Perioperative management of antithrombotic therapy

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  • กรณีที่ หยุด anticoagulant แล้ว ยังมี INR >1.5 ใน 1-2 วันก่อนผ่า  Vit K 1-2 mg
  • Perioperative management of antithrombotic therapy

    1. 1. Perioperative management of antithrombotic therapy Ext. Phatcharapol Udomluck Medical student Naresuan university
    2. 2. Antithrombotic therapy • Long-term anticoagulation therapy for the prevention of thromboembolism due to – Atrial fibrillation – Placement of a mechanical heart-valve prosthesis – Venous thromboembolism • Dual antiplatelet therapy (combination treatment with aspirin and a thienopyridine) after the placement of a coronary-artery stent has dramatically increased
    3. 3. Perioperative management of antithrombotic therapy Goal • Prevent thromboembolic (TE) events – Arterial TE : Prosthetic valve thrombosis (5.9-64.7%) , Cardioembolic stroke (fatality 4.2-14.9) – Venous TE : DVT, PE (fatality 26.4) • Reduced major hemorrhage in the periprocedural period
    4. 4. http://www.drtedwilliams.net/ Dr Ted Williams, PharmD education (2009)
    5. 5. ASSESSMENT OF THROMBOTIC RISK • Valvular atrial fibrillation – Severe valvular heart disease (mechanical valvular prosthesis or mitral-valve repair) : high risk for TE • non-valvular atrial fibrillation – The CHA 2 DS 2 -VASc score
    6. 6. ( Prior MI, PAD, Aortic plaque )
    7. 7. ASSESSMENT OF THROMBOTIC RISK • Mechanical heart valves and venous thromboembolism
    8. 8. ASSESSMENT OF THROMBOTIC RISK Cancer – Increased risk of periprocedural thrombosis • Cancer-specific prothrombotic activity, hormonal therapy, angiogenesis inhibitors, radiotherapy, and the presence of indwelling central venous catheters – Increased risk of bleeding • Prophylactic agents for the prevention of venous thromboembolism, chemotherapy-related hepatic and renal dysfunction and thrombocytopenia
    9. 9. ASSESSMENT OF THROMBOTIC RISK Coronary stents • Some patients with coronary stents may require dual antiplatelet therapy • Premature discontinuation of antiplatelet therapy in anticipation of invasive procedure may lead to stent thrombosis and precipitation of myocardial infarction • Rate of 50% or higher
    10. 10. Coronary stent Bare-metal stent • Risk of thrombosis is highest within 6 Wks after placement of stent • Dual antiplatelet required – ASA(165-325 mg/day) : 1 mo – Clopidogrel : at least 1 mo and Up to 12 mo Drug-eluting stent • Risk of thrombosis is highest within 3-6 mo after placement of stent • Dual antiplatelet required – ASA(165-325 mg/day) • Sirolimus 3 mo • Paclitaxel 6 mo – Clopidogrel : at least 12 mo
    11. 11. Assessment of Periprocedural bleeding risk • Major bleeding depends on procedure – High-risk : Major bleed • intracranial, intraspinal, intraocular, retroperitoneal, int rathoracic, or pericardial bleeding • Additional Risk factors – Residual effects of antithrombotic agents – Active cancer – Chemotherapy – History of bleeding – Reinitiation of antithrombotic therapy within 24 hours after the procedure
    12. 12. HAS-BLED risk score • SBP > 160 mmHg • Chronic dialysis or renal transplantation or serum creatinine ≥ 200 mmol/L • Chronic hepatic disease (e.g. Cirrhosis) or biochemical evidence of significant hepatic derangement • Previous bleeding history and/or predisposition to bleeding, e.g. Bleeding diathesis, anaemia • Concomitant use of drugs, such as antiplatelet agents, NSAIDs
    13. 13. Low – intermediate (HAS-BLED 0-2)
    14. 14. High risk (HAS-BLED score >= 3)
    15. 15. Bridging anticoagulant therapy
    16. 16. Assessment tool for identifying patient-specific and surgical risk factors for patients on anticoagulation therapy who are undergoing elective surgery JAFFER A K Cleveland Clinic Journal of Medicine 2009;76:S37-S44©2009 by Cleveland Clinic
    17. 17. Low risk  Stop anticoagulant but not start bridging anticoagulant
    18. 18. Recommend for Warfarin use • Stop oral anticoagulant 5 day before invasive procedure – Keep INR <1.5 • If follow up INR > 1.5 in 1-2 day before invasive procedure – Vitamin K 1-2 mg • If Continue Warfarin : Keep INR approximately 2.5 • Urgent operative procedure – Oral or IV Vitamin K 2.5-5.0 mg • Emergency operative procedure – FFP + Low dose (IV or Oral) Vitamin K • Mechanical heart valve – Only use FFP ( NOT use Vitamin K  “Warfarin resistance”)
    19. 19. Bridging anticoagulant • Recommend for Moderate to High risk TE – Start when INR <2 – Therapeutic dose SC LMWH or IV UFH – If GFR < 30  IV UFH is preferred • Stop bridging before invasive procedure – Therapeutic SC LMWH or SC UFH : 12-24 hr before procedure (Use half dose in Morning last dose) – IV UFH : 4-6 hr before procedure • Half life 60 – 90 min , Dissipate after discont. 3 – 4 hr
    20. 20. After procedure : Start Oral anticoagulant when keep desired INR level for 3 day Y. Chintammit : Update in internal medicine 2009 : 343 – 349
    21. 21. SC IV UFH : Keep aPTT 1.5 – 2 x control Y. Chintammit : Update in internal medicine 2009 : 343 – 349
    22. 22. Reversal of anticoagulant Reversible anticoagulant agent • Warfarin – Vitamin K and Fresh frozen plasma – Prothrombin complex concentrates preferred in … • CHF, Valvular heart disease, Renal failure • Volume overload from Large volume infusion of FFP • Heparin – Protamine can reverse the action • UFH : Completely reversal • LMWH : Partial reversal
    23. 23. 2011 Clinical Practice Guide on Anticoagulant Dosing and Management of Anticoagulant-Associated Bleeding Complications in Adults
