Management of Antithrombotics with Procedures. Jordan Weinstein, MD

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1 Management of Antithrombotics with Procedures Jordan Weinstein, MD

2 Presenter Disclosure Information Cardiology Update 2013 I have no relevant financial interest and/or arrangement with industry.

3 Novel Oral Anticoagulants (NOA) and Procedures

4 New Anticoagulants and Procedures Not talking about warfarin, antiplatelets Dabigatran, rivaroxaban, apixaban (Edoxaban in future) Elective vs emergent

5 NOA Mechanism Direct Thrombin Inhibitor Dabigatran (pradaxa) Factor Xa Inhibitor RivaroXAban ApiXAban EdoXAban

6 Assessing Risk: To Bridge or Not To Bridge Bleed risk Thrombosis risk Withdrawal of anticoagulant? Hypercoagulable state Short half-life NOA Probably no need to bridge

7 Low Risk for Bleeding Dental procedures Some ophthalmologic procedures

8 High Risk for Bleeding Intracranial, intraspinal, intraocular, retroperitoneal, intrathoracic, pericardial Neuroaxial anesthesia

9 Risks of Thrombosis Atrial fibrillation CHADS2 and other scales

10 CHADS2 Risk Score CHF 1 Hypertension 1 Age > 75 1 Diabetes 1 Stroke or TIA 2

11 CHA2DS2-VASc Risk Score CHF or LVEF < 40% 1 Hypertension 1 Age > 75 2 Diabetes 1 Stroke/TIA/thromboembolism 2 Vascular Disease 1 Age Female 1

12 CHADS2 Score Patients (n = 1733) Adjusted stroke rate % / year

13 CHADS and Atrial Fib CHADS 3 or higher on warfarin Bridge recommended

14 CHA2DS2-VASc Score Patients (n = 7329) Adjusted stroke rate % / year

15 Weight the Risks/Benefits of Holding or Giving the Anticoagulant Easy Low bleed risk with high thrombosis risk AF/prior stroke (CHADS=5) going for dental work High bleed risk with low thrombosis risk AF (CHADS=0) going for partial liver resection

16 Weigh the Risks/Benefits of Holding or Giving the Anticoagulant Difficult Moderate-high bleed risk and high thrombosis risk AF/prior stroke (CHADS=5) patient going for partial liver resection

17 How Long to Hold NOA? Pharmacokinetics Does the drug need to be 100% cleared? Warfarin Usually hold 4-5 days (based on experience) INR < 1.5

18 Pharmacokinetics of NOA Drug Metabolism Half-life Dabigatran 80% renal hours (higher with renal disease) Rivaroxaban Combined 7 hours renal/hepatic Apixaban 25% renal 75% hepatic hours

19 Dabigatran Mostly renal metabolism Package insert CrCI > days CrCI < days Add more time if CNS/spinal procedures

20 Dabigatran Personal experience CrCl > 50 1 day CrCl days CrCl days For CNS/spinal procedures Add another day

21 Rivaroxaban Part renal/liver metabolism Package insert Hold for at least 24 hours

22 Rivaroxaban Personal experience Hold for 1 day For CNS/spinal procedures add 1 day

23 Apixaban Mostly hepatic metabolism Package insert Hold at least 24 hours for low risk bleed Hold at least 48 hours for moderate or high risk bleed

24 Apixaban Personal experience Hold 1 day for low risk bleed Hold 2 days for moderate or high risk bleed

25 Comparison Dabigatran Package insert CrCl > days CrCl < days JW CrCl > 50 1 day CrCl days CrCl days

26 Comparison Rivaroxaban Package insert Hold at least 24 hours JW 1 day

27 Comparison Apixaban Package insert Low risk bleed 24 hours Moderate or high risk bleed 48 hours JW Low risk bleed 1 day Moderate or high risk bleed 2 days

28 NEJM Review Article Management of Antithrombic Therapy in Patients Undergoing Invasive Procedures NEJM 2013; 368: NOA: since no true reversal agents, very conservatively added 1-2 more days to the package insert times?expose higher thrombosis risk

29 Emergent Time is on your side Kcentra (PCC, approved for warfarin) Dialysis (dabigatran) Reversal agent for factor Xa inhibitors in trials

30 Bridging Warfarin with NOA My experience Simpler with shorter half-life Extending proven treatment Time off anticoagulant less

31 When to Restart NOA Quick onset full anticoagulation Compare to warfarin Assess bleed risk

32 Conclusions Shorter half-life with NOA Allows less time off anticoagulant before and after surgery Be aware of differences in NOA when determining the above Be aware of resuming full anticoagulation with NOA post procedure/surgery

33 Questions?

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