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Case #1

Case #1. 83 year old male Mechanical aortic valve Hernia repair. Estimated Rates of Thromboembolism Associated with Various Indications for Oral Anticoagulation, and the Reduction in Risk Due to Anticoagulant Therapy. Kearon C and Hirsh J. N Engl J Med 1997;336:1506-1511. JGH protocol.

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Case #1

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  1. Case #1 • 83 year old male • Mechanical aortic valve • Hernia repair

  2. Estimated Rates of Thromboembolism Associated with Various Indications for Oral Anticoagulation, and the Reduction in Risk Due to Anticoagulant Therapy Kearon C and Hirsh J. N Engl J Med 1997;336:1506-1511

  3. JGH protocol 5000 u Fragmin for High risk bleeding procedures

  4. High Risk Bleeding Procedures Major Orthopedic Surgery Genitourinary surgery Neurosurgery Oacemaker insertion Vascular Surgery Endoscopy with possibility of biopsy Abdominal Hysterectomy Low Risk Bleeding Procedure Non-cancer Abdominal surgery Cholecystectomy Hernia Repair Node dissection Vaginal Hysterectomy Hand surgery Skin procedure Line insertion

  5. Case #2 • 76 year old female • Colonoscopy PMHx: AODM, HBP To bridge or not to bridge?

  6. Validation of Clinical Classification Schemes for Predicting StrokeResults From the National Registry of Atrial FibrillationBrian F. Gage, MD,MSc; Amy D. Waterman, PhD; William Shannon, PhD; Michael Boechler, PhD; Michael W. Rich, MD; Martha J. Radford, MDJAMA. 2001;285:2864-2870. CHADS2 CHF HBP Age>75 AODM CVA/TIA 2 points

  7. 2008 ACCP GUIDELINES 2.4. In patients with a mechanical heart valve or atrial fibrillationor VTE at high risk for thromboembolism, we recommend bridginganticoagulation with therapeutic-dose SC LMWH or IV UFH overno bridging during temporary interruption of VKA therapy (Grade1C); we suggest therapeutic-dose SC LMWH over IV UFH (Grade2C). In patients with a mechanical heart valve or atrial fibrillationor VTE at moderate risk for thromboembolism, we suggest bridginganticoagulation with therapeutic-dose SC LMWH, therapeutic-doseIV UFH, or low-dose SC LMWH over no bridging during temporaryinterruption of VKA therapy (Grade 2C); we suggest therapeutic-doseSC LMWH over other management options (Grade 2C). In patientswith a mechanical heart valve or atrial fibrillation or VTEat low risk for thromboembolism, we suggest low-dose SC LMWHor no bridging over bridging with therapeutic-dose SC LMWH orIV UFH (Grade 2C).

  8. ACCP RISK STRATIFICATION

  9. Case #3 • 43 year old male PMHx: 1996 idiopathic DVT 1999 secondary PE 2003 idiopathic DVT- On lifelong coumadin Due for carpel tunnel surgery repair

  10. CASE #4 • Intracranial bleed on 7W • 51 year old female- from France • Mechanical aortic valve • Presented with seizures secondary to an intracranial bleed- INR = 7.0

  11. Case #5 • 60 year old male • 1993 DVT • Lupus anticoagulant • Thyroid needle biopsy

  12. Estimated Rates of Thromboembolism Associated with Various Indications for Oral Anticoagulation, and the Reduction in Risk Due to Anticoagulant Therapy Kearon C and Hirsh J. N Engl J Med 1997;336:1506-1511

  13. 8(4%) patients had thrombotic events- 6 of them in patients who had to have their Anticoagulation stopped for postoperative bleeding. Kovacs et al, Circulation 2004;110:1658-1663

  14. CHADS 1 CIHR: PERIOP2

  15. NIH TRIAL- similar to PERIOP2 BUT PATIENTS ARE RANDOMIZED TO FRAGMIN vs PLACEBO FOR ENTIRE TRIAL- USING CHADS ≥ 1

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