obtain INR on day of proceedure Restart warfarin post-operatively

33 ALL OTHERS 1. Stop warfarin 5 days prior to procedure 2. Start UFH when INR < 2.0 or after omitting 2 3 doses - Enoxaparin 1 mg/kg every 12 hours - Last dose 24 h prior to surgery 3. Check INR 24 hours prior to procedure 4. Restart Warfarin immediately post op 5. Remember DVT Prophylaxis 6. Hold therapeutic heparin for 48 hr post op 7. Continue ASA

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36 IF VTE WITHIN PRIOR 3 MONTHS 1. Stop warfarin 5 days prior to procedure 2. Start UFH when INR < 2.0 or after omitting 2 3 doses - Enoxaparin 1 mg/kg every 12 hours - Last dose 24 h prior to surgery 3. Check INR 24 hours prior to procedure 4. Restart Warfarin immediately post op 5. Remember DVT Prophylaxis 6. Hold therapeutic heparin for 48 hr post op 7. Continue ASA

37 Guidance statement for restarting anticoagulation post procedure Ensure procedural site hemostasis Consider bleeding consequences with high bleed risk procedures such as cardiac, intracranial or spinal procedures Consider patient specific factors that may predispose to bleeding complications, eg. Platelet dysfunction, antiplatelet medications Generally can resume Warfarin within 24 hours of procedure After 48 hours can bridge with Heparin if high risk of thromboembolic event-stop when INR >2

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40 Interrupting DOAC Therapy-FXa No bridging therapy needed Low risk procedures If CrCl>30 Hold for 24 hours Hold 36 hours <15 Hold > 48 hours High risk procedures If CrCl>30 Hold 48 hours <30 Hold > 72 hours

41 Interrupting DOAC Therapy-DTI No bridging therapy needed Low risk procedures If CrCl>80 Hold for 24 hours Hold 36 hours Hold > 72 hours High risk procedures If CrCl>80 Hold 48 hours Hold > 72 hours Hold > 96 hours <30 Hold > 120 hours

42 Resuming NOACs If high bleeding risk wait hours If low bleeding risk ok to start within 24 hours but consider lower dose if within 24 hours Use of a NOAC will render the patient therapeutically anticoagulated within a few hours Monitor renal function post-op

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44 Neuraxial Anesthesia American society of regional anesthesia guidelines Wait 24 hours to initiate DOAC therapy after catheter removal This recommendation differs from package inserts for the DOACs

45 67 y.o. male with mechanical mitral valve scheduled for routine colonoscopy-chronic AFib on coumadin with history of TIA 6 mos. Prev. 1) Bridge with lovenox 2) Continue coumadin and proceed with colonoscopy 3) Stop coumadin and start Noac 5 days prior to procedure 4) Cancel procedure due to risk

46 Which prosthetic valve location is at highest risk for thromboembolic complications 1) Mitral 2) Aortic 3) Tricuspid

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