Perioperative management in patients with risk for thrombosis Sabine Eichinger Dept. of Medicine I Medical University of Vienna, Austria
Perioperative Management Bleeding risk Thrombotic risk Stop antithrombotics Bridging
Atrial Fibrillation Risk of cerebral infarction CHADS 2 Risk/year Non surgical (%) 0 1.9 (1.2-3.0) 1 2.8 (2.0-3.8) 2 4.0 (3.1-5.1) 3 5.9 (4.6-7.3) 4 8.5 (6.3-11.1) 5 12.5 (8.2-17.5) 6 18.2 (10.5-27.4) Kaatz, J Thromb Haemost 2010
Atrial Fibrillation Risk of cerebral infarction CHADS 2 Risk/year Non surgical (%) 30 days postoperative (%) 0 1.9 (1.2-3.0) 1.01 (0.83-1.21) 1 2.8 (2.0-3.8) 1.62 (1.46-1.79) 2 4.0 (3.1-5.1) 2.05 (1.87-2.24) 3 5.9 (4.6-7.3) 2.63 (2.26-3.04) 4 8.5 (6.3-11.1) 3.62 (2.66-4.80) 5 12.5 (8.2-17.5) 3.65 (1.83-6.45) 6 18.2 (10.5-27.4) 7.35 (2.42-16.3) Kaatz, J Thromb Haemost 2010
Anticoagulation and perioperative management Low bleeding risk Tooth extraction Root canal procedures Small skin excisions Endoscopic procedures with low bleeding risk Cataract surgery Minor bleeding: OR 3.3 (95% CI 1.7-6.2); Jamula, Thromb Res 2009 Perioorbital bleeding and retrobulbar anesthesia: 1/136 (<1%) Katz, Ophthalmology 2003 Dunn, Arch Intern Med 2003
Anticoagulation and perioperative management High bleeding risk Intracranial or intraspinal surgery Coronary artery bypass Major vascular surgery Major orthopedic surgery Major cancer surgery Reconstructive plastic surgery Urogenital surgery Colonpolypectomie (particularly > 1 cm Ø) Prostate- or kidney biopsy
Thromboembolic risk categories Thromboembolic Risk Atrial Fibrillation Mechanical Heart Valves Venous Thromboembolism High CHADS 2 5,6 Mitral valve Older aortic valve (caged-ball, tilting disk) Stroke/TIA < 3 mo VTE < 3 mo Moderate CHADS 2 3,4 Bileaflet aortic valve + risk factor VTE > 3-12 mo Low CHADS 2 0-2 Bileaflet aortic valve w/o risk factor VTE > 12 mo Douketis, Blood 2011
Thromboembolic risk categories Thromboembolic Risk Bridging High YES Moderate Low NO Douketis, Blood 2011
Bridging Thromboembolic Risk Bridging High LMWH therapeutic Moderate Low LMWH therapeutic LMWH low dose none Douketis, Blood 2011
Anticoagulation and perioperative management Practical advice Do not stop VKA too early
Discontinuation of VKA PREOPERATIVE MANAGEMENT Stop warfarin Stop acenocoumarol THROMBOPROPHYLAXIS NO VKA Days -6-5 -4-3 -2-1 0P Check INR if < 1.5: surgery possible Check INR if >2.0: 6-10 mg vit. K p.o. Check INR if >2.0 (>2.5): check daily if <2.0 (<2.5): LMWH (except low thrombotic risk)
Anticoagulation and perioperative management Practical advice Do not stop VKA too early Last therapeutic dose of LMWH 24 h before surgery
Discontinuation of VKA POSTOPERATIVE MANAGEMENT THERAPEUTIC LMWH DOSE High/moderate THROMBOTIC RISK PROPHYLACTIC STOP LMWH IF INR >2.0 RESUME VKA DAYS 0P +1 +2 +3 +4 +5 +6 RESUME VKA Low THROMBOTIC RISK USUAL THROMBOPROPHYLAXIS STOP LMWH IF INR >2.0
Anticoagulation and perioperative management Practical advice Do not stop VKA too early Last therapeutic dose of LMWH 24 h before surgery Resume therapeutic LMWH not before 48 h postop.
