BCC4: Sarah Wesley- To Thin or Not To Thin (The heart and anticoagulation)

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To thin or not to thin? That is a great question which Wesley helps answer with her talk on the heart and anticoagulation. This podcast was recorded at BCC4. Full posts can be found at …

To thin or not to thin? That is a great question which Wesley helps answer with her talk on the heart and anticoagulation. This podcast was recorded at BCC4. Full posts can be found at intensivecarenetwork.com

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  • 1. To thin or not to thin? Dr Sarah Wesley Cairns 2013
  • 2. 64yo CABG x3 • On pump, LIMA to LAD and SVG to OM1 and Cx • PMHx: hypertension and hypercholesterolaemia • What antiplatelet therapy and when? Aspirin Aspirin + Clopidogrel Warfarin
  • 3. 64yo CABG x3 • Aspirin at 6h if bleeding not an issue and daily afterwards • 75-150mg optimal dose • Reduction in mortality/CVA/MI/AKI Aspirin Aspirin + Clopidogrel Warfarin
  • 4. 64yo CABG x3 • Are there any indications for dual (aspirin and clopidogrel) antiplatelet therapy?
  • 5. 64yo CABG x3 • Dual therapy • CABG post acute coronary syndrome • Stent in situ not bypassed by graft • Off-pump CABG • Not indicated specifically for SVG • SVG 15% occlude in 1 year and 50% in 10 years • CASCADE study 2008 • Clopidogrel and aspirin in SVG • Showed no benefit in addition of clopidogrel
  • 6. 64yo CABG x3 • Clopidogrel acceptable alternative if allergic to aspirin • No data showing superior • Aspirin remains drug of choice in routine on-pump CABG
  • 7. 64yo CABG x3 • He goes on to develop AF day 2 • 3 days later remains in rate controlled AF on amiodarone • Would you start any additional anticoagulation? Clopidogrel iv Heparin + Warfarin None
  • 8. 64yo CABG x3 • iv heparin and warfarin if remains in AF for > 48h • Aim INR 2-3 • Double the risk of stroke with no anticoagulation • If reverts to sinus within 48h • Evidence equivocal for aspirin alone or adding warfarin Clopidogrel iv Heparin + Warfarin None
  • 9. Questions ?
  • 10. 72yo tissue AVR • EF 45% with moderate LVH • Sinus rhythm • No previous DVT/PE • No post-operative complications • What anticoagulation therapy should he have and when? Clopidogrel Aspirin Warfarin
  • 11. 72yo tissue AVR • No risk factors for VTE disease -> aspirin alone • Stroke rate of 0.2% for AVR in sinus Clopidogrel Aspirin Warfarin
  • 12. 72yo tissue AVR • Risk factors for VTE disease • AF, EF< 30-35%, hypercoagulable or previous VTE • Warfarin with INR 2-3 Clopidogrel Aspirin Warfarin
  • 13. 54yo Mechanical AVR • What if he was 54 and his original operation was a mechanical AVR? • Normal coronary arteries • No risk factors for cardiovascular disease Clopidogrel + Aspirin Aspirin iv Heparin + Warfarin
  • 14. 54yo Mechanical AVR • Warfarin and iv heparin • Iv heparin continues till INR therapeutic for 2 days • Intensity of warfarin relates to thrombogenicity of valve and risk factors for thrombus formation • INR 2.5 for low risk up to 3.5 for high risk • Risk relates to • Type of valve • Risk factors for VTE disease
  • 15. Mechanical AVR • Warfarin alone or combination warfarin and anti- platelets? • Balance of thrombosis risk vs bleeding
  • 16. Mechanical AVR • Add aspirin to warfarin if risk factors for cardiovascular disease, stents, previous PE, high risk valve • Many guidelines recommend adding aspirin unless concerns over bleeding • Significant reduction in thromboembolism and all cause mortality 9 -> 4/5% • Increase in bleeding risk 5 -> 8%
  • 17. 63yo with mechanical MVR • Second generation valve inserted • Past history of Atrial Fibrillation • EF 40% • What anticoagulation therapy should she have and when?
  • 18. MV repair or tissue MV • What if she’d had a mitral valve repair or tissue valve rather than mechanical valve replacement and was in sinus rhythm?
  • 19. MV repair or tissue MV • 3 months warfarin or antiplatelets • No evidence either is superior • 20% of all thromboembolic events in first month
  • 20. Thrombosis rates • Embolism or valve thrombosis with mechanical valve replacements • No anticoagulation • Aortic valve 4-12% per year • Mitral valve 10-22% per year • AVR with anticoagulation • Warfarin 1% per patient per year • Aspirin 2.2% per patient per year • MVR and AVR with risk factors for VTE • 2% and 4.5% respectively
  • 21. Questions?
  • 22. Stopping anti-platelet agents • Routine CABG stop anti-platelet drug 7 days pre-op • NSTEMI/MI/Prior to PCI • Clear benefits for clopidogrel and aspirin administration shown in many large RCT • Guidelines recommend stopping clopidogrel 5-7 days before surgery if clinical condition allows • 1% increase in risk of MI during this time
  • 23. Stopping Warfarin pre-op • Low risk of thrombosis • Bileaflet mechanical AVR with no other risk factors • Stop warfarin 3-5 days pre-op no heparin required • High risk of thrombosis • Mechanical MVR/Mechanical AVR with risk factors • Stop warfarin and start heparin when INR < 2 • Restart heparin as early after surgery as as bleeding allows
  • 24. What about newer oral antithrombotics? • Direct thrombin inhibitor – Dabigatrin • RE-ALIGN study • vs warfarin in mechanical valves • Stopped early as increased risk of CVA/MI/Thrombosis • Factor Xa inhibitor - Rivaroxaban • Not studied and not recommended