Comprehensive Thrombosis GuidelinesPublished CMENews Author: Lisa NainggolanCME Author: Laurie Barclay, MDDisclosuresRelease Date: July 1, 2008; Valid for credit through July 1, 2009Credits AvailablePhysicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ forphysicians;Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physiciansTo participate in this internet activity: (1) review the target audience, learning objectives, andauthor disclosures; (2) study the education content; (3) take the post-test and/or complete theevaluation; (4) view/print certificate View details.Learning ObjectivesUpon completion of this activity, participants will be able to: 1. Describe new evidence-based American College of Chest Physicians recommendations to prevent and treat thrombosis in pregnant women and children. 2. Describe American College of Chest Physicians recommendations to prevent and treat thrombosis during the perioperative and postoperative period.Authors and DisclosuresLisa NainggolanDisclosure: Lisa Nainggolan has disclosed no relevant financial relationships.Laurie Barclay, MDDisclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.Brande Nicole MartinDisclosure: Brande Nicole Martin has disclosed no relevant financial information.From Heartwire — a professional news service of WebMDJuly 1, 2008 — New recommendations on antithrombotic and thrombolytic therapy from theAmerican College of Chest Physicians (ACCP) have been published as a supplement to theJune issue of Chest . Guidelines panel chair Dr Jack Hirsh (Henderson Research Centre,Hamilton, ON) told heartwire that the 900-page document contains the most comprehensiveadvice to date on the prevention, treatment, and long-term management of thrombotic disorders."Weve markedly increased the number of non-North American participants, so therecommendations are more international. The process of evaluation has improved dramatically —
its much more rigorous, with panelists for each chapter developing questions sent out to anevidenced-based center, which then performed a literature search. Tables of all the clinical trialsthat have been done for every single clinical condition are included. The review process haschanged too, with each chapter and the manuscript as a whole reviewed by two independentpeople," he explained.Hirsh said it is impossible to cover all the subjects discussed in the new guidelines, which consistof 22 chapters, but a good starting point is the almost 40-page-long executive summary. Forheartwire, he tried to pick out some of the most significant changes from previous guidelinesthat are of relevance to cardiologists.First-ever chapter on perioperative managementFor the first time, the guidelines dedicate a full chapter (chapter 10) to the perioperativemanagement of patients on long-term antithrombotic therapy who require surgery or otherinvasive procedures, Hirsh said.Unfortunately, he explained, the previous recommendations for the most appropriate approach tothe pre- and perioperative management of such patients was "based on one randomized trial."People might be taking warfarin, aspirin, or clopidogrel, and doctors need guidance on whether ornot to stop such therapies before surgery.The recommendations offer a couple of options for warfarin: lowering the dose for simpleprocedures, such as cataract surgery; or stopping therapy altogether around 5 days beforesurgery and instead using low-molecular-weight heparins (LMWHs), or heparin, for coverage,Hirsh said. In certain circumstances, warfarin can be continued until 48 hours before surgery,when patients should be given a low dose of vitamin K. For aspirin, the recommendation isnormally to continue therapy, he said. For clopidogrel, it is usually stopped 5 to 7 days beforesurgery.Rather than going into too much detail, Hirsh said he wanted to stress that the guidelines providephysicians with a rationale based on the likelihood of a thromboembolic event in any individualperson weighed against the risk of bleeding when antithrombotic therapy is stopped beforesurgery.HIT: Heparin can still be used for bypass surgeryAnother chapter of relevance to cardiologists is the one on the treatment and prevention ofheparin-induced thrombocytopenia (HIT), Hirsh noted. "If someone has had an issue with HIT andrequires bypass surgery, what do you use as anticoagulation during bypass?"He explained that any anticoagulant, apart from heparin, can be problematic for conventional on-pump bypass surgery because the risk of bleeding is greater, experience is limited, and theprocedure is much riskier.Hirsh said that in someone who has had HIT but who now has a negative HIT antibody level, "itssafe to use heparin for bypass surgery because it is only used short-term and is cleared veryquickly. Physicians are uncomfortable with this because of medico-legal implications, but it isperfectly rational."Another important issue for physicians to understand is that the enzyme-linked immunosorbentassay (ELIZA) test normally used to diagnose HIT "is commonly falsely positive after surgery,"Hirsh explained. It is important for doctors to remember that falling platelet counts continue to
occur four to five days after heparin, he noted "and if you did this ELIZA test on all patients afterbypass surgery, 20% to 30% would be positive. It creates almost as much harm as good."An alternative is to use another test — a serotonin-release test — "which is much more specificbut not always available," he said.Prevention of venous thromboembolism; not much new in AFHirsh said that research has revealed that certain high-risk medical patients and nonorthopedicsurgical patients are not getting venous thromboembolism (VTE) prophylaxis, "when there is goodevidence that it works. Often its not been given because people just dont think about it."Thus, the guidelines recommend that hospitals adopt an opt-out policy when it comes to VTEprevention, in which all relevant patients are routinely given it unless doctors remove it becausethey think it is not warranted.The recommendations also add more about the surgical management of VTE, he noted, andadvice on the duration of anticoagulant therapy following VTE.For atrial fibrillation (AF), there is "not a lot that is new," Hirsh said. The guidelines maketreatment recommendations on the basis of low-, moderate-, and-high risk AF. Hirsh said that oneof the problems with AF is that, despite "an enormous amount of evidence" indicating the benefitsof warfarin, it is "grossly underutilized" for those at moderate or high risk, particularly by familypractitioners.On a related note, he said that there are "more and more randomized clinical trials that have beenpublished that demonstrate the benefits of computer-assisted INR [international normalized ratio]monitoring for warfarin therapy, showing it is superior to physician monitoring, with variousnomograms for dose adjustment being more effective than decisions made off-the-cuff."Other chapters of relevanceOther chapters in the guidelines of relevance to cardiologists include antithrombotic therapy fornon-ST-segment elevation acute coronary syndrome, acute ST-segment elevation myocardialinfarction, primary and secondary prevention of coronary artery disease, and valvular andstructural heart disease.There are also chapters on antithrombotic therapy for peripheral artery occlusive disease, onantithrombotic and thrombolytic therapy for ischemic stroke, and on pregnancy. The informationon the use of antithrombotics in children and neonates has been expanded."Care for children with major cardiac problems has improved dramatically," Hirsh said. "Butthrombosis remains a major cause of secondary complications for these children, so effectiveantithrombotic therapy is critical."Source 1. Hirsh J, Guyatt G, Albers GW, et al. American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest 2008;133(6 suppl):110S-968S. Available at: http://www.chestnet.org/education/hsp/guidelinesAT8.php.The complete contents of Heartwire, a professional news service of WebMD, can be found atwww.theheart.org, a Web site for cardiovascular healthcare professionals.
