16th National Conference on Anticoagulation TherapyOctober 28-30, 2021

Pearls for Managing the Patient with Heart Disease

Presenters:

Bill Dager , PharmD, BCPS, MCCMUC Davis Medical Center

Elaine Hylek, MD, MPHBoston University

Geoff Barnes, MD, MScUniversity of Michigan

Khendi White-Solaru, MDUniversity Hospitals Cleveland

64-year-old, 75kg woman with a history of AF on apixaban 5mg PO twice daily and history of PCI15 months ago on ASA 325mg daily.

Her only other medical history includes Chronic Kidney Disease (CKD) stage 3 and heart failure with an ejection fraction of 45% and low-end diastolic volume. Her medications include Furosemide 20mg PO in the morning and evening. Her daughter has contacted the PCP concerning a few recent falls late in the evening when getting up to go to the bathroom and potential for bleeding complications. The PCP is calling the anticoagulation clinic to follow up and considering stopping the apixaban.

1. What thoughts do you have to reduce her risk of bleeding?2. How important is “fall risk” when determining anticoagulation regimens?3. How strong is her indication for stroke-prevention therapy?

CASE #1

3 months later, he is scheduled for a pacemaker placement due to symptomatic sick sinus syndrome. His INR is 3.3 today.

2. How do you best manage his INR for the scheduled pacemaker procedure?

CASE #2

73-year-old man with AF, HFrEF and noted LV thrombus on ECHO 3 months ago. He is taking warfarin 1mg daily and is scheduled for colonoscopy given recent blood seen on BMs. His most recent EF is 35% (non-ischemic cardiomyopathy).

INR today is 4.2 and his colonoscopy is scheduled in 5 days. The GI doctor requests the INR ≤ 1.5 for the procedure.

1. How do you best manage his INR for the scheduled procedure in 5 days? • Does he need Vitamin K therapy?

60-year-old woman with a history of AF, Anemia, Heart Failure (EF 25%) and CKD stage 4. She is taking and is being admitted with an exacerbation of her heart failure with a 10kg weight gain in the past 2 weeks. On admission, her INR was 2.8 and Anti-Xa level was 2.4 units/ml. Her T Bili was noted to be 4.0 mg/dL and Scr 3.8 mg/dL and Hgb 12 mg/dL.Medications include: Apixaban 5mg daily, Furosemide 40mg daily, Amiodarone 100mg daily, Metoprolol 50mg Twice daily, Lisinopril 20mg/day and Spironolactone 25mg daily, Erythropoietin 5,000 units twice weekly.

1. What could be causing the elevated INR?

2. If a procedure is planned, how long may it take for the INR to drop below 1.5

3. What about the Erythropoetin dose?

CASE #3

71-year-old woman with a history of AF, CAD (MI 3 years ago), DM2, CKD stage 2, who presents to clinic for lifestyle limiting claudication. Currently on ASA, clopidogrel, atorvastatin, empagliflozin, and metformin.

1. Is this patient a candidate for dual pathway inhibition with Rivaroxaban + ASA? If so, why?

2. How to manage her current anti-platelet therapy?

CASE #4