Heparin bridging bleeding risk All patients N=224 Heart valves N=112 AFIB N=112 Major bleeding 15 (6.7%) 8 (7.1%) 7 (6.3%) intraoperative 8 (3.6%) 4 (3.6%) 4 (3.6%) <7 T postop. 5 (2.2%) 4 (3.6%) 1 (0.9%) Kovacs, Circulation 2004 Low bleeding risk N=542 High bleeding risk N=108 All patients N=650 Major bleeding 0.74% 1.85% 0.92% Douketis, Arch Intern Med 2004
Bridging bleeding risk Group TE Events % (95% Cl) Major Bleeding % (95% Cl) Overall Bleeding % (95% Cl) Bridged cohort 0.9% (0.0-3.4) 4.2% (0.0-11.3) 13.1% (0.0-45.2) LMWH dose therapeutic prophylactic/ intermediate 0.4% (0.0-0.9) 0.2% (0.0-0.6) 3.2% (1.3-5.2) 3.4% (0.0-8.7) 13.6% (2.9-24.3) 8.5% (2.9-14.2) Nonbridged cohort 0.6% (0.0-1.2) 0.9% (0.2-1.6) 3.4% (1.1-5.8) Siegal, Circulation 2012
Clinically significant device-pocket hematoma Birnie, N Engl J Med 2013
Anticoagulation and perioperative management Practical advice Do not stop VKA too early Last therapeutic dose of LMWH 24 h before surgery Resume therapeutic LMWH not before 48 h postop. LMWH bridging preoperatively only in patients at high thrombotic risk
Anticoagulation and perioperative management Practical advice Do not stop VKA too early Last therapeutic dose of LMWH 24 h before surgery Resume therapeutic LMWH not before 48 h postop. LMWH bridging preoperatively only in patients at high thrombotic risk VKA postoperative: start low - go slow
Perioperative Management D i r e c t or a l OP a n t i c o a g u l a n t s Stop Start
DOAC and perioperative management Low bleeding risk Do not stop DOAC Perform intervention at trough level OD dosing: halt morning dose until after intervention BID dosing: miss morning dose
Dabigatran, Apixaban Low bleeding risk day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3 Rivaroxaban day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3 P R E O P E R A T I V E P O S T O P E R A T I V E
Dabigatran perioperative management Elective surgery/interventions Renal function (CrCl in ml/min) Half life Last intake before surgery High bleeding risk or major surgery Standard risk 80 ~ 13 h >48 h >24 h 50 to < 80 ~ 15 h >72 h >36 h 30 to < 50 ~ 18 h >96 h >48 h EHRA guidelines, Heidbuchel, Eur Heart J 2013
Rivaroxaban, Apixaban perioperative management Elective surgery/interventions Renal function (CrCl in ml/min) Last intake before surgery High bleeding risk or major surgery Standard risk 80 >48 h >24 h 50 to < 80 >48 h >24 h 30 to < 50 >48 h >24 h 15 to < 30 >48 h >36 h EHRA guidelines, Heidbuchel, Eur Heart J 2013
Rivaroxaban perioperative management High bleeding risk day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3 P R E O P E R A T I V E P O S T O P E R A T I V E usual thromboprophylaxis
Direct oral anticoagulants Restart after surgery Not licensed for postoperative thromboprophylaxis except for elective hip/knee replacement. Immediate and complete hemostasis resume DOAC after 6-8 hours. Maximum concentration within 2-3 h. Start therapeutic dose not before 48-72 h postop. Use LMWH at prophylactic dose until safe to use therapeutic dose.
RE-ly dabigatran in atrial fibrillation Periprocedural bleeding 100 90 80 70 20 15 D110 D150 Warfarin % Cases 60 50 40 30 20 10 5 0 minor major reoperation transfusion 10 0 minor major reoperation transfusion Healey, Circulation 2012
RE-ly dabigatran in atrial fibrillation Periprocedural thromboembolism % Cases 100 90 80 70 60 50 40 30 1 0,8 0,6 0,4 0,2 D110 D150 Warfarin 20 10 0 CV death stroke 0 CV death stroke Healey, Circulation 2012
Direct oral anticoagulants perioperative management Practical advice Prescribe DOAC exactly as licensed Check contraindications Dose according to indication an renal function check renal function and ensure proper diuresis Collect standardized bleeding and thrombotic history Lower dose in case of higher bleeding risk Use platelet function inhibitors together with DOAC with caution Avoid long acting NSARs No preoperative heparin bridging