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Periprocedural Management of Oral Anticoagulation

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Periprocedural Management of Oral Anticoagulation Nicole Hlavacek, PharmD candidate; Drew McMillan, PharmD Periprocedural management candidate; Jeremy Vandiver, PharmD, BCPS University of Wyoming of oral anticoagulation: School of Pharmacy, Laramie (Ms. Hlavacek, Mr. McMillan, and Dr. Vandiver); When and how to hit “pause” Swedish Family Medicine Residency, Littleton, Colo (Dr. Vandiver) Here’s how best to assess patients’ bleeding and [email protected] thrombotic risks and 5 key questions to ask as you The authors reported no consider withholding oral anticoagulants. potential conflict of interest relevant to this article. CASE 1 u PRACTICE Debra P is a 62-year-old African American woman who calls RECOMMENDATIONS your office to report that she has an upcoming routine colo- ❯ Don’t stop oral antico- noscopy planned in 2 weeks. She has been taking warfarin agulation for procedures with for the past 2 years for ischemic stroke prevention secondary minimal bleeding risk, such as minor dermatologic, dental, to atrial fibrillation (AF), and her gastroenterologist recom- or ophthalmic procedures. C mended that she contact her family physician (FP) to discuss periprocedural anticoagulation plans. Ms. P is currently tak- ❯ Reserve periprocedural ing warfarin 5 mg on Mondays, Wednesdays, and Fridays, bridging with a parenteral an- ticoagulant for those patients and 2.5 mg all other days of the week. Her international nor- on warfarin who are at high- malized ratio (INR) was 2.3 when it was last checked 2 weeks est risk for thromboembolism ago, and it has been stable and within goal range for the past (those with severe thrombo- 6 months. Her medical history includes AF, well-controlled philia, active thrombosis, or hypertension, and type 2 diabetes mellitus, as well as gout and mechanical heart valves). B stage 3 chronic kidney disease. Ms. P denies any history of stroke ❯ Stop direct oral anticoagu- or transient ischemic attack (TIA). She is requesting instructions lants 24 to 48 hours prior to on how to manage her warfarin before and after her upcoming most invasive procedures, colonoscopy. and do not employ peri- procedural bridging. C CASE 2 u Strength of recommendation (SOR) Jerry Q is a 68-year-old Caucasian man with longstanding os- A Good-quality patient-oriented teoarthritis who is scheduled to undergo a total left knee ar- evidence throplasty in one week. His orthopedic surgeon recommended B Inconsistent or limited-quality that he contact his FP for instructions regarding managing patient-oriented evidence apixaban perioperatively. Jerry has been taking apixaban 5 mg C Consensus, usual practice, opinion, disease-oriented bid for the past 9 months due to a history of recurrent deep evidence, case series vein thrombosis (DVT) and pulmonary embolism (PE) (both un- provoked). Mr. Q had been taking warfarin following his first DVT 4 years ago, but, after reporting that INR monitoring was a burden, he was started on apixaban. The patient has nor- mal renal function and is relatively healthy otherwise. How should apixaban be managed before and after his upcoming surgery? 210 THE JOURNAL OF FAMILY PRACTICE | APRIL 2018 | VOL 67, NO 4 Countless decisions must be made by health care providers each year regarding if, when, and how to pause and resume oral anticoagulation. And these decisions are not always straightforward. ach year, approximately 15% to 20% of 4. When should the patient resume his patients taking an oral anticoagulant or her oral anticoagulant after the pro- undergo a procedure that carries a cedure, and at what dosage? E 1,2 heightened risk for bleeding. Stopping oral 5. Will bridging with a parenteral anticoagulation is often necessary before— anticoagulant be necessary after the and sometimes briefly after—many of these procedure? procedures in order to minimize the risk of bleeding.3 This means that countless decisions Before addressing these 5 questions, must be made by health care providers each though, physicians must assess patients’ year regarding if, when, and how to pause and thrombotic and bleeding risks.4-6 resume oral anticoagulation. These decisions are not always straightforward, especially when you consider the risks for thrombosis Anticoagulant regimens and and bleeding that are unique to the procedure the risks of discontinuing them and to the individual patient. The 2 most common indications for long- With these variables in mind, the health term oral anticoagulation are venous throm- care provider must make decisions regarding boembolism (VTE), which occurs in ap- anticoagulation during the periprocedural proximately one million Americans every period based on the following 5 questions: year, 7,8 and stroke prevention in the setting 1. Will this patient need to