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

Moderate / High /

Very High

Anticoagulation (warfarin)

WILL NOT need to be

interrupted *

Anticoagulation (warfarin) WILL

need to be interrupted

Classify Patient Risk of

Thromboembolism (TE)

(See Figure B)

Special Population

(VAD)

Low

Moderate

High

Bridging NOT

indicated*

Bridging MAY

be indicated*

Bridging IS

indicated

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

See VAD

bridging

guideline

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.

Figure

A

** It may

be necessary

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

requirements, target INR of 3.0 ¨C 4.0, supratherapuetic INR)

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

- At the Figure

discretion

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

Low Risk

?

?

?

Dental hygiene or single extraction

Selected dermatologic procedures (skin biopsy, skin cancer removal)

Cataract surgery

?

?

?

?

Arthroscopy

Central venous catheter removal

Electrophysiologic Testing

GI endoscopy without biopsy (colonoscopy,

cystoscopy, gastroscopy)

Joint or soft tissue injections

Uncomplicated dental procedures

?

Axillary node dissection

Dilation / curettage

GI endoscopy with biopsy (colonoscopy /

cystoscopy / gastroscopy)

Hemorrhoidal surgery

Minor intra-abdominal surgery (hernia

repair, hysterectomy, appendectomy, bowel

resection, cholecystectomy, polypectomy)

Dental surgery / Complex dental procedures

or multiple tooth extractions

?

?

?

?

?

?

?

Moderate Risk

?

?

?

High Risk

Very High Risk

?

?

?

?

?

?

?

Minor dermatologic procedures other

than above

Non-cataract ophthalmologic

procedures

Non-coronary angiography

Radial coronary angiography +/- PCI

Internal defibrillator / pacemaker

insertion

Minor intrathoracic surgery

Minor orthopedic surgery (hand, foot,

shoulder, carpal tunnel repair)

Minor vascular surgery

(endarterectomy, carotid bypass

surgery)

Sternotomy wire removal

Selective invasive procedures (bone

marrow aspirate / biopsy, lymph node

biopsy, thoracentesis, paracentesis,

arthrocentesis)

?

?

?

?

?

?

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)

?

?

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

Patient Thromboembolic Risk Classification

Indication for

Anticoagulation

Risk Factors

Bioprosthetic Heart

Valve

Mechanical Heart

Valve

? Atrial Fibrillation

? CHF

? HTN

? DM

? Age > 75

? Prior CVA / TIA

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 ¨C 74 (1 point)

? Vascular disease (1 point)

? Female (1 point)

Low Risk Criteria

Moderate Risk

Criteria

High Risk Criteria

? > 3 months after

placement

? Within first 3 months of

placement

? Bileaflet aortic

valve AND no risk

factors

? Medtronic Hall

tilting disc valve

? Prior thromboembolism

during interruption of

warfarin therapy

? Any mitral valve prosthesis

? Older caged-ball / tilting

disc aortic valve prosthesis

? CVA / TIA (within 6

months)

? CHADS2-VASc

score 0 to 4 AND

no prior CVA / TIA

? Bileaflet aortic

valve AND 1 or

more risk

factors

? CHADS2-VASc

score 5 to 6

? Consider Bridge

if CVA / TIA > 3

months

? Prior thromboembolism

during interruption of

warfarin therapy

? CHADS2-VASc score ¡Ý 7

? CVA / TIA (within 3

months)

? Rheumatic valvular heart

disease

Non-severe Thrombophilia:

? Heterozygous factor V

Leiden

? Prothrombin gene mutation

Venous

Thromboembolism

(VTE)

Special Populations

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

? Ventricular Assist Device

(VAD)

? 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

? 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

Pre-Procedural: BRIDGING

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)

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

Post Procedural: Resuming Anticoagulation

Agent

Procedural Bleeding Risk Classification

Very Low / Low

Moderate**

Warfarin

High / Very High

Very Low / Low

LMWH (Dalteparin

& Enoxaparin),

Fondaparinux, IV

UFH

Moderate**

High/ Very High***

When to Resume Anticoagulation*

Restart evening of procedure

Restart evening of procedure

Restart evening of procedure

* Resumption may be deferred 1-2 days if

concerned about bleeding risk

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.

2.

3.

4.

5.

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¨C898.

Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med

2015; 373:823.

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.

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.

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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