Indications for Perioperative Bridging

1
Indications for Perioperative Bridging

• Ann McBride, M.D.
• UW Anticoagulation Service

2

• No financial disclosures

3
Objectives

• Brief review of literature regarding bridging
• Identify risks of pt groups for increased risk of
  thromboembolism when warfarin is interrupted
• Identify pts for whom bridging AC should be
  considered
• Identify pt groups at increased risk for
  postoperative bleeding

4

• PATIENT RISK FACTORS SURGICAL RISK FACTORS
• Thrombosis Bleeding

5
Patients chronically anticoagulated

1. Atrial fibrillation/flutter
2. MHV
3. VTE -PE, DVT

6
(No Transcript)
7
Dunn, Turpie 2003
overall events 29/1868 1.6 overall CVA
7/1868 0.4
8
Periprocedural Bridging with LMWHThree
Prospective Studies, 2004

• PROSPECT 260 pts
• pre and post-op single dose enoxaparin
• major surgery (gt1 hr), minor, inv. procedure
• Pts high risk AF ( 2/3)
• Previous DVT ( 1/3)

9
Periprocedural Bridging with LMWHThree
Prospective Studies, 2004 contd

• Kovacs 224 pts
• pre-op single dose LMWH
• Post-op high risk bleed prophylactic LMWH
• Others single therapeutic
• Pts MHV ( ½)
• AF high risk ( ½)
• 3 month follow up

10
Periprocedural Bridging with LMWHThree
Prospective Studies, 2004 contd

• Douketis 650 pts
• Pre and post-op bid LMWH
• Pre-op LMWH bid
• Post-op high risk bleedno LMWH
• Other bid therapeutic dose

11
Results TE Events Major Bleeds
PROSPECT 4/260 (1.5) 3.5
Kovacs 8/224 (3.6) (incl. 5 MI 1 DVT) 6.7
Douketis Non high risk bleeding High risk bleeding 2/542 (0.4) 2/108 (1.8) (deaths) 0.7 (5.9) 1.8
12
REGIMEN Registry Spyropoulos 2006
Major Bleeds 5.5
3.3 TE Rate 2.4
0.9
13
Atrial FibrillationRisk of Stroke in Patients
with Atrial Fibrillation

• C
• H
• A
• D
• S2

14
Congestive Heart Failure (LV ejection less than
40)

• Hypertension
• Age greater than 75
• Diabetes
• Stroke/TIA

15
CHADS Score Annual CVA Risk
0-1 1-3
2-4 4-8
5-6 12-18
16
Risk StratificationPatients with Chronic Atrial
Fibrillation

• LowBridging Optional
• CHADS score 0 or 1
• Moderate--? Bridging
• CHADS score2-4
• HighBridging Recommended
• CHADS score 5-6
• Recent (within 3 months) CVA/TIA
• Rheumatic Mitral Valve Disease

17
Thrombotic risk with prosthetic heart valves
Mitral gtgt Aortic Position Mitral gtgt Aortic Position Mitral gtgt Aortic Position
Caged ball gt Tilting disc gt Double wing valves
Caged-ball valve Bjork-Shiley valve St. Jude valve
Decreasing thrombotic risk
Heit JA. J Thromb Thrombolysis. 20011281-87.
18
Risk StratificationPatients with Mechanical
Heart Valves

• LowBridging Optional
• Bileaflet AV (St. Jude or CarboMedics) and less
  than 2 CVA risk factors
• ModerateBridging should be considered
• Bileaflet AV and more than 2 CVA risk factors
• (here Risk Factors refer to Atrial fibrillation,
  CHF, age greater than 75, HTN, DM)
• HighBridging advised
• Mitral Valve Replacement
• Recent (within past 3 months) CVA/TIA
• Caged-ball (Starr-Edwards) or tilting disc AV
  (Bjork-Shiley, Medtronic)

19
Risk StratificationPatients with VTE

• HighBridging Strongly Recommended
• Recent episode of VTE (within past 3 months)
• ModerateBridging should be considered
• VTE within the past 6 months
• History of VTE after surgery
• Active Cancermetastatic, recent treatment
• Prot C, Prot S, Antithrombin Deficiency
• LowBridging Optional
• None of these risk factors outlined above
  present
• Pt with previous VTE recurrence when warfarin
  was interrupted

20
Postoperative Bleeding Risks

• Non-surgical
• Uremia
• Thrombocytopenia
• Coagulation Factor Deficiency
• Recent Bleed (i.e., GI)

21
Surgical

• Lowno interruption of OAC needed
• Cataract
• Dermatology
• Simple dental
• Joint and Soft Tissue Aspiration/Injection
• Laparascopic Cholescystectomy, Hernia Repair
  

22
Surgical, contd

• Moderate
• Screening Colonoscopy or Diagnostic EGD at UW
• Complicated Dental surgery
• Bronchoscopy
• Other Orthopedic Surgery
• Other intra thoracic surgery
• Other intra-abdominal surgery

23
Surgical, contd

• High
• Major vascular
• Permanent pacemaker
• Internal defibrillator
• Prostatectomy
• Bladder Tumor resection
• Lung resection
• Hip/Knee Joint Replacement
• Intestinal Anastomosis
• Bowel Polypectomy
• Kidney or Prostate Bx
• Cervical Cone Bx
• Bronchoscopy with Bx

24
Surgical, contd

• Very High Risk
• Intracranial Surgery
• CABG
• Heart Valve
• Spinal Surgery

25
Example of Patient Instructions
Warfarin Holding/LMWH Plan for
Date Lovenox Morning Lovenox Evening Warfarin Dose Lab Test
2/03 HOLD HOLD HOLD
2/04 HOLD HOLD HOLD
2/05 70 mg 70 mg HOLD
2/06 70 mg 70 mg HOLD
2/07 70 mg HOLD HOLD INR and Platelets
2/08 Procedure HOLD 70 mg 4 mg
2/09 70 mg 70 mg 4 mg
2/10 70 mg 70 mg 4 mg
2/11 70 mg 70 mg 4 mg
2/12 70 mg To be Determined To be Determined INR and Platelets
26
Points to Consider

• If target INR 2.0-3.0, pt to be WITHIN target
  range at time of withholding warfarin
• If INR 2.0-3.0, after 3-4 warfarin doses held,
  INR level will be less than 1.5
• Most surgeries/procedures can be performed
  reasonably safely when INR less than 1.5
• 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 resuming
  warfarin, INR will typically be greater than 2.0

27
Cases

• 75 yo pt atrial fibrillationdental work
• 70 yo pt atrial fibrillation, no hx
  CVA/TIAcolonoscopy at UW
• 82 yo MVR scheduled for cystocele repair
• 50 yo hx recurrent VTE (DVT LLE x2) on OAC x 6
  yrs without recurrence scheduled for screening
  colonoscopy
• 50 yo hx recurrent VTE (DVT LLE x2) on OAC x 6
  yrs without recurrence scheduled for screening
  colonoscopy, with protein C deficiency

28
Cases, contd

• 44 yo M with unprovoked DVT RLE 4 yrs earlier
  heterozygous FV Leiden, scheduled for lap hernia
  repair
• 68 yo with atrial fibrillation and AVR scheduled
  for colonoscopy
• 65 yo met lung ca, DVT 9 months ago, scheduled
  for laparotomy
• 77 yo with atrial fibrillation, HTN, DM, CHF
  scheduled for prostate bx
• 77 yo with atrial fibrillation, HTN, CHF, DM, no
  hx TIA/CVA scheduled colonoscopy