Clinical ContextAntithrombotic and thrombolytic treatments are in widespread use for prophylaxis and therapeuticintervention for arterial, venous, and cardiac thrombosis. Despite the long-term experience in useof these therapies, certain clinical situations in thrombosis treatment present unique challenges,such as during pregnancy, in childhood, or in the perioperative period.Therefore, the ACCP issued new evidence-based guidelines for thrombosis prevention andtreatment, supporting previous recommendations regarding routine use of preventive therapiesand highlighting management in children, pregnant women, and other specific patient subgroups.Study Highlights • An international panel of 90 experts developed this 8th Edition of the ACCP Antithrombotic and Thrombolytic Therapy Guidelines. • The revised guidelines include more than 700 comprehensive recommendations concerning prophylaxis, therapy, and long-term management of thrombotic disorders in pregnant women and children and in perioperative and postoperative patients. • The revised recommendations also support previous guidelines concerning the routine use of aspirin and other therapies to prevent thrombosis. • Because warfarin and other vitamin K antagonists (VKA) increase the risk for birth defects and miscarriage, pregnant women should ideally stop taking VKAs before 6 weeks of fetal gestation. • Some pregnant women with certain types of mechanical heart valves should continue VKAs, because alternative anticoagulants may be less effective in preventing stroke and valve thrombosis. • For other pregnant women, LMWH or unfractionated heparin (UFH) should be substituted for VKAs. • 2 options for implementing this recommendation are to continue VKA while conducting frequent pregnancy tests, then substituting LMWH or UFH when pregnancy is confirmed; or substituting VKAs with LMWH or UFH before conception. • The latter option prevents fetal exposure to VKA but presents additional challenges. LMWH and UFH are more expensive than VKAs; they must be administered via once- or twice- daily injection; and long-term use of LMWH or UFH has been linked to osteoporosis. • Recommendations on pediatric management and prevention of thrombosis have been significantly expanded since the previous guideline. • Childhood stroke is one of the 10 leading causes of death in children. Embolism or thrombosis usually causes arterial ischemic stroke (AIS). • Diagnosis of AIS is difficult in children because predisposing health conditions are markedly different from those in adult stroke and because nearly 15% of children with AIS have no clear risk factors. • Until the underlying causes are determined, children with AIS should initially receive antithrombotic treatment, followed by maintenance therapy to prevent long-term recurrence. • The revised recommendations regarding prevention and treatment of thrombosis after interventions for congenital heart disease highlight appropriate treatment options for children with ventricular assist devices and prosthetic heart valves. • The revised guidelines emphasize the perioperative management of patients receiving long-term antithrombotic treatment who must undergo surgery or other invasive procedures. • To minimize surgical bleeding, most patients must temporarily discontinue antithrombotic treatment immediately before and during surgery.
• Because discontinuing antithrombosis can increase the risk for a thromboembolic event; however, this risk must be weighed against the risk for bleeding when deciding whether or not to interrupt antithrombotic therapy just before surgery. • Routine thromboprophylaxis use is recommended for patients undergoing major general, gynecologic, or orthopaedic surgery as well as bariatric and coronary artery bypass surgery. • Most patients who are hospitalized should receive thromboprophylaxis, but routine thromboprophylaxis use is not recommended for patient groups with a very low risk for VTE. • Patients undergoing laparoscopic surgery, knee arthroscopy, or those who take long airplane flights are considered to be at low risk. In these cases, decisions about thromboprophylaxis should be based on individual patient risk. • Aspirin alone is not recommended to prevent VTE in any patient population because there are more effective methods.Pearls for Practice • Pregnant women should ideally stop taking VKAs before 6 weeks of fetal gestation, but some pregnant women with certain types of mechanical heart valves should continue VKAs because alternative anticoagulants may be less effective to prevent stroke and valve thrombosis. For other pregnant women, LMWH or UFH should be substituted for VKAs. Until the underlying causes are determined, children with AIS should initially receive antithrombotic treatment, followed by maintenance therapy to prevent long-term recurrence. • To minimize surgical bleeding, most patients must temporarily discontinue antithrombotic treatment immediately before and during surgery. Because discontinuing antithrombotic treatment can increase the risk for a thromboembolic event, however, this risk must be weighed against the risk for bleeding when deciding whether to interrupt antithrombotic therapy just before surgery. Routine use of thromboprophylaxis is recommended for patients undergoing major general, gynecologic, or orthopaedic surgery as well as bariatric and coronary artery bypass surgery.CME/CE Test