15/06/2017
Thrombosis Patients with clots – when to involve the haematology team How to decide which anticoagulant and for how long When to call for help….. Difficulties with anticoagulation Bleeding vs thrombotic risk Bleeding on anticoagulation Invasive procedures on anticoagulation
Bleeding How to manage the medical patient with a bleeding disorder Acquired coagulopathies Thrombosis
1 15/06/2017
VTE – things to consider Is it safe to anticoagulate my patient? Many patients with VTE are managed as out-patients Default setting for patient with new VTE is in nurse led clinics anticoagulation to prevent propagation of clot and Diagnosis of DVT/PE – NICE guidelines recurrence Know your diagnostic algorithms and apply properly Choice of drugs Misuse of d dimers LMW heparin Age adjusted d dimer DOAC All new cases VTE discussed at thrombosis MDT (if we Vitamin K antagonist know about them) Unfractionated heparin A thorough assessment at diagnosis is essential to Occasional patients will have contra-indications to guide treatment anticoagulation, but these will be rare and difficult
When is anticoagulation difficult? Example Bleeding patient 75 year old man with acutely swollen and painful right leg Eg patient with hereditary bleeding disorder Doppler US shows proximal DVT (extensive) Patient with thrombocytopenia Routine bloods prior to anticoagulation show normal clotting, LFTs, U&E Patient with bleeding lesion eg varices Hb 145 WCC 6.6 Platelets 4 (normal blood film) Patient requires urgent invasive procedure
What would you do? Always a balance between bleeding risk and thrombotic risk – often no easy or correct answer.
2 15/06/2017
How long do I anticoagulate my patient IVC filters for? Only indication is the acute treatment of proximal DVT 53 year old man and/or PE in patient with absolute contra-indication to Sudden onset pleuritic chest pain and SOB anticoagulation (JTH 2017; 15; 3-12) In good health, no previous medical problems Why? CTPA shows large left PE with right heart strain Society of Interventional Radiology – over 10 years 842 complications How long should he be treated with anticoagulants? reported to FDA Filter migration, IVC perforation, fracture Thrombotic occlusion of filters resulting in lower limb problems 24 year old woman on COCP Problems greatest in filters that stay in longer than 30 days Ankle fracture in plaster 6 weeks Frequently forgotten Anticoagulation is needed if filters cannot be removed when 2 weeks later develops below knee DVT bleeding risk is passed, or awaiting removal. How long should she be treated with anticoagulants?
Diagnostic issues – thrombosis at Duration of anticoagulation unusual sites Things to consider: Intra-abdominal thrombosis What is the recurrence risk for my patient (provoked vs 40 year old woman unprovoked VTE; other patient specific factors)? 2015, abdominal pain and nausea. Diagnosis pancreatitis and portal vein thrombosis What is the relative risk of anticoagulant therapy vs the risk of recurrent thrombosis? Treated with warfarin 6 months Recurrent symptoms shortly after stopping warfarin – What is the risk that my patient may die as a result of extensive portal, splenic and superior mesenteric vein recurrent VTE or as a result of taking anticoagulant thrombosis therapy? ?investigations
3 15/06/2017
Abdominal vein thrombosis Other unusual sites Presenting feature of myeloproliferative neoplasm Upper limb thrombosis (even with normal FBC) Frequently line associated Clear guidance on treatment (BCSH, ACCP guidelines) Portal vein thrombosis - Commonest cause is cirrhosis, but MPNs account for 25% of cases Involve vascular surgeons to look for thoracic outlet obstruction Budd Chiari – up to half may have MPN Cerebral vein thrombosis JAK2 mutation <1% of all stroke PNH – very rare, but important and treatable Often younger and 75% female Blood counts usually abnormal, but may not be Association with OCP No clear evidence to guide treatment and duration of anticoagulation, but consensus statements available Role of thrombophilia testing uncertain
Problems with anticoagulation How to choose an anticoagulant drug My patient is bleeding – what do I do? My patient needs an invasive procedure – what do I do about their anticoagulation?
