Indications for Perioperative Bridging Ann McBride, M.D.

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Indications for Perioperative Bridging Ann McBride, M.D.

  1. 1. Indications for Perioperative Bridging Ann McBride, M.D. UW Anticoagulation Service
  2. 2. <ul><li>No financial disclosures </li></ul>
  3. 3. Objectives <ul><li>Brief review of literature regarding bridging </li></ul><ul><li>Identify risks of pt groups for increased risk of thromboembolism when warfarin is interrupted </li></ul><ul><li>Identify pts for whom bridging AC should be considered </li></ul><ul><li>Identify pt groups at increased risk for postoperative bleeding </li></ul>
  4. 4. <ul><li>PATIENT RISK FACTORS SURGICAL RISK FACTORS </li></ul><ul><li>Thrombosis Bleeding </li></ul>
  5. 5. <ul><li>Atrial fibrillation/flutter </li></ul><ul><li>MHV </li></ul><ul><li>VTE -PE, DVT </li></ul>Patients chronically anticoagulated
  6. 7. Dunn, Turpie 2003 overall events 29/1868 1.6 overall CVA 7/1868 0.4
  7. 8. Periprocedural Bridging with LMWH Three Prospective Studies, 2004 <ul><li>PROSPECT 260 pts </li></ul><ul><ul><li>pre and post-op single dose enoxaparin </li></ul></ul><ul><ul><li>major surgery (>1 hr), minor, inv. procedure </li></ul></ul><ul><ul><li>Pts: high risk AF (~ 2/3) </li></ul></ul><ul><ul><li>Previous DVT (~ 1/3) </li></ul></ul>
  8. 9. Periprocedural Bridging with LMWH Three Prospective Studies, 2004 cont’d <ul><li>Kovacs 224 pts </li></ul><ul><ul><li>pre-op single dose LMWH </li></ul></ul><ul><ul><li>Post-op high risk bleed prophylactic LMWH </li></ul></ul><ul><ul><li>Others single therapeutic </li></ul></ul><ul><ul><li>Pts: MHV (~ ½) </li></ul></ul><ul><ul><li>AF – high risk (~ ½) </li></ul></ul><ul><ul><li>3 month follow up </li></ul></ul>
  9. 10. Periprocedural Bridging with LMWH Three Prospective Studies, 2004 cont’d <ul><li>Douketis 650 pts </li></ul><ul><ul><li>Pre and post-op bid LMWH </li></ul></ul><ul><ul><li>Pre-op LMWH bid </li></ul></ul><ul><ul><li>Post-op high risk bleed—no LMWH </li></ul></ul><ul><ul><li>Other – bid therapeutic dose </li></ul></ul>
  10. 11. 0.7% * (5.9%) 1.8% 2/542 (0.4%) 2/108 (1.8%) (deaths) <ul><li>Douketis </li></ul><ul><li>Non high risk bleeding </li></ul><ul><li>High risk bleeding </li></ul>6.7% 8/224 (3.6%) (incl. 5 MI + 1 DVT) <ul><li>Kovacs </li></ul>3.5% 4/260 (1.5%) <ul><li>PROSPECT </li></ul>Major Bleeds TE Events Results
  11. 12. REGIMEN Registry Spyropoulos 2006 Major Bleeds 5.5% 3.3% TE Rate 2.4% 0.9%
  12. 13. Atrial Fibrillation Risk of Stroke in Patients with Atrial Fibrillation <ul><li>C </li></ul><ul><li>H </li></ul><ul><li>A </li></ul><ul><li>D </li></ul><ul><li>S2 </li></ul>
  13. 14. Congestive Heart Failure (LV ejection less than 40%) <ul><li>Hypertension </li></ul><ul><li>Age greater than 75 </li></ul><ul><li>Diabetes </li></ul><ul><li>Stroke/TIA </li></ul>
  14. 15. 12-18% 5-6 4-8% 2-4 1-3% 0-1 % Annual CVA Risk CHADS Score
  15. 16. Risk Stratification—Patients with Chronic Atrial Fibrillation <ul><li>Low—Bridging Optional </li></ul><ul><li>CHADS score = 0 or 1 </li></ul><ul><li>Moderate--? Bridging </li></ul><ul><li>CHADS score=2-4 </li></ul><ul><li>High—Bridging Recommended </li></ul><ul><li>CHADS score =5-6 </li></ul><ul><li>Recent (within 3 months) CVA/TIA </li></ul><ul><li>Rheumatic Mitral Valve Disease </li></ul>
  16. 17. Thrombotic risk with prosthetic heart valves Decreasing thrombotic risk Heit JA. J Thromb Thrombolysis . 2001;12:81-87. St. Jude valve Bjork-Shiley valve Caged-ball valve Double wing valves Tilting disc > Caged ball > Mitral >> Aortic Position
  17. 18. Risk Stratification—Patients with Mechanical Heart Valves <ul><li>Low—Bridging Optional </li></ul><ul><li>Bileaflet AV (St. Jude or CarboMedics) and less than 2 CVA risk factors </li></ul><ul><li>Moderate—Bridging should be considered </li></ul><ul><li>Bileaflet AV and more than 2 CVA risk factors </li></ul><ul><li>(here Risk Factors refer to Atrial fibrillation, CHF, age greater than 75, HTN, DM) </li></ul><ul><li>High—Bridging advised </li></ul><ul><li>Mitral Valve Replacement </li></ul><ul><li>Recent (within past 3 months) CVA/TIA </li></ul><ul><li>Caged-ball (Starr-Edwards) or tilting disc AV (Bjork-Shiley, Medtronic) </li></ul>
