The “spot sign” (arrow), contrast extravasation after contrast-enhanced computed tomography, is associated with a high risk of hematoma expansion.
As far as bleeding/hemorrhagic outcomes, one must consider major and minor bleeding, as well as thrombocytopenia (and HIT). In modern-day treatment one most consider both sides of the scale, and the fact that as more aggressive antithrombotic therapies are used to reduce ischemic complications, the frequency of adverse bleeding outcomes rises.
The profile of the patient at high risk for bleeding is characterized by older age, renal failure, often female, with a prior history of bleeding.
Put a slightly different way, physiologic hemostasis and pathological thrombosis are two sides of the same coin. As the degree of anticoagulation increases, the risk of bleeding increases, but the risk of ischemic clinical events goes down. A balance must be struck between freely flowing blood (that doesn’t clot and cause events) and TOO-freely flowing blood (as at the site of bleeding, where physiologic hemostasis is impaired.
Does bleeding influence the prognosis of ACS patients or is it a necessary evil of ACS therapy?
These data form the GRACE registry show that there is an association between bleeding and morality across the spectrum of unstable ischemic syndromes.
BALANCING THROMBOSIS AND BLEEDING RISKS
BALANCING THROMBOTIC AND BLEEDING RISKS Dr Syed Raza MD, MRCP(UK),Dip Card(UK),CCT(UK),FCCP
OBJECTIVES1. Burden of thrombosis and anti thrombotic related bleeding complications2. Assessment of thrombotic and bleeding risks3. How best to maintain a balance4. How to manage common anti thrombotic related bleeding complications
• Due to increasing number of elderly population, prevalence of thrombosis related complications and bleeding associated with anti thrombotic treatment is constantly rising.• There are various tools to assess thrombotic risk but assessment of bleeding risk is often ignored.
Antithrombotic therapy has revolutionized themedical management of patients.Over the past 20 years, the development of newantithrombotic medications and strategies hasreduced ischemic events very significantly.
YING - YANG PRINCIPLE• With every approach to reduce thrombosis, however, there is an accompanying risk of increasing bleeding complications .• Conversely, reducing bleeding complications may increase thrombotic (ischemic) events.
Thrombosis vs Bleeding• They both increase morbidity and mortality• Balancing both ends of the spectrum is essential, and an individualized approach to therapy is advocated.
Case Scenario• 50-year-old woman scheduled to undergo elective laparoscopic cholecystectomy – PMH : COPD – No personal or family history of VTE – Medications: Spiriva®, albuterol – Stopped smoking 1 year ago• What should we recommend for perioperative VTE prophylaxis in this patient?
Baseline Risk of VTEBahl et al. Ann Surg. 2010;251:344-350.
The Antithrombotic Therapy andPrevention of Thrombosis. ACCP Feb.2012• significantly impacted the more than 600 recommendations for the prevention, diagnosis, and treatment of thrombosis• DVT prophylaxis not for everybody• Risk stratification for VTE is recommended (many may receive unnecessarily)• Bleeding risk is to be assessed.
If the patient develops hemorrhagic stroke but high thrombotic risk Will you …..• 1.Stop all anticoagulant• 2.Use only prophylactic dose anticoagulant.• 3.IVC Filter• 4.Continue Oral anticoagulant maintaining low level INR
FACTORS INFLUENCING DECISION ON RE/COMMENCING AFTER ICH• Size of expanding haematoma• Time from onset of haemorrhage• Degree of INR rise• Radiological finding – ‘Spot Sign’
What do the guidelines say ?Initiation of anticoagulant after ICH – only if risk of thrombosis outweighs risk of bleeding.The European Stroke Initiative : 10-14 daysAmerican College of Cardiology : 7-10 daysAmerican College of Chest Physicians : LMWH next day. No clear guidelines on Oral anticoagulant.
