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Management of Anticoagulated Patients in Invasive Procedures

This article discusses the management of anticoagulated patients during invasive procedures, with a focus on a specific clinical scenario. It provides guidance on whether to continue or interrupt anticoagulation therapy and suggests alternative strategies.

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Management of Anticoagulated Patients in Invasive Procedures

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  1. Διαχείριση αντιπηκτικής αγωγής εν όψει προγραμματισμένων επεμβατικών πράξεων Γεώργιος Ντάιος Παθολογική Κλινική, Πανεπιστήμιο Θεσσαλίας

  2. Disclosures Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. Honoraria: Medtronic; Quintiles; CHUV; Belgian Stroke Council; Boehringer-Ingelheim. Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Elpen; Bayer Support to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica;Elpen; Bristol Myers Squibb. Participation in trials: • NAVIGATE-ESUS / Steering Committee member, National Coordinator (Greece) & Principal Investigator (Larissa) • PRECIOUS / National Coordinator (Greece) & Executive Committee member. • ENOS / National Coordinator (Greece). • FOURIER / Principal investigator (Larissa). • GLORIA-AF / Sub-investigator (Larissa). • EBBINGHAUS / Principal Investigator (Larissa). • BIOSIGNAL / Principal Investigator (Larissa). • PREVISE / Principal investigator (Larissa).

  3. Clinical scenario • ♂, 84yrs • Arterial hypertension on amlodipine • Atrial fibrillation on dabigatran • Cardioembolic stroke (2011) – full recovery • Deep venous thrombosis (right leg) 2009

  4. 13/09/2013 Cholangitis / Choledocholithiasis 21/12/2013 Cholecystectomy/ Stent insertion 30/01/2014 ERCP / Stent removal 23/09/2013 ERCP/ Sphincterotomy

  5. Question Continue with dabigatran, no need to interrupt it. Stop dabigatran5 days before the intervention and start it again 1 day after the intervention. Stop dabigatran1 day before the intervention and start it again 1 day after the intervention. Stop dabigatran 5 days before the intervention and continue with low-dose LMWH; switch back to dabigatran 1 day after the intervention. Stop dabigatran 5 days before the intervention and continue with high-dose LMWH; switch back to dabigatran 1 day after the intervention. Stop dabigatran 5 days before the intervention and continue with acenocoumarol; switch back to dabigatran 1 day after the intervention I don’t know, will ask Kostas Vemmos.

  6. 13/09/2013 Cholangitis / Choledocholithiasis 21/12/2013 Cholecystectomy/ Stent insertion 30/01/2014 ERCP / Stent removal 23/09/2013 ERCP/ Sphincterotomy 23/01/2014 Stop Dabigatran Ivor 2500x1 31/01/2014 Left hemiplegia Drowsiness

  7. Interventions in anticoagulated patients: not rare

  8. Interventions in anticoagulated patients: types Healey. Circulation. 2012;126:343-348

  9. Interventions in anticoagulated patients: not rare

  10. Interventions in anticoagulated patients: types Sherwood. Circulation. 2014;1850-59

  11. Estimate thromboembolic risk in AF: CHADS2

  12. Estimate thromboembolic risk in AF: CHA2DS2VASC

  13. Thrombotic risk in patients with mechanical valve Any mitral-valve prosthesis, any caged-ball or tilting-disk aortic-valve prosthesis, multiple mechanical heart valves, or stroke, TIA, or cardioembolicevent. Bileaflet aortic-valve prosthesis and atrial fibrillation. Bileaflet aortic-valve prosthesis without atrial fibrillation, prior stroke or thromboembolic event, or known intracardiacthrombus. Douketis. Chest 2012; 141(2)(Suppl):e326S–e350S

  14. Thrombotic risk in patients with VTE Venous thromboembolism within previous 3 months, severe thrombophilia, unprovoked VTE, or active cancer (cancer diagnosed ≤6 months or patient undergoing cancer therapy). Venous thromboembolism within previous 3–12 months, non-severe thrombophilia, or recurrent VTE. Venous thromboembolism >12 months previously and no other risk factor (e.g., provoked and transient). Douketis. Chest 2012; 141(2)(Suppl):e326S–e350S

  15. Major bleeding: definition • Major bleeding is generally defined as bleeding that is: • fatal, • intracranial, • requires surgery to correct, • lowers the hemoglobin by ≥2 g/dL, • or requires transfusion of ≥2 units packed red cells Schulman. J ThrombHaemost. 2005;3:692-4.

  16. Periprocedural bleeding risks: high-risk Spyropoulos. Blood 2012; 120:2954-62

  17. Baron. NEJM 2013; 368:2113-24

  18. Estimate bleeding risk in AF: HAS-BLED

  19. Bleeding vs. thromboemblicrisk

  20. Bridging VKA with LMWH Rio-Antirio bridge

  21. “ To bridge or not to bridge? ” Spyropoulos. Blood 2012; 120:2954-62

  22. “ To bridge or not to bridge? ” Siegal. Circulation. 2012;126:1630-1639

  23. “ To bridge or not to bridge? ” - bleeding Siegal. Circulation. 2012;126:1630-1639

  24. “ To bridge or not to bridge? ” – major bleeding Siegal. Circulation. 2012;126:1630-1639

  25. “ To bridge or not to bridge? ” – thromboembolism Siegal. Circulation. 2012;126:1630-1639

  26. “ To bridge or not to bridge? ”

  27. “ To bridge or not to bridge? ” Steinberg. Circulation. 2015;online early

  28. “ To bridge or not to bridge? ” Birnie. N Engl J Med 2013;368:2084-93

  29. “ To bridge or not to bridge? ” Birnie. N Engl J Med 2013;368:2084-93

  30. “ To bridge or not to bridge? ” Birnie. N Engl J Med 2013;368:2084-93

  31. “ To bridge or not to bridge? ” Birnie. N Engl J Med 2013;368:2084-93

  32. “ Do not bridge !!!! ” https://bridge.dcri.duke.edu/ Douketis. N Engl J Med 2015

  33. “ Do not bridge !!!! ” https://bridge.dcri.duke.edu/ Douketis. N Engl J Med 2015

  34. NOACs: New oral anticoagulants

  35. NOACs take over from VKAs Marzec, et al. Circulation 2015

  36. Pre-operative discontinuations of NOACs Heidbuchel. European Heart Journal 2013

  37. Postoperative resumption of NOACs Heidbuchel. European Heart Journal 2013

  38. NOACs & elective interventions www.vatspace.com(modified)

  39. Question Continue with dabigatran, no need to interrupt it. Stop dabigatran 5 days before the intervention and start it again 1 day after the intervention. Stop dabigatran1 day before the intervention and start it again 1 day after the intervention. Stop dabigatran 5 days before the intervention and continue with low-dose LMWH; switch back to dabigatran 1 day after the intervention. Stop dabigatran 5 days before the intervention and continue with high-dose LMWH; switch back to dabigatran 1 day after the intervention. Stop dabigatran 5 days before the intervention and continue with acenocoumarol; switch back to dabigatran 1 day after the intervention I don’t know, will ask Kostas Vemmos.

  40. Take-home messages

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