Disclosures The Perioperative No financial conflicts of interest - PDF document

◆ 12/3/17 Disclosures The Perioperative No financial conflicts of interest ■ Management of Oral Chair of the ABIM Focused-Practice in Hospital ■ Medicine Self Examination Process committee Anticoagulants ◆ No exam questions will be disclosed in the presentation Margaret C. Fang, MD, MPH Medical Director, UCSF Anticoagulation Clinic Anticoagulants and Invasive Session Objectives Procedures Learn when and how to stop and restart oral ■ anticoagulants for patients undergoing invasive Approximately 2 – 3 million people in the U.S. ■ procedures take anticoagulants ◆ Warfarin Each year, ~10-20% of these patients need to ■ ◆ Direct oral anticoagulants (DOACs) temporarily stop their anticoagulants for an Review risk factors for thrombosis and procedure- invasive procedure ■ related bleeding Understand when should you use “bridging” This is a common situation! ■ ■ anticoagulation ◆ 1

◆ 12/3/17 Goals of Periprocedural Estimating Periprocedural Anticoagulation Bleeding Risk Minimize thrombotic risk in patients who require ■ ■ Bleeding risk is related to both temporary interruption of anticoagulation patient-specific and procedure-specific ◆ Requires estimating the unique thrombotic risk of patients with atrial fibrillation (AF), mechanical heart factors valves, and venous thromboembolism (VTE) Minimize procedural complications related to ■ anticoagulation ◆ Requires estimating the bleeding risk and potential consequences of procedural-bleeding Determine who should be “bridged” ■ ◆ Use of an anticoagulant with a faster offset (e.g., intravenous heparin or LMWH) during temporary interruption of a longer-acting anticoagulant ◆ Bridging ~triples the risk of periprocedural bleeding Patient-related Bleeding Procedure-Related Risk Factors Bleeding Risk Factors HAS-BLED variables (hypertension, abnormal High bleeding risk procedures ■ ■ renal/liver function, prior stroke, prior bleeding, ◆ Most cardiothoracic and vascular surgeries labile INR, age>65, drug/alcohol use, antiplatelets) ◆ Major abdominal surgeries ◆ Major orthopedic surgeries Recent bleed (within 3 months) or history of ■ Procedures where bleeding can be catastrophic bleeding with prior bridging or similar procedure ■ ◆ Intracranial/Spinal/Neuraxial procedures Quantitative or qualitative platelet abnormality ■ ◆ Biliary sphincterotomy, variceal treatment (e.g., uremia) ◆ Kidney biopsy, urologic surgery Elevated/supratherapeutic INR on warfarin ■ Lower risk procedures ■ BleedMAP periprocedural bleeding risk score ◆ Laparoscopic cholecystectomy, hernia repair ■ ◆ Mitral mechanical valve, Active cancer, Bleeding ◆ Arthroscopy history, Platelets<150,000, Moderate / High bleeding ◆ Biopsies (thyroid, breast, lymph node, prostate) risk procedure, Restarted bridging within 24 hours * Comprehensive list available in 2017 ACC Periprocedural Anticoagulation Pathway Appendix Tafur et al, 2012 J Thromb Haemostasis ◆ 2

◆ 12/3/17 Procedures That Can Be Some Cardiac Procedures Can Be Performed on Uninterrupted Performed on Anticoagulation Anticoagulation Catheter ablation (COMPARE trial) Dental extractions, root canals, cleaning Ø ■ Pacemaker or defibrillator implantation (BRUISE Diagnostic endoscopy or bronchoscopy without Ø ■ CONTROL trial) biopsy ◆ In both trials, bridging had worse outcomes than Diagnostic gynecologic procedures ■ uninterrupted warfarin ◆ Colposcopy, hysteroscopy, endometrial biopsy, IUD ✦ Higher rates of TE and bleeding after ablation insertion ✦ 4x the rate of pocket hematomas after device Minor skin procedures (biopsy, suturing) implantation ■ ◆ On-DOAC vs interrupted DOAC (BRUISE CONTROL-2) Cataract surgery ■ ✦ Similar and low rates of bleeding in both arms Some vascular procedures (e.g., IVC filter ■ If a patient is at high thromboembolism risk à do placement, PICC lines, venography) ■ the procedure on warfarin rather than bridge. May not need to interrupt DOAC as well. Estimating Thrombotic The BRIDGE Trial Risk — 1813 patients with AF randomized to ■ Atrial fibrillation bridging vs. no bridging ◆ CHA 2 DS 2 -VASc stroke risk score — Mean CHADS 2 = 2.3 (only 3% had CHADS 2 ◆ Recent stroke/TIA 5-6) ■ Venous thromboembolism ◆ History and timing of previous VTE No Bridging Bridging P value ◆ Risk factors for VTE: active cancer, hypercoagulable Arterial 0.4% 0.3% 0.73 states thromboembolism (stroke/TIA/peripheral ■ Mechanical heart valves embolism) ◆ Type and position of prosthetic valve Major bleeding 1.3% 3.2% 0.005 ◆ Concomitant AF and stroke risk factors Minor bleeding 12% 21% <0.001 Reserve bridging anticoagulation for patients with Ø Death 0.5% 0.4% 0.88 high thrombotic risk Douketis JD et al. NEJM 2015 ◆ 3

