1 / 27

What is New for 2011:

What is New for 2011:. Anticoagulation in. Older Surgical Patients. Laurie G. Jacobs, MD. Professor of Clinical Medicine. Peri-Operative Anticoagulation. • New Anticoagulants • VTE prophylaxis. • Chronic anticoagulation for AF and implications for peri-operative care.

megara
Download Presentation

What is New for 2011:

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. WhatisNewfor2011: Anticoagulationin OlderSurgicalPatients LaurieG.Jacobs,MD ProfessorofClinicalMedicine

  2. Peri-Operative Anticoagulation •NewAnticoagulants •VTEprophylaxis •ChronicanticoagulationforAFand implicationsforperi-operativecare •Peri-operativemanagement

  3. PointsofAction ofAnticoagulants apixaban,rivaroxaban,edoxaban, otamixaban,betrixaban,YM150,TAK442 Xa X Warfarin Fondaparinux Heparin,LMWH Hirudin,bivalirudin, Argatroban,dabigatran Platelet activation Prothrombin(II) Fibrinogen Thrombin(IIa) Fibrin venous thrombosis arterial thrombosis

  4. NewOralAnticoagulants

  5. IndependentRiskFactors forFirstVTE RISKFACTOR Adj.pop.Attrib.risk* 95%CI Hospitalizationornursinghome Hospitalizationwithsurgery Hospitalizationwithoutsurgery Nursinghome Activemalignantneoplasm Trauma Congestiveheartfailure Priorcentralvenouscatheterorpacemaker Neurologicaldiseasew/extremityparesis Priorsuperficialveinthrombosis 58.8 23.8 21.5 13.3 18.0 12.0 9.5 9.1 6.9 5.4 53.4-64.2 20.3-27.3 17.3-25.6 9.9-16.8 13.4-22.6 9.0-14.9 3.3-15.8 5.7-12.6 3.5-10.2 3.0-7.7 HeitJA,etal.ArchInternMed.2002;162:1245-1248. *age,sex,yr

  6. RiskFactorsforVTE •Stasis • Advancedage •Hypercoagulability • Immobility(bedrest>4d) • • • • • • CHF,severeCOPD Stroke,paralysis,casting SpinalcordInjury Increasedviscosity Obesity Varicoseveins • • • • • • Advancedage Activecancer Highestrogenstates Thrombophilia Inflammatorystates Surgery • Increasedbloodviscosity •EndothelialDamage • Surgery,esp.orthopedic • PriorDVT,PE • Centrallines,devices • Trauma

  7. AgeDistributionof DVTPatients 30 HospitalizedMedicalPatients HospitalizedNonmedicalPatients 25 20 15 10 5 0 Percentage 1-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 >90 Age(years) PiazzaG,etal.Chest.2007;132:554-561.

  8. Peri-operative Hypercoagulability •VTEriskfactorsprevalentinsurgicalpatients •VTERiskis100Xgreaterthaninnon-operative period Plasminogenactivatorinhibitor-1 Hypercoagulability Stasis Endothelialdamage •“ReboundHypercoagulability”withdiscontinuation oforalanticoagulants thrombin-AT[TAT]complexes d-dimer prothrombinfragmentsF1&2 fibrinopeptideA factorVIII

  9. VTERisk&Prophylaxis GeertsWH.CHEST2008;133:381S

  10. DVTProphylaxis •Non-pharmacological Methods •Anticoagulants •Heparins –SCUFHeparin –LMWH –fondaparinux •Warfarin •Newagents: –FactorXainhibitors • • • • compressionstockings legelevation earlymobilization intermittentpneumatic compression •Footpumps –DirectThrombininhibitors

  11. VTEProphylaxisinTHR *Apixaban2.5mgpobid;12-24hpostop **Enoxaparin40mgsc12hpreop,thenpostop ADVANCE-3;pts.Followed60+daysafterlastdose LassenMR,etal.NEnglJMed2010:363:2487-98

  12. VTEProphylaxis: GeneralSurgeryBleedingRisk Prophylaxis Injectionsitebruising6.9% Woundhematoma5.7% Drainsitebleeding2.0% Hematuria1.6% GIbleeding0.2% Retroperitonealbleeding<0.1% Discontinuation2% Surgicalintervention0.7% Control 2.8% 0.8% 0.6% 0 1.9% 0 0 0.7% Meta-analysis:52RCTsVTEpx(33,813pts) LeonardiMJetal.ArchSurg2006;141:790-99.

  13. Indicationsfor ChronicAnticoagulation •ArterialDisease •Atrialfibrillation •RecurrentSystemic Embolism •MechanicalHeart Valves •Rheumaticmitral disease(&hxSE,AFor LAdiam.>5.5cm) •VenousDisease •ProphylaxisofVTE •SecondaryPrevention (Treatment)ofVTE –Deepvenous thrombosis –Pulmonaryembolism

  14. Warfarinv.Dabigatran forAFStrokeorSE(Re-Ly) RandomizedEvaluationofLongTermAnticoagulationTherapy Cumulative hazardrate months Dabigitran150mg;TTR44-70%;Reductionsincompositecardiovascularendpointsandmortality btwndabigatranandwarfarinareattenuatedbyINRcontrol ConnollySJetal.NEnglJMed2009;361:1139-1151

  15. Peri-OpDecision-Making: ChronicAnticoagulation BleedingRisk •Individualbleedingrisk •Surgicalriskforbleeding ThromboembolicRisk •Indication –Mechheartvalve –Atrialfibrillation –Venousthrombosis •Individualriskfactors •Surgicalriskfactors

