Periprocedural management of oral anticoagulation: When and how to hit “pause”

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Applied Evidence

Periprocedural management of oral anticoagulation: When and how to hit “pause”

J Fam Pract. 2018 April;67(4):210-216,219-222

By

Nicole Hlavacek, PharmD Candidate

Drew McMillan, PharmD candidate

Jeremy Vandiver, PharmD, BCPS

Here’s how best to assess patients’ bleeding and thrombotic risks and 5 key questions to ask as you consider withholding oral anticoagulants.

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PRACTICE RECOMMENDATIONS

› Don’t stop oral anticoagulation for procedures with minimal bleeding risk, such as minor dermatologic, dental, or ophthalmic procedures. C

› Reserve periprocedural bridging with a parenteral anticoagulant for those patients on warfarin who are at highest risk for thromboembolism (those with severe thrombophilia, active thrombosis, or mechanical heart valves). B

› Stop direct oral anticoagulants 24 to 48 hours prior to most invasive procedures, and do not employ periprocedural bridging. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Connelly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361:1139-1151.

2. Steinberg BA, Kim S, Piccini JP, et al. Use and associated risks of concomitant aspirin therapy with oral anticoagulation in patients with atrial fibrillation: insights from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Registry. Circulation. 2013;128:721-728.

3. 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.

4. Adam SS, McDuffie JR, Ortel TL, et al. Comparative effectiveness of warfarin and newer oral anticoagulants for the long-term prevention and treatment of arterial and venous thromboembolism. Department of Veteran Affairs Evidence-Based Synthesis Project #09-010; 2012. Available at: https://www.ncbi.nlm.nih.gov/books/NBK97541/. Accessed October 15, 2017.

5. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and Expert Panel Report. Chest. 2016;149:315-352.

6. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol. 2014;64:2246-2280.

7. Centers for Disease Control and Prevention. Venous thromboembolism in adult hospitalizations — United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012 June 8;61:401-404. Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm. Accessed October 15, 2017.

8. Anderson FA, Wheeler HB, Goldberg HJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991;151:933-938.

9. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012;33:2451-2496.

10. Garwood CL, Korkis B, Grande D, et al. Anticoagulation bridge therapy in patients with atrial fibrillation: recent updates provide a rebalance of risk and benefit. Pharmacotherapy. 2017;37:712-714.

11. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation. J Am Coll Cardiol. 2017;69:871-898.

12. Douketis J, Tosetto A, Marcucci M, et al. Patient-level meta-analysis: effect of measurement timing, threshold, and patient age on ability of D-dimer testing to assess recurrence risk after unprovoked venous thromboembolism. Ann Intern Med. 2010;153:523-531.

13. Becattini C, Agnelli G, Schenone A, et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med. 2012;366:1959-1967.

14. Tosetto A, Testa S, Martinelli I, et al. External validation of the DASH prediction rule: a retrospective cohort study. J Thromb Haemost. 2017;15:1963-1970.

15. Rodger MA, Le Gal G, Anderson DR, et al. Validating the HERDOO2 rule to guide treatment duration for women with unprovoked venous thrombosis: multinational prospective cohort management study. BMJ. 2017;356:j1065.

16. Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I9-I16.

17. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 8th ed. Chest. 2008;133:381S-453S.

18. Spyropoulos AC, Douketis JD. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood. 2012;120:2954-2962.

19. Eisen GM, Baron TH, Dominitz JA, et al. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc. 2002;55:775-779.

20. Burnett AE, Mahan CE, Vazquez SR. Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis. 2016;41:206-232.

21. Witt DM, Clark NP, Kaatz S, et al. Guidance for the practical management of warfarin therapy in the treatment of venous thromboembolism. J Thromb Thrombolysis. 2016;41:187-205.

22. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373:823-833.

23. Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131: 488-494.

24. Clark NP, Witt DM, Davies LE, et al. Bleeding, recurrent venous thromboembolism, and mortality risks during warfarin interruption for invasive procedures. JAMA Intern Med. 2015;175;1163-1168.

25. Sjögren V, Grzymala-Lubanski B, Renlund H, et al. Safety and efficacy of bridging with low-molecular-weight heparin during temporary interruptions of warfarin: a register-based cohort study. Clin Appl Thromb Hemost. 2017;23:961-966.

26. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893-2962.

27. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S.

