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Perioperative Management of Oral Anticoagulation

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Perioperative Management of Oral Anticoagulation Faculty Disclosures Perioperative Management of Oral Anticoagulation There are no actual or potential conflicts of interest associated with this presentation. Victoria Lambert, PharmD, CACP Medication Management Pharmacist - Victoria Lambert Janki Shah, PharmD, BCACP Anticoagulation Care Provider - Janki Shah William W. Backus Hospital What’s the hype about interrupting Learning Objectives anticoagulation therapy? • Review recommendations for when to interrupt oral anticoagulation therapy . Anticoagulation serves an important role in reducing • Review guidelines for determining thromboembolic risk the risk of thromboembolism or stroke • Review recommendations for bridging therapy . A number of patients are at risk of developing implementation as clinically indicated arterial or venous thromboembolism if anticoagulation therapy needs to be withheld • Review cases for appropriate method to manage oral . Patients will eventually need to undergo some type anticoagulation interruption based on risk stratification of procedure . Perioperative management is a common clinical • Apply case-specific monitoring parameters for anticoagulation bridge therapy dilemma What do we do? Douketis JD et al. Chest. 2012;141(2 Suppl):e326S-e350S. Dubois V et al. Thromb J. 2017;15:14. When to interrupt anticoagulation and implement “bridging”? What is bridging therapy? • Ask yourself 4 questions… • “In the absence of a universally accepted definition, we define bridging anticoagulation as the administration of a • Does anticoagulation need to be withheld? short-acting anticoagulant, for an ~10-12 day period during interruption of VKA therapy when the INR is not within a therapeutic range”. • What is the patient’s risk for clotting? • What is the patient’s risk for bleeding? • What oral anticoagulant is the patient taking? Douketis JD et al. Chest. 2012;141(2 Suppl):e326S-e350S. 1 Does anticoagulation need to be Ask the Audience withheld? Warfarin therapy must be interrupted for all • Continue anticoagulation: surgical procedures? * CAUTION: spinal/epidural • Dental procedures (2C) procedures + anticoagulants • Cataract Removal (2C) INCREASE risk of a. True hematoma = possible b. False • Endoscopy (diagnostic) paralysis c. Not sure • Joint injections* • Knees, wrist, hip • Minor dermatologic procedures (2C) • Consider procedures that do not pose increased bleeding risk while on anticoagulation Douketis JD et al. Chest. 2008;133(6 Suppl):299S-339S. Douketis JD et al. Chest. 2012;141(2 Suppl):e326S-e350S. Grant PJ et al. Anesthesiol Clin. 2009;27(4):761-77. Discontinue oral anticoagulation Ask the Audience therapy: • Orthopedic surgeries • To assess the risk of clotting, we need • TKR, THR to review? • Biopsy a. The patient's anticoagulation indication • Breast, Lung b. The type of procedure • Neurosurgery c. Co-morbidities • Hernia Surgery d. All of the above • Colonoscopy • Family history of cancer/polyps Douketis JD et al. Chest. 2008;133(6 Suppl):299S-339S. Douketis JD et al. Chest. 2012;141(2 Suppl):e326S-e350S. What is the patients’ risk of clotting? Limited studies have been done to guide warfarin interruption for atrial fibrillation • Considerations Atrial fibrillation: BRIDGE Trial provides some insight into risk stratification • Underlying indication for anticoagulation NOT applicable to VTE and mechanical valve patients therapy Further studies are warranted for warfarin • Patient’s risk factors for thromboembolism interruption in other disease states • Morbid obesity, hypercoagulable state, immobility To date, there are no validated risk stratification • Duration of anticoagulation cessation schemes to reliably separate VKA‐treated patients into • MHV – TE risk 0.046%/day risk strata for thromboembolism and bleeding. • A fib – TE risk 0.013%/day Advance planning and coordination is required to optimally manage perioperative anticoagulation Douketis JD et al. Chest. 2008;133(6 Suppl):299S-339S. Douketis JD et al. Chest. 2012;141(2 Suppl):e326S-e350S. Douketis JD et al. Chest. 2008;133(6 Suppl):299S-339S. Jaffer AK et al. Am J Med. 2010;123(2):141-50 Grant PJ et al. Anesthesiol Clin. 2009;27(4):761-77. McBane RD et al. Arterioscler Thromb Vasc Biol. 2010;30(3):442-8. 