Bleeding Management Strategies. Aiming for the best Outcomes August 27, Amit Gupta, MD FACC FSCAI Interventional Cardiologist CANM

Transcription

1 Bleeding Management Strategies Aiming for the best Outcomes August 27, 2016 Amit Gupta, MD FACC FSCAI Interventional Cardiologist CANM

2 Learning Objectives Review the use of anti-coagulants in patients with valvular and non-valvular atrial fibrillation Review drug therapy for atrial fibrillation patients undergoing PCI Review optimal duration of anti-platelet agents after coronary and vascular intervention Review management of pre-op anticoagulation and anti-platelet agents Review anti-coagulation in pregnancy Review management strategies for bleeding

3 Atrial fibrillation Review the use of anti-coagulants in patients with valvular and non-valvular atrial fibrillation

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5 Antiplatelet therapy

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8 NOACS

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10 NOAC: Clinical Trials

11 1800-BAD DRUG??

12 What is valvular atrial fibrillation 1. Rheumatic mitral stenosis 2. Mitral valve repair 3. ANY Prosthetic valve Use only warfarin, NOACS are contraindicated

13 PCI with Atrial fibrillation Review drug therapy for Atrial fibrillation patients undergoing PCI

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18 North American Consensus Statement Regarding Antithrombotic Therapy in Atrial Fibrillation Requiring a Stent Low dose aspirin: 81mg per day Clopidogrel is preferred in combination with aspirin and warfarin Prasugrel and Ticagrelor cannot be recommended Warfarin dose adjusted INR between 2-2.5

19 Atrial fibrillation and PCI CHADSVASC score <2: Hold warfarin and prescribe Dual-antiplatelet therapy based on stent type CHADSVASC score >/=2: Warfarin to keep INR Clopidogrel for all patients, duration based on stent type (One month for BMS and one year for DES-shorter course OK for newer DES). Then may switch to low dose ASA Verify-NOW testing to check for clopidogrel resistance Consider ASA, Plavix and warfarin triple therapy till INR therapeutic No role for prasugrel, ticagrelor and NOACs with triple therapy

20 Guidelines for major surgery What to stop and when?

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23 DAPT Duration: CAD: Minimum ACS: Medically treated: ASA plus Clopidogrel or Ticagrelor for one year ACS: Treated with PCI: ASA plus Clopidogrel or Ticagrelor or Prasugrel for one year Stable angina: Treated with PCI: ASA and Clopidogrel- duration based on type of therapy -PTCA: DAPT for 2-4 weeks -Bare Metal Stent: DAPT for 4 weeks -Drug Eluting Stent: DAPT for one year

24 DAPT Duration: PAD: Minimum Medically treated: ASA or Clopidogrel Intervention: ASA plus Clopidogrel - PTA: 30 days - DES: 60 days (Zilver-PTX) - BMS: 30 days -DEB: 60 days (on label use for both brands)

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26 Guidelines for major surgery Clopidogrel: Stop 5 days prior Prasugrel: Stop 7 days prior Ticagrelor: Stop 5 days prior NOACS: Stop 2 days prior ASA should be continued perioperatively in low dose for all patients with coronary stents unless bleed risk is prohibitive such as in neurosurgery Resume clopidogrel with loading dose post op

27 Anticoagulation for Mechanical Valves Mechanical bi-leaflet (newer) aortic valve: Warfarin INR target 2.5 plus ASA 81mg a day Mechanical mitral valve: Warfarin INR target 3 plus ASA 81mg a day Older AVR, Any PVR, TVR: INR target 3 Prior embolic event: INR target 3 High risk patients (EF<30, Hypercoag, prior embolism, A. Fib): INR target 3

28 Trans catheter aortic valves (TAVI) Aspirin 81mg indefinitely Clopidogrel 75mg daily for up to 6 months post implant

29 Who needs bridging for surgery?

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34 Key points: Bridging mechanical valves Newer generation aortic prosthesis: No bridging needed, if no other risk factors present Use heparin for any MVR, AVR with one risk factor (EF<30, Hypercoag state, AF and prior embolism) Lovenox dosing based on anti-xa levels is acceptable Continue AC for minor procedures including dental and skin-bleeding can be controlled

35 Review anti-coagulation in pregnancy

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42 Warfarin related bleeding Fresh frozen plasma Kcentra (Prothrombin Complex Concentrate, Human) Blood transfusion Vitamin K

43 Kcentra Kcentra is a purified, heat-treated, nanofiltered, plasma protein concentrate made from pooled human plasma. Kcentra contains all 4 Vitamin-K dependent coagulation factors (II, VII, IX and X), and the antithrombotic Proteins C and S Factor IX is the lead factor for the potency Does not require crossmatch or thawing, can be given more rapidly Kcentra demonstrated superiority compared with plasma in achieving early INR reduction ( 1.3 at 30 minutes after end of infusion).

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45 Praxbind (idarucizumab) Humanized monoclonal antibody fragment (Fab) When reversal of the anticoagulant effects of Pradaxa (dabigatran) is needed: -For emergency surgery/urgent procedures -In life-threatening or uncontrolled bleeding

46 Summary Remember no NOACS in valvular AF. Use CHA2DS2-VASC score to risk stratify post PCI. Minimize triple antithrombotic therapy. Prasugrel and Ticagrelor cannot be recommended with warfarin. DAPT duration based on device-varied for CAD and PAD. Stop P2Y12 antagonist 5-7 days before surgery. Know INR targets for valves (no more a range) No bridging for newer AVR in the absence of risk factors. Low dose warfarin safe in first trimester of pregnancy. Kcentra and Praxbind for reversal.

47 Questions?