Guideline for Peri-Procedural Anticoagulation and Bridging ...

Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin

** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **

Classify Procedural Risk of Bleeding

(See Figure A)

Very Low / Low

Anticoagulation (warfarin) WILL NOT need to be interrupted *

Moderate / High / Very High

Anticoagulation (warfarin) WILL need to be interrupted

Classify Patient Risk of Thromboembolism (TE)

(See Figure B)

Low

Bridging NOT indicated*

Moderate

Bridging MAY be indicated*

High

Special Population (VAD)

Bridging IS indicated

See VAD bridging guideline

Discontinue warfarin 5 days before procedure **

Resume warfarin postprocedure based on

procedural risk of bleeding

(See Figure D)

Discontinue warfarin 5 days before procedure **

Clinical judgement should be used to balance the risk of bleeding and clotting to determine if patient should be bridged

or not.

No Bridge

Bridge

Discontinue warfarin 5 days before procedure **

(See Figure C for PreProcedural Bridging)

Resume warfarin/ LMWH post-procedure based on procedural risk of bleeding

(See Figure D)

* For patients NOT requiring warfarin interruption, INR should be checked prior to procedure to ensure not supratherapeutic. For more complex dental procedures, it may be appropriate to hold 1-2 doses if risk of TE is low.

** It maFyigbuerneeAcessary to hold warfarin longer than 5 days for select patient populations (e.g. elderly, liver dysfunction, low dose

requirements, target INR of 3.0 ? 4.0, supratherapuetic INR)

- At the FdiisgcureretioAn of the MD performing the procedure, it may be appropriate to check an INR the day before procedure to

ensure INR is at baseline. If INR is greater than 1.5, a small dose of Vitamin K may be considered - Even in the scenario that "bridging" is not indicated, post-procedure DVT prophylaxis should still be considered in procedures that require routine prophylaxis

Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin

** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **

Figure A

Procedural Bleeding Risk Classification*

Very Low Risk

Dental hygiene or single extraction Selected dermatologic procedures (skin biopsy, skin cancer removal)

Cataract surgery

Low Risk

Arthroscopy Central venous catheter removal Electrophysiologic Testing GI endoscopy without biopsy (colonoscopy,

cystoscopy, gastroscopy) Joint or soft tissue injections Uncomplicated dental procedures

Minor dermatologic procedures other than above

Non-cataract ophthalmologic procedures

Non-coronary angiography

Radial coronary angiography +/- PCI

Internal defibrillator / pacemaker

insertion

Axillary node dissection

Minor intrathoracic surgery

Dilation / curettage

Minor orthopedic surgery (hand, foot,

GI endoscopy with biopsy (colonoscopy /

shoulder, carpal tunnel repair)

cystoscopy / gastroscopy)

Minor vascular surgery

Moderate Risk Hemorrhoidal surgery Minor intra-abdominal surgery (hernia

(endarterectomy, carotid bypass surgery)

repair, hysterectomy, appendectomy, bowel Sternotomy wire removal

resection, cholecystectomy, polypectomy) Selective invasive procedures (bone

Dental surgery / Complex dental procedures

marrow aspirate / biopsy, lymph node

or multiple tooth extractions

biopsy, thoracentesis, paracentesis,

arthrocentesis)

High Risk

Intestinal anastomosis surgery Major vascular surgery (abdominal aortic aneurysm repair, aortofemoral bypass) Major urologic surgery (prostatectomy, bladder tumor resection) Major lower limb orthopedic surgery (hip replacement, knee replacement) Major thoracic surgery (lobectomy, pneumonectomy) Selected invasive procedures (renal biopsy, lung biopsy, hepatic biopsy, prostate biopsy,

cervical cone biopsy, pericardiocentesis, colonic polypectomy)

Very High Risk Cardiac surgery (coronary artery bypass, heart valve replacement, heart transplantation) Neurosurgery (intracranial or spinal surgery)

* To estimate the risk of bleeding for a specific procedure not included above consider the following: procedures that are likely to incur a higher risk of bleeding include those in a closed area/cavity as well as highly complex or invasive procedures, those involving a large surface area and procedures expected to result in a large amount of inflammation.

Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin

** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **

Figure B

Indication for Anticoagulation

Bioprosthetic Heart Valve

Patient Thromboembolic Risk Classification

Risk Factors

Low Risk Criteria

Moderate Risk Criteria

High Risk Criteria

> 3 months after placement

Within first 3 months of placement

Mechanical Heart Valve

Atrial Fibrillation CHF HTN DM Age > 75 Prior CVA / TIA

Bileaflet aortic valve AND no risk factors

Medtronic Hall tilting disc valve

Bileaflet aortic valve AND 1 or more risk factors

Prior thromboembolism during interruption of warfarin therapy

Any mitral valve prosthesis Older caged-ball / tilting

disc aortic valve prosthesis CVA / TIA (within 6

months)