2 Thrombosis Risk Strength of the Recommendations Grading System CHEST Guidelines Chest guidelines vs. ASH guidelines Grade of Methodologic Strength Recommendation Benefit vs Risk and Burdens Supporting Evidence Strong ‐ 1A High quality evidence Benefit>risk/burden or vice versa RCT, exceptionally strong evidence from observational studies Strong ‐ 1B Moderate quality evidence Benefit>risk/burden or vice versa RCT with limitations, strong evidence from observational studies Evidence based practice guidelines which Strong ‐ 1C Low or very low quality evidence Benefit>risk/burden or vice versa Evidence for at least one critical outcome with serious flaws or indirect evidence incorporate data from existing literature. Weak ‐ 2A High quality evidence Benefit closely balanced with risks + burdens RCT, exceptionally strong evidence from observational studies Weak ‐ 2B Moderate quality evidence Benefit closely balanced with risks + burdens RCT with limitations, strong evidence Atrial fibrillation Most common from observational studies indications for Weak ‐ 2C Low or very low quality evidence Uncertainty in estimates of benefits, risks, Evidence for at least one critical outcome and burden; benefits, risk + burden may be closely with serious flaws or indirect evidence Mechanical Heart Valves long term balanced VTE anticoagulation ASH Guidelines Type of Recommendation Strength of Recommendation Strong Recommendation Most individuals should follow the recommended course of action. Different choices will be appropriate for individual patients, and clinicians must help each patient Conditional Recommendation arrive at a management decision consistent with the patient’s values and preferences Douketis JD et al. Chest. 2008;133(6 Suppl):299S-339S. Douketis JD et al. Chest. 2012;141(2 Suppl):e326S-e350S. Douketis JD et al. Chest. 2012;141(2 Suppl):e326S-e350S. Witt DM et al. Blood Adv. 2018;2(22):3257-3291. Witt DM et al. Blood Adv. 2018;2(22):3257-3291. Risk Stratification for Perioperative TE What is CHADS2 Scoring? Risk Mechanical Heart Valve Venous Thromboembolism Atrial Fibrillation High • Mitral Mechanical • VTE within 3 months • CHADS2 score: ≥ 5 • Clinical prediction rule for estimating the risk of stroke in Valve Severe thrombophilia • CHA DS -VASc score ≥ 2 2 patients with nonrheumatic atrial fibrillation. • Any mechanical valve (protein C, S or 7 antithrombin deficiency, with history Stroke/ • Stroke or TIA within 3 TIA APAS, or multiple months thrombophilias) • Aortic mechanical • Rheumatic valvular • Used to determine the degree of anticoagulation needed. valve with the • Active cancer treated heart disease following risk factors: within 6 months • Hx of ischemic stroke or AF, prior stroke/ TIA, • Recurrent VTE occurring systemic embolism HTN, DM, CHF, age with previous occurring with previous >75, EF <35% interruption of interruption of anticoagulant therapy anticoagulant therapy Low • Bileaflet aortic valve • Single VTE event greater • CHADS2 score: 0-4 prosthesis without than 12 months ago and • CHA2DS2-VASc Score: AF and no other risk no other risk factors 0-6 factors for stroke • Non-severe • No prior stroke or TIA thrombophilia (heterozygous Factor V Leiden mutation) Witt DM et al. Blood Adv. 2018;2(22):3257-3291. Woller SC. Anticoagulation update: DOACs, VTE Guideliens, Bridging, and iCentra. 2016. Douketis JD et al. Chest. 2008;133(6 Suppl):299S-339S Ask the Audience CHADS2 Score • Which is the correct description of CHADS 2 Total Risk Level Stroke scoring? CHADS2 Risk Criteria Score Score Rate a. CHF, hypertension, age >65, DM, prior history of stroke CHF 1 0‐2Low1.9‐4 b. Cardiomyopathy, hypertension, age >75, Hypertension 1 DM, prior history of stroke c. CHF, hypertension, age > 75, DM, prior Age ≥ 75 1 3‐4Intermediate5.9‐8.5 history of stroke DM 1 d. CHF, hyperlipidemia, age >75, DM, prior 5‐6 High 12.5‐ Stroke/Tia 2 history of stroke 18.2 Douketis JD et al. Chest. 2008;133(6 Suppl):299S-339S Gage BF et al. JAMA. 2001;285(22):2864-70. 3 What about CHA2DS2VASc? CHA2DS2-VASc Score CHA2DS2 VASc Risk Criteria Score • Refinement of CHADS2 CHF 1 Total Risk Level Stroke • Additional common stroke risk factors Score Rate Hypertension 1 • Female gender, vascular disease, age range 65-74 0‐4Low1.3‐4 Age ≥ 75 2 • Max score is 9 DM 1 . More patients classified as high risk? 5‐6Intermediate6.7‐9.8 Stroke/Tia 2 . Score ≥2 may benefit from anticoagulation therapy Vascular Disease* 1 7‐9High9.6‐15.2 . More patients require bridging for warfarin Agr 65‐74 1 interruption? Female sex 1 • Prior myocardial infarction, peripheral artery disease, aortic plaque January CT et al. Circulation. 2014;130(23):2071‐104. Pre Procedure Planning Pre Procedure Plan Low/Intermediate TE Risk • For the bridging patient Hold warfarin 5 days prior to procedure (Grade 1C) • Aim to minimize ATE or VTE No Bridging (Grade 2C) • No established single “heparin” bridging regimen Check INR 1 day prior to procedure • Variability exists in If INR > 1.5, consider administering a low dose of po • The type of anticoagulant Vitamin K ie) 1 mg • Intensity of anticoagulation High TE Risk Bridging anticoagulation suggested instead of no bridging • Timing of perioperative administration (Grade 2C) Refers to therapeutic dose bridging regimen ‐ most widely studied and used in clinical practice Douketis JD et al. Chest.
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