indications for perioperative bridging ann mcbride, m.d. uw anticoagulation service
TRANSCRIPT
Indications for Perioperative Bridging
Ann McBride, M.D.Ann McBride, M.D.
UW Anticoagulation ServiceUW Anticoagulation Service
• No financial disclosuresNo financial disclosures
Objectives
• Brief review of literature regarding bridgingBrief review of literature regarding bridging• Identify risks of pt groups for increased risk of Identify risks of pt groups for increased risk of
thromboembolism when warfarin is interruptedthromboembolism when warfarin is interrupted• Identify pts for whom bridging AC should be Identify pts for whom bridging AC should be
consideredconsidered• Identify pt groups at increased risk for Identify pt groups at increased risk for
postoperative bleedingpostoperative bleeding
PATIENT RISK FACTORSPATIENT RISK FACTORS SURGICAL RISK FACTORSSURGICAL RISK FACTORS
ThrombosisThrombosis BleedingBleeding
1.1. Atrial fibrillation/flutterAtrial fibrillation/flutter
2.2. MHVMHV
3.3. VTE -PE, DVTVTE -PE, DVT
Patients chronically anticoagulated
Dunn, Turpie 2003
overall events 29/1868 1.6overall CVA 7/1868 0.4
Periprocedural Bridging with LMWHThree Prospective Studies, 2004
1.1. PROSPECT 260 ptsPROSPECT 260 pts
pre and post-op single dose enoxaparin pre and post-op single dose enoxaparin
major surgery (>1 hr), minor, inv. proceduremajor surgery (>1 hr), minor, inv. procedure
Pts: high risk AF (~ 2/3)Pts: high risk AF (~ 2/3)
Previous DVT (~ 1/3)Previous DVT (~ 1/3)
Periprocedural Bridging with LMWHThree Prospective Studies, 2004 cont’d
2.2. Kovacs 224 ptsKovacs 224 pts
pre-op single dose LMWHpre-op single dose LMWH
Post-op high risk bleed prophylactic LMWHPost-op high risk bleed prophylactic LMWH
Others single therapeuticOthers single therapeutic
Pts: MHV (~ ½)Pts: MHV (~ ½)
AF – high risk (~ ½)AF – high risk (~ ½)
3 month follow up3 month follow up
Periprocedural Bridging with LMWHThree Prospective Studies, 2004 cont’d
3.3. Douketis 650 ptsDouketis 650 pts
Pre and post-op bid LMWHPre and post-op bid LMWH
Pre-op LMWH bidPre-op LMWH bid
Post-op high risk bleed—no LMWHPost-op high risk bleed—no LMWH
Other – bid therapeutic doseOther – bid therapeutic dose
ResultsResults TE EventsTE Events
Major Major BleedsBleeds
1.1. PROSPECTPROSPECT 4/260 (1.5%)4/260 (1.5%) 3.5%3.5%
2.2. KovacsKovacs 8/224 (3.6%) 8/224 (3.6%)
(incl. 5 MI + 1 DVT)(incl. 5 MI + 1 DVT)
6.7%6.7%
3.3. DouketisDouketis
Non high risk Non high risk bleedingbleeding
High risk bleedingHigh risk bleeding
2/542 (0.4%)2/542 (0.4%)
2/108 (1.8%)2/108 (1.8%)
(deaths)(deaths)
0.7% * 0.7% * (5.9%)(5.9%)
1.8%1.8%
REGIMEN RegistrySpyropoulos 2006
Major Bleeds 5.5% 3.3%TE Rate 2.4% 0.9%
Atrial FibrillationRisk of Stroke in Patients
with Atrial Fibrillation
C
H
A
D
S2
Congestive Heart Failure (LV ejection less than 40%)
HypertensionHypertension
Age greater than 75Age greater than 75
DiabetesDiabetes
Stroke/TIAStroke/TIA
CHADS ScoreCHADS Score % Annual CVA Risk% Annual CVA Risk
0-10-1 1-3%1-3%
2-42-4 4-8%4-8%
5-65-6 12-18%12-18%
Risk Stratification—Patients with Chronic Atrial Fibrillation
Low—Bridging OptionalLow—Bridging OptionalCHADS score = 0 or 1CHADS score = 0 or 1
Moderate--? BridgingModerate--? BridgingCHADS score=2-4CHADS score=2-4
High—Bridging RecommendedHigh—Bridging RecommendedCHADS score =5-6CHADS score =5-6Recent (within 3 months) CVA/TIARecent (within 3 months) CVA/TIARheumatic Mitral Valve DiseaseRheumatic Mitral Valve Disease
Thrombotic risk with prosthetic heart valves
Mitral >> Aortic PositionMitral >> Aortic PositionCaged ball >Caged ball > Tilting disc >Tilting disc > Double wing valvesDouble wing valves
Caged-ball valveCaged-ball valve Bjork-Shiley valveBjork-Shiley valve St. Jude valveSt. Jude valve
Decreasing thrombotic risk
Heit JA. J Thromb Thrombolysis. 2001;12:81-87.
