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Peri-Operative anticoagulation /antiplatelet therapy A Shift in Paradigm

Peri-Operative anticoagulation /antiplatelet therapy A Shift in Paradigm. BMHGT 04/29/09. Balancing Thromboembolic and Bleeding Risks in the Perioperative Period. Thromboembolic risks: (1)Disease specific thromboembolic risks when discontinuing warfarin or ASA )stents

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Peri-Operative anticoagulation /antiplatelet therapy A Shift in Paradigm

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  1. Peri-Operative anticoagulation /antiplatelet therapyA Shift in Paradigm BMHGT 04/29/09

  2. Balancing Thromboembolic and Bleeding Risks in the Perioperative Period • Thromboembolic risks: (1)Disease specific thromboembolic risks when discontinuing warfarin or ASA )stents (2)Hypercoagulability associated with surgery. • Bleeding risks: (1) the patient (2) the use of anticoagulant/antiplatelet therapy (3) the surgery or procedure

  3. Thromboembolic risk when discontinuing OAC

  4. Bleeding Risks Patient: • Previous history of bleeding, especially with invasive procedures or trauma • Use of concomitant antiplatelet and nonsteroidal antiinflammatory medications. Procedure: • High :include major operations and procedures (lasting >45 minutes) • Low : include non-major operations and procedures (lasting <45 minutes) Perioperative anticoagulants: • 2-day period : 2 to 4% for major surgery 0 to 2% for non-major surgery.

  5. Warfarin • INR starts to fall at approximately 29 hours after the last dose of warfarin • A half-life of approximately 22 hours • It is reasonable to start bridging therapy approximately 60 hours after the last dose of warfarin.

  6. Perioperative bridging algorithm • Low risk of ATE or VTE: No heparin bridging preoperatively and only prophylactic doses of LMWH or UFH postoperatively in conjunction with resumption of warfarin.

  7. Low-molecular-weight-heparin (LMWH) • Allowed bridging therapy to be administered to outpatients. • Doses of LMWH that are recommended for treatment of venous thromboembolism are administered once or twice daily, generally for 3 days before surgery. • Required to determine whether the benefit of bridging therapy outweighs the associated risks of bleeding.

  8. Unfractionated heparin (UFH) Advantage: • A short half-life(60 minutes) • easily reversed (by protamine sulfate) Disadvantage: • Intravenous administration necessitates hospitalization before surgery, • Inconvenient and expensive.

  9. Perioperative bridging protocol Instructions regarding IV UFH use • 1. Should start at least 2 days prior to surgery at therapeutic dose using a validated, aPTT-adjusted, weight-based nomogram (ie, 80 U/kg bolus dose IV followed by a maintenance dose of 18 U/kg/h IV) • 2. Discontinue 6 hours prior to surgery • 3. Restart no less than 12 hours postoperatively at the previous maintenance dose once hemostasis is achieved • 4. Discontinue IV UFH when INR is in therapeutic range (1.9)

  10. Perioperative bridging protocol Instructions regarding LMWH use: • 1. Should start at least 2 days prior to surgery at BID therapeutic dose (ie, enoxaparin 1 mg/kg SC BID or dalteparin 100 IU/kg SQ BID) • 2. Discontinue at least 12 hours prior to surgery (if surgery is in early A.M. consider holding previous evening dose) • 3. Restart usual therapeutic dose within 12–24 hours after surgery once hemostasis is achieved • 4. Discontinue LMWH when INR in therapeutic range (1.9)

  11. Perioperative bridging protocol Instructions regarding warfarin use: • 1. Stop warfarin at least 4 days prior to surgery • 2. Check INR 1 day prior to surgery If 1.5, proceed with surgery If 1.5 to 1.8, consider low-level reversal with Vitamin K If 1.8, recommend reversal with Vitamin K (either 1 mg SC or 2.5 mg PO) • 3. Recheck INR day of surgery • 4. Restart maintenance dose of warfarin the evening of surgery • 5. Daily INR until in therapeutic range (1.9)

  12. Recommendations The Seventh American College of Chest Physician Consensus Conference: • Intermediate risk of thromboembolism－prophylactic (or higher) dose UFH or LMWH as perioperative bridging therapy • High risk of thromboembolism－ full-dose UFH or LMWH • Low risk of bleeding－ Continue warfarin therapy at a lower dose to maintain an INR of 1.3 to 1.5.

  13. Orthopedic surgery in patients with coronary stents • Bare metal stents • Drug eluted stents (sirolimus/pacltaxel) • Dual antiplatelet therapy recommended for 12 months • Life long ASA in low bleeding risk pts • 45% mortality on stopping ASA (without surgery)_- • Heparin does not prevent stent thrombosis

  14. Current recommendations • Assess stent thrombosis risk • Defer surgery (bare metal one month; 12 month for drug eluted ) • Do not stop ASA; use coumadin with ASA for VTE prophylaxis (never ASA alone) • Assess resources to revitalize thrombosed stent in hospital ( very high mortality)

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