CASE 1

Debra P is a 62-year-old African American woman who calls your office to report that she has an upcoming routine colonoscopy planned in 2 weeks. She has been taking warfarin for the past 2 years for ischemic stroke prevention secondary to atrial fibrillation (AF), and her gastroenterologist recommended that she contact her family physician (FP) to discuss periprocedural anticoagulation plans. Ms. P is currently taking warfarin 5 mg on Mondays, Wednesdays, and Fridays, and 2.5 mg all other days of the week. Her international normalized ratio (INR) was 2.3 when it was last checked 2 weeks ago, and it has been stable and within goal range for the past 6 months. Her medical history includes AF, well-controlled hypertension, and type 2 diabetes mellitus, as well as gout and stage 3 chronic kidney disease. Ms. P denies any history of stroke or transient ischemic attack (TIA). She is requesting instructions on how to manage her warfarin before and after her upcoming colonoscopy.

CASE 2

Jerry Q is a 68-year-old Caucasian man with longstanding osteoarthritis who is scheduled to undergo a total left knee arthroplasty in one week. His orthopedic surgeon recommended that he contact his FP for instructions regarding managing apixaban perioperatively. Jerry has been taking apixaban 5 mg bid for the past 9 months due to a history of recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE) (both unprovoked). Mr. Q had been taking warfarin following his first DVT 4 years ago, but, after reporting that INR monitoring was a burden, he was started on apixaban. The patient has normal renal function and is relatively healthy otherwise. How should apixaban be managed before and after his upcoming surgery?

Each year, approximately 15% to 20% of patients taking an oral anticoagulant undergo a procedure that carries a heightened risk for bleeding.^1,2Stopping oral anticoagulation is often necessary before—and sometimes briefly after—many of these procedures in order to minimize the risk of bleeding.³ This means that countless decisions must be made by health care providers each year regarding if, when, and how to pause and resume oral anticoagulation. These decisions are not always straightforward, especially when you consider the risks for thrombosis and bleeding that are unique to the procedure and to the individual patient.

With these variables in mind, the health care provider must make decisions regarding anticoagulation during the periprocedural period based on the following 5 questions:

Will this patient need to have his/her oral anticoagulant stopped prior to the procedure?
If the patient’s oral anticoagulation needs to be held, when should it be stopped and for how long?
Will periprocedural bridging with a parenteral anticoagulant be necessary prior to the procedure?
When should the patient resume his or her oral anticoagulant after the procedure, and at what dosage?
Will bridging with a parenteral anticoagulant be necessary after the procedure?

Before addressing these 5 questions, though, physicians must assess patients’ thrombotic and bleeding risks.^4-6

Anticoagulant regimens and the risks of discontinuing them

The 2 most common indications for long-term oral anticoagulation are venous thromboembolism (VTE), which occurs in approximately one million Americans every year,^7,8 and stroke prevention in the setting of AF (AF occurs in 3-6 million US adults per year).⁶

Countless decisions must be made by health care providers each year regarding if, when, and how to pause and resume oral anticoagulation. And these decisions are not always straightforward.

Warfarin is also often used in patients with mechanical heart valves for long-term stroke prevention; however, direct oral anticoagulants (DOACs) are not recommended for patients with mechanical heart valves because trials have not yet demonstrated their safety or efficacy in this population.^4,5,9

Who’s at highest risk for an acute thromboembolic event?

When planning for interruptions in oral anticoagulation, it is important to identify patients at highest risk for an acute thromboembolic event. Patients with 10% or higher annual risk for VTE or ischemic stroke are generally placed into this high-risk category (TABLE 1^3,5,6,9-11).³ Keep in mind that the absolute risk for thromboembolism during a brief period of oral coagulation interruption is relatively low, even in those patients considered to be at high risk. Using a mathematical approach (although simplistic), a patient with a 10% annual risk for a thromboembolic event would have <0.3% chance for developing such an event in the acute phase, even if their anticoagulation was withheld for up to 10 days ([10%/365 days] × 10 days).

Patients with mechanical heart valves. Nearly all patients with a mechanical heart valve are at moderate to high risk for ischemic stroke.³

For patients with AF, the CHADS₂ and CHA₂DS₂-VASc scoring tools can be used to estimate annual thrombosis risk based on the presence of risk factors (TABLE 2^10,11).^6,9-11 It should be noted, however, that these scoring tools have not been validated specifically for periprocedural risk estimations. Nonetheless, the latest 2017 American College of Cardiology (ACC) guidelines recommend the use of the CHA₂DS₂-VASc scoring tool for making decisions regarding perioperative bridging in patients with AF.¹¹