◆ 12/3/17 Atrial Fibrillation Bridging for VTE DON’T bridge patients at low TE risk — Observational study of 1178 patients with ■ ◆ CHA 2 DS 2 -VASc ≤ 4 and no prior TE VTE comparing bridging to no bridging No Bridging Bridging P value MAYBE bridge patients at intermediate TE risk IF no N=1257 N=555 ■ significant bleeding risk Recurrent VTE at 30 0.2% 0.0% 0.56 ◆ CHA 2 DS 2 -VASc 5 or 6 and TE not recent (>3 months) days ◆ If no history of TE, advise not bridging Clinically relevant 0.2% 2.7% 0.01 bleeding at 30 days ◆ If high bleeding risk, advise not bridging — Bridging increased bleeding risk without CONSIDER bridging patients at high TE risk ■ reducing VTE risk ◆ CHA 2 DS 2 -VASc ≥ 7 or recent TE (within 3 months) — No difference by baseline VTE risk ◆ Delay elective surgeries if possible in patients with recent TE — Only 3% were categorized as high VTE risk 2017 ACC Periprocedural Anticoagulation Pathway Clark et al. JAMA Intern Med 2015 Venous Thromboembolism Mechanical Heart Valves DON’T bridge patients at low VTE risk DON’T bridge patients with low risk valves ■ ■ ◆ Distant history of VTE (> 12 months prior) ◆ Bileaflet aortic valves without AF or other risk factors MAYBE bridge patients at intermediate VTE risk IF ■ no significant bleeding risk CONSIDER bridging patients at intermediate risk ■ ◆ Active cancer ◆ Bileaflet aortic valve with ≥ 1 of the following: AF, ◆ History of recurrent VTE prior stroke/TIA, heart failure, HTN, diabetes, age ≥ 75 ◆ Non-severe thrombophilia (e.g., Factor V Leiden) CONSIDER bridging patients at high VTE risk ■ DO bridge patients at high risk ◆ Recent VTE (within 1-3 months) ■ ◆ Mitral valve prosthesis ◆ Severe thrombophilia (e.g., APLAS) ◆ Caged-ball or tilting disc aortic valves ◆ History of VTE during interruption of anticoagulation ◆ Recent stroke/TIA (within 6 months) ◆ Delay elective surgeries if possible in patients with ◆ Multiple prosthetic valves recent VTE (within 3 months) Douketis et al. ACCP Guidelines 2012 Witt et al., 2016 Journal of Thrombosis and Thrombolysis ◆ 4

◆ 12/3/17 Periprocedural Warfarin Management First determine the goal INR for procedure ■ Developing a ◆ Consider whether the procedure can be done on uninterrupted or reduced-dose warfarin Periprocedural Hold warfarin for the number of days needed to Anticoagulation Plan ■ achieve the target INR ◆ For full reversal of anticoagulant effect (INR<1.5), usually hold for 5 days ◆ May need to hold longer in patients with higher INR baseline therapeutic ranges If bridging, start parenteral agent ~24-48 hours ■ after last dose of warfarin, or when INR < 2 Periprocedural Warfarin INR Targets for Common Inpatient Procedures Management Low Bleeding Risk Moderate High Risk, Difficult In high bleeding risk patients, check INR prior to Bleeding Risk to Detect or ■ Control Bleeds procedure to ensure within acceptable range GOAL INR ≤ 2.0 <1.5 <1.5 Post-procedure: can usually restart warfarin the ■ Vascular Dialysis access Tunneled lines TIPS evening after procedure (takes days to become procedures IVC filter placement Port placement therapeutic) PICC line placement Angiography Central line removal If using bridging anticoagulation ■ Venography ◆ Administer VTE prophylaxis (if indicated) Non-vascular Drainage catheter Intra-abdominal Renal biopsy procedures exchange biopsies/drain Biliary interventions ◆ Full-dose bridging once hemostasis is achieved Thoracentesis Lung biopsy Nephrostomy tube ✦ Usually no sooner than 48-72 hours after high bleeding Paracentesis Liver biopsy Lumbar punctures risk procedures Superficial abscess G-tube drainage placement 2012 Society of Interventional Radiology Consensus Guidelines ◆ 5