Atrial Fibrillation

CHADS2-VASc Score CHF (1 point) HTN (1 point) DM (1 point) Prior CVA / TIA / TE (2

points) Age > 75 (2 point) Age 65 ? 74 (1 point) Vascular disease (1 point) Female (1 point)

CHADS2-VASc score 0 to 4 AND no prior CVA / TIA

CHADS2-VASc score 5 to 6

Consider Bridge if CVA / TIA > 3 months

Prior thromboembolism during interruption of warfarin therapy

CHADS2-VASc score 7 CVA / TIA (within 3

months) Rheumatic valvular heart

disease

Venous Thromboembolism

(VTE)

Non-severe Thrombophilia: Heterozygous factor V

Leiden Prothrombin gene mutation

Severe Thrombophilia: Deficiency of antithrombin Protein C or S deficiency Homozygous factor V

Leiden Antiphospholipid antibody

syndrome Heterozygous factor V

Leiden in addition to Prothrombin gene mutation

Single VTE more than 12 months ago AND no other risk factors

VTE within past 3 to 12 months

Non-severe thrombophilia

Recurrent VTE

Prior thromboembolism during interruption of warfarin therapy

Active cancer Less than 3 months since

VTE Severe thrombophilia

Special Populations

Ventricular Assist Device (VAD)

See VAD Bridging Guideline

Note: Previous literature and current guidelines historically risk-stratified patients using CHADS2, however CHADS2-VASc has since been validated and adopted into clinical practice

Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin

** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **

Figure C

Agent Therapeutic LMWH (Dalteparin &

Enoxaparin), dosed Q 12 Hours Therapeutic LMWH (Dalteparin &

Enoxaparin), dosed Q 24 Hours Prophylactic LMWH (Dalteparin &

Enoxaparin), dosed Q 24 Hours Fondaparinux*

IV Unfractionated Heparin (UFH)

Pre-Procedural: BRIDGING

When to Initiate

When to Discontinue**

Give last dose 24 hours prior to procedure

24 to 48 hours after last dose of warfarin (based on INR)

Give last dose 24 hours prior to procedure

Give last dose 12-24 hours prior to procedure Give last dose 36-48 hours prior to procedure Discontinue 4-6 hours prior to procedure

Note: For dosing recommendations, please refer to the drug specific DAG

* There is limited data to support bridging with Fondaparinux; however, this is the drug of choice for patients with Heparin-Induced Thrombocytopenia ** Time between last dose of parenteral agent and procedure may need to be extended in patients with renal dysfunction or if regional anesthesia is required. Please see the BWH Regional Anesthesia in Anticoagulated Patients guidelines for more information.

Figure D

Agent

Warfarin

LMWH (Dalteparin & Enoxaparin), Fondaparinux, IV UFH

Post Procedural: Resuming Anticoagulation

Procedural Bleeding Risk Classification

When to Resume Anticoagulation*

Very Low / Low

Restart evening of procedure

Moderate** High / Very High

Restart evening of procedure Restart evening of procedure * Resumption may be deferred 1-2 days if concerned about bleeding risk

Very Low / Low Moderate**

High/ Very High***

Restart 12-24 hours after Procedure Patient risk for TE = Moderate * Restart 24-48 hours after procedure Patient Risk for TE = High * Restart 24 hours after procedure Patient risk for TE = Moderate * Do not restart LMWH Patient Risk for TE = High * Restart 48-72 hours after procedure

* Hemostasis should be established prior to resumption of any anticoagulation ** Warfarin resumption after procedures thought to have moderate bleeding risk may be deferred for 1-2 days at the discretion of MD if unexpected perioperative bleeding occurs *** For patients at high / very high risk, it may be appropriate to resume LMWH or IV UFH therapy 24 hours after the procedure

- Even in the scenario that "bridging" is not indicated, post-procedure DVT prophylaxis should still be considered in procedures that require routine prophylaxis

- For Moderate risk TE patients with a Moderate procedural bleeding risk: a prophylactic LMWH dose may be used to bridge post-procedure to reduce the risk of bleeding even if therapeutic dose LMWH is used prior to procedure

- For High risk TE patients with a High procedural bleeding risk other options include: o Post-procedure bridging with prophylactic LMWH until bleeding risk minimized then transition back to therapeutic dose LMWH o Post-procedure bridging with prophylactic LMWH only o Resumption of warfarin alone with no LMWH/IV UFH

- Restart warfarin with 15-20% increase of previous maintenance dose & retest INR within 3-4 days

Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin

** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **

- Due to lack of evidence for preventing arterial TE, some clinicians wouldn't consider Prophylactic LMWH after surgery unless part of routine VTE prophylaxis References:

1. Doherty, J.U., Gluckman, T.J., Hucker, W.J. et al, 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017;69:871?898.

2. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015; 373:823.

3. Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012.

4. Olesen JB, Lip GYH, Hansen ML, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: Nationwide cohort study BMJ. 2011.

5. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-e350S. doi:10.1378/chest.11-2298.

Approved by Pharmacy and Therapeutics Committee: 11/2017

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