Risk Stratification—Patients with Mechanical Heart Valves
Low—Bridging OptionalLow—Bridging OptionalBileaflet AV (St. Jude or CarboMedics) and less than 2 CVA risk factorsBileaflet AV (St. Jude or CarboMedics) and less than 2 CVA risk factors
Moderate—Bridging should be consideredModerate—Bridging should be consideredBileaflet AV and more than 2 CVA risk factorsBileaflet AV and more than 2 CVA risk factors
(here Risk Factors refer to Atrial fibrillation, CHF, age greater than 75, HTN, (here Risk Factors refer to Atrial fibrillation, CHF, age greater than 75, HTN, DM)DM)
High—Bridging advisedHigh—Bridging advisedMitral Valve ReplacementMitral Valve Replacement
Recent (within past 3 months) CVA/TIARecent (within past 3 months) CVA/TIACaged-ball (Starr-Edwards) or tilting disc AV (Bjork-Shiley, Medtronic)Caged-ball (Starr-Edwards) or tilting disc AV (Bjork-Shiley, Medtronic)
Risk Stratification—Patients with VTE
High—Bridging Strongly RecommendedHigh—Bridging Strongly RecommendedRecent episode of VTE (within past 3 months)Recent episode of VTE (within past 3 months)
Moderate—Bridging should be consideredModerate—Bridging should be consideredVTE within the past 6 monthsVTE within the past 6 monthsHistory of VTE after surgeryHistory of VTE after surgeryActive Cancer—metastatic, recent treatmentActive Cancer—metastatic, recent treatment
Prot C, Prot S, Antithrombin DeficiencyProt C, Prot S, Antithrombin Deficiency
Low—Bridging OptionalLow—Bridging OptionalNone of these risk factors outlined above presentNone of these risk factors outlined above present
**Pt with previous VTE recurrence when warfarin was interrupted**Pt with previous VTE recurrence when warfarin was interrupted
Postoperative Bleeding Risks
Non-surgicalNon-surgical
UremiaUremia
ThrombocytopeniaThrombocytopenia
Coagulation Factor DeficiencyCoagulation Factor Deficiency
Recent Bleed (i.e., GI)Recent Bleed (i.e., GI)
Surgical
Low—no interruption of OAC neededLow—no interruption of OAC needed
CataractCataract
DermatologyDermatology
Simple dentalSimple dental
Joint and Soft Tissue Aspiration/InjectionJoint and Soft Tissue Aspiration/Injection
Laparascopic Cholescystectomy, Hernia Repair ***Laparascopic Cholescystectomy, Hernia Repair ***
Surgical, cont’d
ModerateModerateScreening Colonoscopy or Diagnostic EGD at UWScreening Colonoscopy or Diagnostic EGD at UW
Complicated Dental surgeryComplicated Dental surgery
BronchoscopyBronchoscopy
Other Orthopedic SurgeryOther Orthopedic Surgery
Other intra thoracic surgeryOther intra thoracic surgery
Other intra-abdominal surgeryOther intra-abdominal surgery
Surgical, cont’d
HighHigh
Major vascularMajor vascularPermanent pacemakerPermanent pacemakerInternal defibrillatorInternal defibrillatorProstatectomyProstatectomyBladder Tumor resectionBladder Tumor resectionLung resectionLung resectionHip/Knee Joint ReplacementHip/Knee Joint ReplacementIntestinal AnastomosisIntestinal AnastomosisBowel PolypectomyBowel PolypectomyKidney or Prostate BxKidney or Prostate BxCervical Cone BxCervical Cone BxBronchoscopy with BxBronchoscopy with Bx
Surgical, cont’d
