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Common Challenges of Anticoagulation Management ELIQUIS_PPT_Template_V1jz 1/30/2018 2:35:20 AM Common Challenges of Anticoagulation Management

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Cases Cessation of anticoagulation in a patient with an intracerebral bleed Peri-operative management and bridging of anticoagulation Patient switched to aspirin presents with a stroke Elderly patient with multiple co-morbidities Warfarin patient requiring multiple procedures Warfarin-stable patient

81 year old falls off mobility scooter, develops intracerebral bleed Case 1 81 year old falls off mobility scooter, develops intracerebral bleed History Non-valvular atrial fibrillation (NVAF), diabetic, excess alcohol, major compliance issues Initially commenced on warfarin 5 years ago, INR fluctuating between 1.2  and 4.0 Serious fall from mobility scooter resulting in an intracerebral bleed Warfarin ceased as perceived falls risk; health improved and alcohol consumption decreased Recommenced on NOAC (rivaroxaban) 2yrs ago via Webster Pak and daily nurse supervision Episode of severe peri-rectal bleeding dropping Hb to 90; colonoscopy not done due to comorbidities Now off all anticoagulants

In all cases (i.e. all patients at risk of falls) 81-year-old falls off mobility scooter, develops intracerebral bleed Audience interaction According to the 2016 European Society (ESC) guidelines for the management of AF, anticoagulation should only be withheld in patients at risk of falls: In all cases (i.e. all patients at risk of falls) In patients with severe uncontrolled falls (e.g. epilepsy or advanced multi system atrophy with backwards falls) In patients who have previously had an intracerebral bleed due to a fall In patients who do not want to receive an anticoagulant Correct answer B. Reference 1. 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: 2893-962. Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.

Return to Main Menu Discussion Case 1 81-year-old falls off mobility scooter, develops intracerebral bleed Audience discussion Falls are associated with increased mortality in AF. But there is no evidence that patients at high risk of falls are at increased risk of major bleeds.1,2 How do you currently manage AF patients requiring anticoagulation that are at falls risk? Discussion Reference 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: 2893-962. Banerjee A, Clementy N, Haguenoer K et al. Prior history of falls and risk of outcomes in atrial fibrillation: the Loire Valley Atrial Fibrillation Project. Am J Med 2014; 127: 972-8. Return to Main Menu Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. Banerjee A et al. Am J Med 2014; 127: 972-8.

80-year-old on NOAC requiring surgery Case 2 80-year-old on NOAC requiring surgery History 80-year-old male, chronic NVAF well controlled on apixaban Prostate obstructive symptoms, booked for transurethral resection of the prostate (TURP) NOAC ceased 48 hours pre-operatively, uneventful procedure. Day 2 post op, had small cerebral infarction Day 3 had arterial embolus in the left leg treated with embolectomy and fasciotomy in city Returns home on warfarin from major teaching hospital; no reason why this was the choice of anticoagulant

Comments on this course of action? Case 2 80 year old on NOAC requiring surgery Audience discussion Do we switch him back to a NOAC? Comments on this course of action? Return to Main Menu

Patient on aspirin presenting with stroke Case 3 Patient on aspirin presenting with stroke 68 year old female, CHA2DS2VASc = 2 Admitted to Emergency Department with non-valvular AF and congestive cardiac failure (CCF) Apixaban 5mg BD started Cardiologist switched to aspirin Subsequent admission with stroke

In male patients with a CHA2DS2-VASc score of 1 Case 3 Patient on aspirin presenting with stroke Audience interaction When is antiplatelet monotherapy recommended for stroke prevention in AF patients, according to 2016 the European Society (ESC) guidelines for the management of AF? In male patients with a CHA2DS2-VASc score of 1 In male or female patients without additional stroke risk factors Antiplatelet monotherapy cannot be recommended for stroke prevention in AF patients, regardless of stroke risk In female patients with a CHA2DS2-VASc score of 2 Correct answer C. Reference 1. 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: 2893-962. Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.

Return to Main Menu Discussion Case 3 Patient on aspirin presenting with stroke Audience discussion Do we switch AF patients on aspirin to an OAC? Discussion Return to Main Menu

Elderly patient with co-morbidities Case 4 Elderly patient with co-morbidities 84 year old hypertensive, very active male in NVAF In discussion with treating physician for >10 years regarding the potential benefit of anticoagulant, but patient not impressed with being on "rat poison" and needing monthly blood tests/finger pricks NOACs became available, he is convinced to commence apixaban Reviewed 1 month later, all ok Reviewed another 2 months later, had ceased apixaban as 2 episodes of epistaxis Patient unable to be convinced that he should recommence his NOAC

Return to Main Menu Discussion Case 4 Elderly patient with co-morbidities Audience discussion How do we manage an AF patient that refuses any anticoagulation? Discussion Return to Main Menu

74-year-old on warfarin requiring multiple procedures Case 5 74-year-old on warfarin requiring multiple procedures History 74-year-old male, paroxysmal non-valvular AF and pacemaker for conversion pauses, on warfarin Elective admission for permanent pacemaker (PPM) generator change. Stopped warfarin 7 days prior, heparin bridging when INR < 2. Surgery delayed due to a cardiothoracic surgery emergency Post-operative heparin infusion until INR > 2. Hematoma, discharged 8 days post admission Subsequent infection ~3 months later, device extracted. New device implanted Warfarin & bridging resulted in time in hospital and complications

Return to Main Menu Discussion Case 5 Patient on warfarin requiring multiple procedures Audience discussion OAC interruptions should be minimised to prevent stroke.1 Are we bridging NOAC patients undergoing cardiovascular interventions that could be performed safely on continued therapy? Discussion Reference 1. 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: 2893-962. Return to Main Menu Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.

70-year-old warfarin-stable patient Case 6 70-year-old warfarin-stable patient History 70-year-old male (farmer), paroxysmal non-valvular AF, on warfarin CHA2DS2VASc = 3; monthly INRs are stable Complained of not being able to have his green leafy vegetables from his own garden when in season – issue of dietary restriction Switched to NOAC (apixaban) No problems

Return to Main Menu Discussion Case 6 Stable warfarin patient Audience discussion According to the 2016 European Society of Cardiology (ESC) guidelines for the management of AF, a NOAC is recommended in preference to a vitamin K antagonist for patients eligible for anticoagulation1 . When should we consider switching a warfarin-stable patient to a NOAC? Discussion Reference 1. 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: 2893-962. Return to Main Menu Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.

End of presentation Q & A