  18. 19. Risk Stratification—Patients with VTE <ul><li>High—Bridging Strongly Recommended </li></ul><ul><li>Recent episode of VTE (within past 3 months) </li></ul><ul><li>Moderate—Bridging should be considered </li></ul><ul><li>VTE within the past 6 months </li></ul><ul><li>History of VTE after surgery </li></ul><ul><li>Active Cancer—metastatic, recent treatment </li></ul><ul><li>Prot C, Prot S, Antithrombin Deficiency </li></ul><ul><li>Low—Bridging Optional </li></ul><ul><li>None of these risk factors outlined above present </li></ul><ul><li>**Pt with previous VTE recurrence when warfarin was interrupted </li></ul>
  19. 20. Postoperative Bleeding Risks <ul><li>Non-surgical </li></ul><ul><li>Uremia </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Coagulation Factor Deficiency </li></ul><ul><li>Recent Bleed (i.e., GI) </li></ul>
  20. 21. Surgical <ul><li>Low—no interruption of OAC needed </li></ul><ul><li>Cataract </li></ul><ul><li>Dermatology </li></ul><ul><li>Simple dental </li></ul><ul><li>Joint and Soft Tissue Aspiration/Injection </li></ul><ul><li>Laparascopic Cholescystectomy, Hernia Repair *** </li></ul>
  21. 22. Surgical, cont’d <ul><li>Moderate </li></ul><ul><li>Screening Colonoscopy or Diagnostic EGD at UW </li></ul><ul><li>Complicated Dental surgery </li></ul><ul><li>Bronchoscopy </li></ul><ul><li>Other Orthopedic Surgery </li></ul><ul><li>Other intra thoracic surgery </li></ul><ul><li>Other intra-abdominal surgery </li></ul>
  22. 23. Surgical, cont’d <ul><li>High </li></ul><ul><li>Major vascular </li></ul><ul><li>Permanent pacemaker </li></ul><ul><li>Internal defibrillator </li></ul><ul><li>Prostatectomy </li></ul><ul><li>Bladder Tumor resection </li></ul><ul><li>Lung resection </li></ul><ul><li>Hip/Knee Joint Replacement </li></ul><ul><li>Intestinal Anastomosis </li></ul><ul><li>Bowel Polypectomy </li></ul><ul><li>Kidney or Prostate Bx </li></ul><ul><li>Cervical Cone Bx </li></ul><ul><li>Bronchoscopy with Bx </li></ul>
  23. 24. Surgical, cont’d <ul><li>Very High Risk </li></ul><ul><li>Intracranial Surgery </li></ul><ul><li>CABG </li></ul><ul><li>Heart Valve </li></ul><ul><li>Spinal Surgery </li></ul>
  24. 25. Example of Patient Instructions Warfarin Holding/LMWH Plan for INR and Platelets To be Determined To be Determined 70 mg 2/12 4 mg 70 mg 70 mg 2/11 4 mg 70 mg 70 mg 2/10 4 mg 70 mg 70 mg 2/09 4 mg 70 mg HOLD 2/08 Procedure INR and Platelets HOLD HOLD 70 mg 2/07 HOLD 70 mg 70 mg 2/06 HOLD 70 mg 70 mg 2/05 HOLD HOLD HOLD 2/04 HOLD HOLD HOLD 2/03 Lab Test Warfarin Dose Lovenox Evening Lovenox Morning Date
  25. 26. Points to Consider <ul><li>If target INR 2.0-3.0, pt to be WITHIN target range at time of withholding warfarin </li></ul><ul><li>If INR = 2.0-3.0, after 3-4 warfarin doses held, INR level will be less than 1.5 </li></ul><ul><li>Most surgeries/procedures can be performed reasonably safely when INR less than 1.5 </li></ul><ul><li>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 </li></ul>
  26. 27. Cases <ul><li>75 yo pt atrial fibrillation—dental work </li></ul><ul><li>70 yo pt atrial fibrillation, no hx CVA/TIA—colonoscopy at UW </li></ul><ul><li>82 yo MVR scheduled for cystocele repair </li></ul><ul><li>50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopy </li></ul><ul><li>50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopy, with protein C deficiency </li></ul>
  27. 28. Cases, cont’d <ul><li>44 yo M with unprovoked DVT RLE 4 yrs earlier; + heterozygous FV Leiden, scheduled for lap hernia repair </li></ul><ul><li>68 yo with atrial fibrillation and AVR scheduled for colonoscopy </li></ul><ul><li>65 yo met lung ca, DVT 9 months ago, scheduled for laparotomy </li></ul><ul><li>77 yo with atrial fibrillation, HTN, DM, CHF scheduled for prostate bx </li></ul><ul><li>77 yo with atrial fibrillation, HTN, CHF, DM, no hx TIA/CVA scheduled colonoscopy </li></ul>

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