Very High RiskVery High Risk
Intracranial SurgeryIntracranial Surgery
CABGCABG
Heart ValveHeart Valve
Spinal SurgerySpinal Surgery
Example of Patient InstructionsWarfarin Holding/LMWH Plan for
DateDate
LovenoxLovenox
MorningMorning
LovenoxLovenox
EveningEvening
WarfarinWarfarin
DoseDose Lab TestLab Test
2/032/03 HOLDHOLD HOLDHOLD HOLDHOLD
2/042/04 HOLDHOLD HOLDHOLD HOLDHOLD
2/052/05 70 mg70 mg 70 mg70 mg HOLDHOLD
2/062/06 70 mg70 mg 70 mg70 mg HOLDHOLD
2/072/07 70 mg70 mg HOLDHOLD HOLDHOLD INR and INR and PlateletsPlatelets
2/082/08
ProcedureProcedure
HOLDHOLD 70 mg70 mg 4 mg4 mg
2/092/09 70 mg70 mg 70 mg70 mg 4 mg4 mg
2/102/10 70 mg70 mg 70 mg70 mg 4 mg4 mg
2/112/11 70 mg70 mg 70 mg70 mg 4 mg4 mg
2/122/12 70 mg70 mg To be To be DeterminedDetermined
To be To be DeterminedDetermined
INR and INR and PlateletsPlatelets
Points to Consider
• If target INR 2.0-3.0, pt to be WITHIN target range at time of If target INR 2.0-3.0, pt to be WITHIN target range at time of withholding warfarinwithholding warfarin
• If INR = 2.0-3.0, after 3-4 warfarin doses held, INR level will be less If INR = 2.0-3.0, after 3-4 warfarin doses held, INR level will be less than 1.5than 1.5
• Most surgeries/procedures can be performed reasonably safely when Most surgeries/procedures can be performed reasonably safely when INR less than 1.5INR less than 1.5
• After surgery, when pt resumes warfarin, most pts resume their pre-op After surgery, when pt resumes warfarin, most pts resume their pre-op dose (some give loading dose, we tend not to). After 4 to 5 days of dose (some give loading dose, we tend not to). After 4 to 5 days of resuming warfarin, INR will typically be greater than 2.0resuming warfarin, INR will typically be greater than 2.0
Cases
• 75 yo pt atrial fibrillation—dental work75 yo pt atrial fibrillation—dental work
• 70 yo pt atrial fibrillation, no hx CVA/TIA—colonoscopy 70 yo pt atrial fibrillation, no hx CVA/TIA—colonoscopy at UWat UW
• 82 yo MVR scheduled for cystocele repair82 yo MVR scheduled for cystocele repair
• 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopywithout recurrence; scheduled for screening colonoscopy
• 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopy, without recurrence; scheduled for screening colonoscopy, with protein C deficiencywith protein C deficiency
Cases, cont’d
• 44 yo M with unprovoked DVT RLE 4 yrs earlier; + 44 yo M with unprovoked DVT RLE 4 yrs earlier; + heterozygous FV Leiden, scheduled for lap hernia repairheterozygous FV Leiden, scheduled for lap hernia repair
• 68 yo with atrial fibrillation and AVR scheduled for 68 yo with atrial fibrillation and AVR scheduled for colonoscopycolonoscopy
• 65 yo met lung ca, DVT 9 months ago, scheduled for 65 yo met lung ca, DVT 9 months ago, scheduled for laparotomylaparotomy
• 77 yo with atrial fibrillation, HTN, DM, CHF scheduled 77 yo with atrial fibrillation, HTN, DM, CHF scheduled for prostate bxfor prostate bx
• 77 yo with atrial fibrillation, HTN, CHF, DM, no hx 77 yo with atrial fibrillation, HTN, CHF, DM, no hx TIA/CVA scheduled colonoscopyTIA/CVA scheduled colonoscopy