Bleeding Risk Assessment Tools• 1.ACS – CRUSADE• 2. AF – HAS – BLED• 3.DVT/PE – Out Patient Bleeding Risk Index• 4.DVT- PE – IMPROVE• 5. DVT/PE – HEMORR2HAGES
THROMBOTIC AND BLEEDINGRISK ASSESSMENT IN ACUTECORONARY SYNDROME
Antiplatelet agents Aspirin– “No doctor, I am on no medication…”– Commonest cause of post op wound oozing– Ticlopidine– Dipyridamole– Clopidogrel– Prasugrel– Ticagrelor
Evolving Paradigm for Evaluating ACS Management Strategies Composite Adverse Event Endpoints► Angina ► Major Bleeding► MI ► Minor Bleeding ► Thrombocytopenia Ischemic Hemorrhag Complications e HIT
Predictors of Major Bleeding in ACS • Older Age • Female Gender Independent • Renal Failure Predictors of Major Bleeding • History of Bleeding in Marker Positive • Right Heart Catheterization Acute Coronary • GPIIb-IIIa antagonists Syndromes • Dual anti platelet • Use of anticoagulant • NSAIDS and COX2 InhibitorsMoscucci, GRACE Registry, Eur Heart J. 2003 Oct;24(20):1815-23.
Balancing Events and Bleeding Risk of events Risk of bleedingRisk Degree of Anticoagulation Hemostasis Thrombosis Two sides of the same coin
Bleeding in ACS Question to be answered:Does bleeding influence theprognosis of ACS patients ?
Major Bleeding Predicts Mortality in ACS 24,045 ACS patients in the GRACE registry, in-hospital death 40.0 P<0.001 30.0 22.8Patients (%) 18.6 No Bleed 20.0 16.1 15.3 Bleed 10.0 7.0 5.1 5.3 3.0 0.0 Overall Unstable NSTEMI STEMI ACS AnginaMoscucci M et al. Eur Heart J 2003;24:1815-23.
Warfarin therapy and Bleeding• Most serious complication of Warfarin• Common cause for litigation• Most common sites of serious bleeding: – Epistaxis and gum bleed – Soft tissue including wounds• Serious but less common sites of bleeding: _ Intracranial GIT
Incidence of Bleeding in Warfarin therapyFatal bleeding 0.1-1%(Bleeding is cause of death)Major bleeding 0.5-6.5%(GIT, retroperitoneal, intracranial orintra occular bleedingorany bleeding from an orifice + shock /needing transfusion or invasiveprocedure)Minor bleeding 6.2 - 21.8%
Management of Overanticoagulated patient on Warfarin: Serious or life-threatening Bleeding• Admit to Hospital (ICU) – urgent referral• Stop Warfarin temporarily• Local control of bleeding• Reversal of INR• Monitor INR 6 hrly and repeat Rx
Reversal of Anticoagulation• 1.Vitamin K (Several hours) – 5-10 mg I/V• 2.Fresh Frozen Plasma (few hours) 10-50 U/Kg• 3.Prothrombin Protein Complex ( minutes) – 10- 50 U/Kg• 4.Recombinant factor VII a (minutes) – 40-80 microgram/Kg
PERIOPERATIVE MANAGEMENT• Perioperative management of patients on warfarin or antiplatelet therapy involves assessing and balancing individual risks for thromboembolism and bleeding.• Discontinuing anticoagulant and antiplatelet therapy is usually necessary for major surgery but increases the risk of thrombotic events.
Managing Peri-operativeanticoagulant therapy : 3 Options• 1. Continue oral anticoagulant• 2. Stop therapy before surgery and re-start after surgery (eg. Low risk AF)• 3. Bridge therapy (eg. MVR, High risk AF, Recent VTE) Bridge therapy, is an effective means of reducing the risk of thromboembolism but may increase the risk of bleeding
How do I bridge ?• Bridging is use of heparin for a brief period (period between stopping and recommencing oral anti coagulant)• 1. Unfractionated Heparin• 2.Low Molecular Weight Heparin
Chronic anticoagulation and surgery – (Bridging) : RecommendationsStop Warfarin at least 5 days beforeStart UF Heparin or LMWH once INR less that 1.2Stop Heparin 6-24 hrs before surgeryStart Warfarin soon after surgeryStart Heparin after 24 hrs of surgery if no active bleedingStop Heparin once therapeutic INR is achieved
Patient Education• Why they have been prescribed anti platelet and anticoagulant.• Duration of treatment.• Advise on compliance• Importance of monitoring• Interaction with drugs and diet• Side effects /bleeding : when to seek medical attention
Take Home Message Anticoagulants are being under utilized due to fear of bleeding.• Assessment of bleeding risk must be objective with the use of bleeding risk tools.• Physicians must maintain a fine balance between thrombosis and bleeding• Antithrombotic agents are double edged swored that the physicians must chose carefully