    24. 24. 2011 Clinical Practice Guide on Anticoagulant Dosing and Management of Anticoagulant-Associated Bleeding Complications in Adults
    25. 25. Reversal warfarin • ACCP (2008) guidelines recommends • Oral doses of vitamin K – 1-2.5 mg for an INR between 5 and 9 – 2.5-5 mg for INR ≥ 9, no significant bleeding – 10 mg for serious bleeding and elevated INR
    26. 26. 2011 Clinical Practice Guide on Anticoagulant Dosing and Management of Anticoagulant-Associated Bleeding Complications in Adults * heparin-induced thrombocytopenia
    27. 27. Reversal of anticoagulant Nonreverssible anticoagulant agent – Reliable reversibility has not been proved • Direct factor Xa inhibitors (Rivaroxaban) – Prothrombin complex concentrates (contain factor II, VII, IX, X and protein C ,S) • Direct thrombin inhibitor (Dabigatan) – Life-threatening bleeding that cannot be managed with supportive care and local hemostatic measures – Hemodialysis or charcoal hemoperfusion can be considered
    28. 28. Perioperative management of antiplatelet therapy
    29. 29. Antiplatelet • Antiplatelet drugs (irreversible) – ASA, clopidogrel, ticlopidine, and prasugrel – For each day after interruption 10% to 14% of normal platelet function is restored; later, it takes 7 to 10 days for an entire platelet pool to be replenished
    30. 30. Antiplatelet • Antiplatelet drugs (reversible) – Dipyridamole, Cilostazol, and NSAIDs • Dipyridamole, a pyridopyrimidine derivative with antiplatelet and vasodilator properties, has a half-life of 10 h • Cilostazol, a phosphodiesterase inhibitor with anti-platelet and vasodilator properties, has a half-life of 10 h • NSAID have half-lives that vary from – 2 to 6 h (ibuprofen, ketoprofen, indomethacin) – to 7 to 15 h (celecoxib, naproxen, difl unisal) – to . 20 h (meloxicam, nabumetone, piroxicam)
    31. 31. Antiplatelet • Patients who were receiving a VKA and ASA typically resumed ASA at the same time as the VKA, which was within 24 h after surgery
    32. 32. Schematic of different therapeutic options for inhibition of platelet P2Y12 receptor. Ferreiro J L , and Angiolillo D J Circ Cardiovasc Interv 2012;5:433-445 Copyright © American Heart Association
    33. 33. Assessment • Optimal preoperative management of patients with coronary artery stents depends on many factors • Relative risks and benefits of stopping versus continuing antiplatelet therapy – Identification of patients at high risk for a perioperative event after cessation of antiplatelet therapy – Identifi cation of patients at high risk of bleeding • The risk of perioperative bleeding increases when two or more antiplatelet agents are used
    34. 34. Recommendation of ACCP 2012
    35. 35. Minor surgery • In patients who are receiving ASA for the secondary prevention of cardiovascular disease and are having minor dental or dermatologic procedures or cataract surgery – suggest continuing ASA around the time of the procedure instead of stopping ASA 7 to 10 days before the procedure
    36. 36. Non-cardiac surgery • In patients at moderate to high risk for cardiovascular events – suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C) • In patients at low risk for cardiovascular events – suggest stopping ASA 7 to 10 days before surgery instead of continuation of ASA (Grade 2C)
    37. 37. CABG surgery • suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C) • In patients who are receiving dual antiplatelet drug therapy and require CABG surgery – suggest continuing ASA around the time of surgery and stopping clopidogrel/prasugrel 5 days before surgery instead of continuing dual antiplatelet therapy around the time of surgery (Grade 2C)
    38. 38. Patients with Coronary Stents having Surgery • Surgery for at least 6 weeks after placement bare-metal stent • Surgery for at least 6 months after placement drug-eluting stent instead of undertaking surgery within these time periods (Grade 1C) • In patients who require surgery within 6 weeks of placement of a bare-metal stent or within 6 months of placement of a drug-eluting stent – suggest continuing dual antiplatelet therapy around the time of surgery instead of stopping dual antiplatelet therapy 7 to 10 days before surgery (Grade 2C)
    39. 39. Resumption of antiplatelet • Clopidogrel administered at maintenance doses has a delayed onset of action, and treatment can therefore be reinitiated within 24 hours after the procedure • Treatment with other antiplatelet agents, including aspirin, can be reinitiated within 24 hours • Caution when reinitiating treatment with prasugrel or ticagrelor because of – their rapid onset of action, potent antiplatelet inhibition, and the lack of agents to reverse their effects
    40. 40. Canadian Cardiovascular Society (CCS) class of angina • Class I – Angina only during strenuous or prolonged physical activity • Class II – Slight limitation, with angina only during vigorous physical activity • Class III – Symptoms with everyday living activities, i.e., moderate limitation • Class IV – Inability to perform any activity without angina or angina at rest, i.e., severe limitation
    41. 41. GRACE
    42. 42. Killip class • I: no clinical signs of heart failure • II: crackles, S3 gallop and elevated jugular venous pressure • III: frank pulmonary oedema • IV: cardiogenic shock - hypotension (systolic < 90 mmHg) and evidence of peripheral vasoconstriction (oliguria, cyanosis, sweating)

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