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Antiplatelets, Anticoagulants What are the consequences

Antiplatelets, Anticoagulants What are the consequences. Dr Jeremy Wright Cardiologist Hearts1st, Greenslopes Private Hospital. Outline. 2 clinical cases Overview of haemostasis Antiplatelet medications Anticoagulant medications Strategy for peri-procedural management. Case 1.

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Antiplatelets, Anticoagulants What are the consequences

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  1. Antiplatelets, AnticoagulantsWhat are the consequences Dr Jeremy Wright Cardiologist Hearts1st, Greenslopes Private Hospital

  2. Outline • 2 clinical cases • Overview of haemostasis • Antiplatelet medications • Anticoagulant medications • Strategy for peri-procedural management

  3. Case 1 • 86yo female • RCA stent 6 months ago • Hb 55, large colorectal cancer • Transfusion, staged anterior resection • Pre-op phone assessment advised stop Aspirin and Clopidogrel 1 week prior to surgery • Anterior resection performed • In recovery - chest pain and intermittent bradycardia

  4. Case 1 • Multiple VF arrests • Aspirated • Intubated • Angio showed stent thrombosis • IV heparin, eptifibatide • Prolonged stay in ICU • Discharged home 1 month later

  5. Case 2 • 83 yo female • 2 days post stent to LAD • Aspirin and Clopidogrel • Pleural effusion • Pleural tap requested to exclude empyema • Large haemothorax • Deceased despite resuscitation

  6. Haemostasis

  7. Haemostasis Antiplatelets Anticoagulants

  8. Antiplatelet medications • Aspirin • Cartia, Astrix, etc • Clopidogrel • Plavix, Iscover • Prasugrel • Effient • Ticagrelor • Brilinta • Fish Oil, Chinese Herbs • GP IIb/IIIa inhibitors – Reopro, Aggrastat

  9. Coronary Artery Stents • Three ‘Generations’ 1.) Bare Metal (BMS) 2.) Drug Eluting (DES) (first generation) 3.) Drug Eluting (DES) (second generation) • BMS require dual antiplatelet therapy for at least 1 month • DES require dual antiplatelet therapy for at least 6 months • Aspirin must continue

  10. Anticoagulants • Older agents • Oral: Warfarin • Injection: Heparin, Clexane, Danaparoid, Fondaparinux • New oral agents • Dabigatran (Pradaxa) • Rivaroxaban (Xarelto) • Apixaban (Eliquis) • New injection agents • Lepirudin (Refludan) • Bivalirudin (Angiomax) • Desirudin (Revasc)

  11. Time required for medications to wear off • Antiplatelets: 7 days • Warfarin: 5 days • Injections: 6-24 hours • New oral agents • Dabigatran (Pradaxa) 2 days if eGFR>50, otherwise 5 days • Rivaroxaban (Xarelto) 1-2 days • Apixaban (Eliquis) 1-2 days

  12. General Principles • Assess thromboembolic risk of stopping medication • Why taking the medication • How long ? • Previous bleeding problems • Assess bleeding risk associated with the procedure • Ultimate responsibility lies with the Dr performing the procedure, assisted by the referring Dr • Bridging medications may be required in some circumstances

  13. Confused? • CSANZ 2009 • Warfarin for prosthetic valves ?

  14. Confused? • Society of Interventional Radiology Consensus Guidelines • J Vasc Interv Radiol 2009; 20:S240-S249

  15. Take home messages • Critical to find out what the patient is taking – oral, SC, IV • There are many new medications • If not sure, look it up or ask • These decisions can be complex • Communication is the key

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