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

,; ,; ,

Applied Evidence

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

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

PDF Download

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.

DOACs. Consider the patient’s individual and procedural risks for bleeding when determining when to resume a DOAC postoperatively. That’s because unlike warfarin, which takes several days to take full effect, DOACs provide a nearly immediate anticoagulation effect.^20,21 For procedures that have a low bleeding risk, it is recommended to resume therapeutic anticoagulation 24 hours after the procedure has ended.^3,11,20 For procedures that have a high risk for bleeding, resumption of therapeutic anticoagulation should be delayed until 48 to 72 hours after the procedure has ended.^3,11,20

5. Is postoperative bridging with parenteral anticoagulation necessary?

Warfarin. If a patient was deemed to be at sufficient VTE risk to be bridged preoperatively, then that patient likely also should be bridged postoperatively, particularly if the surgery itself is associated with a heightened thrombotic risk. While warfarin can generally be resumed postoperatively the same day as the procedure, full therapeutic doses of a LMWH should not be initiated sooner than 24 hours postoperatively, and initiation should be delayed for 48 to 72 hours for procedures with the highest bleeding risk (such as neurosurgery).^3,11,21 Prophylactic doses of LMWH can generally be resumed as early as 12 hours postoperatively for procedures with high VTE risk (such as major orthopedic surgery).¹⁷

DOACs. In patients undergoing a procedure that carries both a high thromboembolic and high bleeding risk (such as major orthopedic surgery), initiation of a full-dose DOAC may need to be delayed for 2 to 3 days; however, more immediate VTE prophylaxis is usually necessary.^3,17 Prophylaxis after such procedures can begin 12 hours after the procedure with a low-intensity LMWH, which should be continued until it is deemed safe to resume full-intensity DOAC therapy.^3,17,18 If the patient is undergoing major orthopedic surgery, an FDA-approved prophylactic dose of a DOAC could be a temporary alternative to LMWH.²⁷

CASE 1

Ms. P’s upcoming colonoscopy may require a biopsy and would be classified as a procedure with low bleeding risk (per TABLE 3), so warfarin should be withheld prior to her procedure. You could check her INR 5 to 7 days before her colonoscopy to guide how many doses need to be withheld; however, given the patient’s tight INR control over the previous 6 months, you can assume her INR will be in goal range at that check. As a result, you recommend that she avoid an extra INR check and stop taking her warfarin 5 days prior to the colonoscopy.

Cohort studies involving patients taking warfarin for VTE, mechanical heart valves, or atrial fibrillation have failed to show a reduction in the incidence of thrombotic events with LMWH bridging.

Ms. P has a CHA₂DS₂VASc score of 3, which puts her at a relatively low risk for acute ischemic stroke over the next 1 to 2 weeks. Given the results of the BRIDGE trial, you recommend no parenteral bridging agent before or after her procedure. You also recommend that the patient resume her usual dose of warfarin the same day as her procedure (in the evening) unless her gastroenterologist recommends otherwise. You schedule her for a follow-up INR 5 to 7 days after her colonoscopy.

CASE 2

Mr. Q’s total knee arthroplasty (TKA)—a procedure associated with a high risk of bleeding—requires an interruption in his apixaban therapy. Additionally, he is at high risk for recurrent thromboembolism, given his history of recurrent, unprovoked DVTs; however, he is past the highest risk period (VTE within the past 3 months; his last one was 9 months ago). He is otherwise healthy and has normal renal function, so his apixaban should be withheld for a total of 4 doses (48 hours) prior to his procedure. He should resume his full dose of apixaban 48 to 72 hours after his procedure to minimize the risk for bleeding.

However, given that a TKA is a procedure associated with a high rate of postoperative VTE, initiate prophylactic anticoagulation (such as enoxaparin 40 mg subcutaneously daily or apixaban 2.5 mg PO bid) about 12 hours after the procedure and continue it until full-dose apixaban is resumed.

CORRESPONDENCE
Jeremy Vandiver, PharmD, BCPS, University of Wyoming School of Pharmacy, 1000 E. University Ave., Dept. 3375, Laramie, WY 82071; jvandive@uwyo.edu.