  16. RiskStratificationfor Thromboembolism Geertsetal.Chest2001:119:132S-175S;Douketisetal.Chest2008;133:299-339

  17. Peri-OpAnticoagulation inNonCardiacSurgery Douketisetal.Chest2008;133:299-339

  18. Peri-operativeEvents withAnticoagulation •MechanicalHeartValveStudy1 •556pts/580procedures:372Ao,136Mitral,48multiple;warfarin d/c4-5daysprior,restartedafterhemostasis,bridging.At3mos: •0.9%thromboembolism •3.6%majorbleeding •nodifferencebwtnbridging,andtypeofac •GeneralSurgeryStudyofACPatients2 •603surgicalpatientsonwarfarin,themajorityofwhomdidnothave interruptionoftherapypriortosurgery •Peri-operativemajorbleeding9.5%(7.1–12.1) •Oddsratio1.6(0.4–4.0)ifINR3.0vs.2.0 1DanielsR,etal.ThrombRes2009;124:300-5;2TornMetal.BrJHaematol2003;123:676–82

  19. GuidelinesforSurgery onAC

  20. InterruptionofOral Anticoagulation: ElectiveSurgery •Discontinuewarfarin5dayspriortosurgery –mayneedtodiscontinueearlierwithmechanicalvalves asINRfallsfromagreaterlevel –INRfallsmoreslowlyintheelderly •CHECKINRbeforesurgery;INRfalls exponentiallywithwidevariabilitybetween patients,slowerwithage •IfINR>1.5pre-opday1-2,administer1–2mg oralvitaminK(comesas5mgtab,thuswould give½taborscdose) Douketisetal.Chest2008;133:299-339

  21. Resumptionof AnticoagulantTherapy •Mayresume12-24hourspost-op(eveningof,or dayafter)orwhenhemostasisisestablished •~48hrsrequiredforapartialanticoagulanteffect (INR>1.5) •Ifresumeatpatient’spriordose,~5.1+1.1days toachieveatherapeuticINR •Ifresumewithdoublepatient’susualdoseforday 1–2,atherapeuticINRisachievedat4.6days

  22. BridgeTherapy Pre-operativePeriod •Ifpre-opINR2-3,lastdosewarfarin5daysbeforesurgery (hold4doses); •Ifpre-opINR3-4.5(orelderly),lastdose6daysbefore surgery(hold5doses) •StartLMWH36hrsafterlastwarfarindose –Enoxaparin1mg/kgscorDalteparin100IU/Kgq12 –Lastdose½doseLMWH~24hpriortoprocedure •Writtenplanforpatient,internist,surgeon,anesthesiologist •Phonenumberforquestionsoranemergency Jafferetal.CCJM2003;70:973 WhiteRHetal.AnnInternMed1995;122:40-2

  23. BridgeTherapy Post-op •Afterdiscussionwithsurgeon,restartLMWH~24hrs post-operatively(withhemostaticcontrol) –fulldosesforminorsurgeries –prophylacticdosesforday1-2ifhighbleedingrisk •Afterdiscussionwithsurgeon,startwarfarinatpre-op doseonpost-opday1 •DailyPT/INRuntildischargeandperiodicallythereafter untilINRistherapeutic(ongoing) •CBCwithPlateletcountday3and7(HITscreening) •DiscontinueLMWHwhenINRisintherapeuticrangefor twoconsecutivedays(oftenINR2-3)

  24. LMWH&Regional Anesthesia(orAnalgesia) •Pre-operatively •Otheranticoagulantsheld(andclopidogrel,perhapsalso asa) •Needleplacement –12hrsafterprophylacticLMWH –24hrsafterLMWHifdose>1mg/kg •Post-operatively • • • • Indwellingcatheterremovedprior totwicedailyLMWH Removecatheter12-24hrsafterlastdoseLMWH FirstdoseLMWH2hrsaftercatheterremoval IfusingoncedailyLMWH,firstdose6-8hrspost-op, seconddose24hrslater HorlockerT.RegAnesthPainMed2003;28:172-97 ASRA.comAmericanSocietyofRegionalAnesthesiaandPainMedicine

  25. Anti-PlateletAgents andSurgery •Aspirin –Irreversiblyinhibitsplateletcyclooxygenase –Circulatingplateletpoolreplaced7–10days –Actswithinminutes •Clopidogrel(thienopyridines) –InhibitsADPreceptor-mediatedplateletactivationandaggregation –Stop7daysbeforesurgery –Mayrequireloadingonrestarting300-600mg;takes3–7daysto reachpeakanti-plateletaggregationactivityon75mgdose •NSAIDS –Reversiblyinhibitplateletcyclooxygenase;COX-2inhibitorshave lesseffect –Inhibitrenalprostaglandinsynthesissocanworsenrenalfailurewith otherdrugs

  26. AntiplateletAgentsand PerioperativeRisk •Cannoteasilymeasurebleedingriskwithantiplatelets •Individualvariabilityinbleedingriskwithantiplatelets •Iflowcardiacrisk,nostents,noncardiacsurgery,may electtostopASAorclopidogrel7–10dayspreop; resume24hrspostopwithadequatehemostasis •Forhighcardiacrisk,noncardiacsurgery,continueASA to,andaftersurgery •Forcardiacsurgery,orforpatientswithcoronarystents, consultcardiologyandguidelines(ACCP,ACC/AHA)

  27. NewAnticoagulants andSurgery •NewAgents •Maynotsubstantiallychangethromboticrisks; howeverifadherenceispoor,thismayincrease •Maynotsubstantiallychangebleedingrisk •Mayeliminatetheneedformonitoring •Mayeliminatetheneedforbridgingwhen patientscantakep.o.medications •Mayincreasethenumberofpatientsonchronic anticoagulationduetoeaseoftherapy

More Related