have his/her of AF (AF occurs in 3-6 million US adults per oral anticoagulant stopped prior to year).6 the procedure? Warfarin is also often used in patients IMAGE: © JOE GORMAN 2. If the patient’s oral anticoagulation with mechanical heart valves for long-term needs to be held, when should it be stroke prevention; however, direct oral anti- stopped and for how long? coagulants (DOACs) are not recommended 3. Will periprocedural bridging with a for patients with mechanical heart valves be- parenteral anticoagulant be necessary cause trials have not yet demonstrated their prior to the procedure? safety or efficacy in this population.4,5,9 CONTINUED MDEDGE.COM/JFPONLINE VOL 67, NO 4 | APRIL 2018 | THE JOURNAL OF FAMILY PRACTICE 211 TABLE 1 Patients at high risk for thromboembolism3,5,6,9-11 Venous thromboembolism Atrial fibrillation Mechanical heart valve High-risk characteristics Acute VTE within the past 90 days † Mitral valve position CHADS2 score of 5 or 6 Active malignancy Older generation valve in CHA2DS2-VASc score of 7-9 aortic position (caged-ball or Severe thrombophilia* Stroke within the past 90 days tilting disc) Aortic position with additional risk factors‡ Annual risk (without 10% or higher anticoagulation) VTE, venous thromboembolism. *Severe thrombophilia includes protein C or S deficiency, antithrombin deficiency, antiphospholipid antibody syndrome, and more than one type of thrombophilia. † CHADS2 and CHA2DS2-VASc are tools used to determine a patient’s risk of stroke in the presence of atrial fibrillation. They are discussed in greater detail in TABLE 2. ‡Additional risk factors include atrial fibrillation, heart failure, hypertension, history of stroke or transient ischemic attack, and advanced age. Who’s at highest risk of the CHA2DS2-VASc scoring tool for making for an acute thromboembolic event? decisions regarding perioperative bridging in When planning for interruptions in oral patients with AF.11 anticoagulation, it is important to identify ❚ Patients with previous VTE. Multiple patients at highest risk for an acute throm- aspects of a patient’s past medical history boembolic event. Patients with 10% or higher need to be taken into account when estimat- annual risk for VTE or ischemic stroke are ing annual and acute risk for VTE. Patients at generally placed into this high-risk category the highest risk for VTE recurrence (annual (TABLE 13,5,6,9-11).3 Keep in mind that the ab- VTE risk ≥10%) include those with recent solute risk for thromboembolism during a VTE (past 90 days), active malignancy, and/- brief period of oral coagulation interruption or severe thrombophilias (TABLE 13,5,6,9-11).3,5,6 is relatively low, even in those patients con- Patients without any of these features can sidered to be at high risk. Using a mathemati- still be at moderate risk for recurrent VTE, as cal approach (although simplistic), a patient a single VTE without a clear provoking fac- with a 10% annual risk for a thromboembolic tor can confer a 5% to 10% annualized risk event would have <0.3% chance for develop- for recurrence.12,13 Previous proximal DVT ing such an event in the acute phase, even if and PE are associated with a higher risk for their anticoagulation was withheld for up to recurrence than a distal DVT, and males have 10 days ([10%/365 days] × 10 days). a higher recurrence risk than females.5,12 ❚ Patients with mechanical heart There are scoring tools, such as DASH valves. Nearly all patients with a mechani- (D-dimer, Age, Sex, Hormones) and the “Men cal heart valve are at moderate to high risk for Continue and HERDOO2,” that can help es- ischemic stroke.3 timate annualized risk for VTE recurrence; ❚ For patients with AF, the CHADS2 and however, they are not validated (nor particu- CHA2DS2-VASc scoring tools can be used to larly useful) when making decisions in the estimate annual thrombosis risk based on perioperative period.14,15 the presence of risk factors (TABLE 210,11).6,9-11 ❚ Additional risk factors. Consider ad- It should be noted, however, that these scor- ditional risk factors for thromboembolism, ing tools have not been validated specifically including estrogen/hormone replacement for periprocedural risk estimations. Nonethe- therapy, pregnancy, leg or hip fractures, im- less, the latest 2017 American College of Car- mobility, trauma, spinal cord injury, cen- diology (ACC) guidelines recommend the use tral venous lines, congestive heart failure, 212 THE JOURNAL OF FAMILY PRACTICE | APRIL 2018 | VOL 67, NO 4 ORAL ANTICOAGULATION TABLE 2 Patient has atrial fibrillation? Consider these tools for stroke risk assessment10,11 Tool Features Point value Interpretation Ischemic stroke risk CHADS2 score Congestive heart failure 1 Score of ≥1 merits consideration of long-term anticoagulation Hypertension 1 Score of 5 or 6: Highest risk for Age ≥75 years 1 thromboembolism
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