4 15/06/2017
How to choose a drug Anticoagulants and bleeding/surgery Know the licensed indications First and foremost – think bleeding risk vs DOACs - uncomplicated DVT, PE, SPAF thrombotic risk DOACs not licensed for arterial thrombosis, APS, thrombosis Vitamin K antagonists at unusual sites, mechanical heart valves, venous stents and Vitamin K is your friend! IVC filters PCCs have thrombotic risk and expose patient to plasma Extended use Should be reserved for urgent emergency reversal only Know the contra-indications DOACs Cancer associated VTE Only dabigatran has a specific reversal agent (Praxbind – idarucizumab) Bleeding risk Andexanet – reversal agent in phase 3 trials for anti Xa Reversibility inhibitors (including enoxaparin) Does this matter?
The medical patient with a bleeding disorder Patients with known bleeding disorders usually carry and alert card and have alerts on hospital systems Bleeding Many are expert patients – always listen to patients and carers Severe bleeding disorders do not protect from thrombotic disease eg MI in people with haemophilia Many drugs (especially for cardio-vascular disease) increase bleeding risk
5 15/06/2017
Patient with chest pain and moderate haemophilia B 63 year old man with moderate haemophilia B (F9 No evidence based guidance, but consensus guidelines level 4%) suggest treat haemophilia immediately to normalise Chest pain on exertion for a few years coagulation Given low dose aspirin, but oral bleeding so stopped PCI safe after factor replacement Admitted with symptoms and signs suggestive of acute Choice of stent coronary syndrome Anti-platelet therapy Post procedure, drug eluting stent – 6 months dual ?management anti-platelet therapy required Factor 9 prophylaxis with EHL F9 concentrate once a week
Other difficult problems What to do with the patient with a bleeding disorder and high risk AF? Coagulopathy in medical in- VWD and anti-platelet therapy patients
Always involve the haemostasis team before making a decision about treatment – we are available 24 hours a day
6 15/06/2017
The medical patient with abnormal clotting Key parts of the assessment Is the patient bleeding? Take a proper bleeding history Although evidence is poor, a properly structured bleeding Does the patient require an invasive procedure? history is better than random laboratory tests for predicting Is it likely that this patient has a significant hereditary bleeding risk during invasive procedures or acquired bleeding disorder? Key points are details of previous haemostatic challenges and questions to assess patterns of bleeding symptoms (temporal Hereditary bleeding disorders that cause bleeding are and physical) rare but treatable Drug history very important Acquired disorders are common, but the ones that cause Family history may be relevant bleeding are rare! Laboratory tests guided by clinical history Screening tests Specific tests depending on results of screening or history
76 year old man INR 2.9 Admitted with extensive bruising to left leg and thigh, PT 35 sec (9-12) and left arm APTT 65 sec (22-32) Warfarin for AF 50/50 mix – partial correction Usually stable anticoagulant control Hb 8g/dL What next?
7 15/06/2017
Acquired haemophilia After warfarin reversal with vitamin K Suspect acquired haemophilia in patients with a recent onset of spontaneous s/c bleeding, muscle or retro-peritoneal bleeds or unexpected bleeding after an invasive procedure Especially: PT 11.5 sec (9-12) elderly patients APTT 55 sec (22-32) Auto-immune disease Malignancy Post-partum Inhibitor screen: POSITIVE APTT prolonged and does not correct in a 50:50 mix after 2 hour incubation (inhibitor screen) F8 6iu/dL Other coag tests normal Inhibitor titre 39.1 U/mL F8 will be low (does not correspond to bleeding risk) Very significant bleeding risk and mortality (8%)
Other coagulopathies in general medicine Coagulopathy in liver disease 65 year old patient with known idiopathic liver Liver disease leads "rebalanced" haemostasis cirrhosis requires central line placement Impaired hepatic function leads to both procoagulant and anticoagulant effects PT 14s (9-12) APTT 38 (22-32) Platelets 85 Standard coagulation testing does not assess What would you do? prothrombotic and fibrinolytic changes No evidence to support ‘routine’ administration of FFP prior to invasive procedure Global measures of haemostasis eg ROTEM may be better at assessing bleeding risk Thrombocytopenia (<50) and severe hypofibrinogenaemia increase risk of bleeding Increased risk of thrombosis eg PVT
8 15/06/2017
Conclusions and questions The balance between bleeding risk and thrombotic risk is key There is often ‘no right answer’ A good clinical assessment is essential Many medical procedures and treatments have implications for patients with bleeding and thrombotic disorders We are here to help, but assess your patient first and collect all the relevant information….
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