PeriOperative Management of Anticoagulation

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Peri-Operative Management of Anticoagulation

• Edward T. A. Fry, MD, FACC, FSCAI
• Director, Interventional Cardiology
• St. Vincent Hospital, Indianapolis
• The Heart Center of Indiana
• The Care Group, LLC

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Anticoagulation and Surgery

• Assess need to stop anticoagulation
• Passive vs active reversal
• Target INR pre-op
• Assess thromboembolic risk off vs bleeding risk
  on anticoagulation
• Need for Bridging pre- and post-op
• LMWH vs UFH

Bleeding Clotting
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Not All Procedures Require Discontinuation of
Anticoagulation
Low Risk of Bleeding Increased Risk of
Bleeding Cataracts Complex Ophthal.
Procedures EGD /- Bx ERCP / sphincterotomy Colo
noscopy /- Bx Polypectomy Most dental
procedures Oral Surg., Complex dentistry Skin Bx,
Mohs Plastic surgery Joint Aspiration Epidural
injection
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Risks of Thromboembolism off Anticoagulation
Cleveland Clinic J. Med 200370973

• Indication of anticoagulation, patient factors,
  time off therapy, /- reversal.
• High risk
• 1 year risk of ATE gt10 or 1 month risk of VTE gt
  10.
• Intermediate risk
• 1 year risk of ATE 5-10, 1 month risk of VTE
  2-10
• Low risk
• 1 year risk of ATE lt5, 1 month risk of VTE lt
  2

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Risks of Thromboembolism off Anticoagulation

• High Risk Need Bridging
• Hypercoaguable Protein C or S deficient, Factor
  V Leiden def., Anti-phospholipid Ab. Arterial or
  VTE lt 3 mo
• Valvular Dz Old mechanical valves, recent valve
  lt 3 mo, Mechanical MVR, MS with Afib
• Atrial Fib. Rheumatic Dz, Cardiac thrombus, AF
  with prior embolus, AF with other risks
• Intra-cardiac shunts

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Risks of Thromboembolism off Anticoagulation

• Intermediate risk Individualized Bridging
• gt 2 prior CVA / TIAs without risk of cardiac
  embolus.
• Low profile mechanical mitral valve
• Older mechanical AVR (eg Starr-Edwards)
• AF without prior ATE but with other risks
• VTE 3-6 month ago

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Risks of Thromboembolism off Anticoagulation

• Low Risk Bridging not necessary
• Low profile AVR
• Bioprosthetic valve
• Cerebrovascular Dz without recent CVA
• Single VTE gt 6 mo
• Atrial fibrillation without other risks

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Reversing Anticoagulation Pre-Op

• Passive Stopping Warfarin
• INR will fall to lt 1.5 in 5 days (longer if
  steady-state INR gt 3.0)
• Most procedures can be done if lt 1.5 (lt1.2 if
  neuosurgical or cardiothoracic)
• Reversal (Emergent)
• FFP Volume, Transfusion risks
• Vitamin K PO vs IV/SC
• Warfarin resistance
• Direct Thrombin Inhibitors - Ximelagatran

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Bridging with Enoxaparin Anticoagulation
Clinic

• Check baseline INR and CBC, stop warfarin 5-7
  days before scheduled procedure
• Check daily INR, check CBC 1 day pre-op
• When INR lt2.0, start Enoxaparin 1 mg/kg SC q12
  hrs. Hold 24 hrs before procedure.
• When acceptable post-op, resume previous
  maintenance dose of warfarin. Check INR qD
• Start Enoxaparin 1mg/kg SC q12 hrs, continue
  until INR gt2.0.

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Stent Patients on Clopidogrel

• Bleeding risk increased if within 5 days of last
  dose CURE
• Post-op risk of stent thrombosis (MI) upto 10 if
  off clopidogrel and ASA in first 6 wk
• Need for ASA/clopidogrel with DES may be upto 3
  months
• Risk of stent thrombosis is 10 for patients post
  stenting and coronary brachytherapy

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Be compulsive
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Resources

• Jaffer AK, et al. Cleveland Clinic J. of Med.
  200370973.
• Kearon C and Hirsch J, NEJM 19973361506
• Indiana Hemostasis and Thrombosis Center
• 317-871-0000
• TCG Pre-Op Evaluation Center
• 317-338-5050
• TCG Protime-Clinic