Indications for Perioperative Bridging Ann McBride, M.D. UW Anticoagulation Service

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Objectives Brief review of literature regarding bridgingBrief review of literature regarding bridging Identify risks of pt groups for increased risk of thromboembolism when warfarin is interruptedIdentify risks of pt groups for increased risk of thromboembolism when warfarin is interrupted Identify pts for whom bridging AC should be consideredIdentify pts for whom bridging AC should be considered Identify pt groups at increased risk for postoperative bleedingIdentify pt groups at increased risk for postoperative bleeding

PATIENT RISK FACTORSSURGICAL RISK FACTORS ThrombosisBleeding

1.Atrial fibrillation/flutter 2.MHV 3.VTE -PE, DVT Patients chronically anticoagulated

Dunn, Turpie 2003 overall events29/ overall CVA 7/

Periprocedural Bridging with LMWH Three Prospective Studies, PROSPECT 260 pts pre and post-op single dose enoxaparin major surgery (>1 hr), minor, inv. procedure Pts: high risk AF (~ 2/3) Previous DVT (~ 1/3)

Periprocedural Bridging with LMWH Three Prospective Studies, 2004 cont’d 2.Kovacs 224 pts pre-op single dose LMWH Post-op high risk bleed prophylactic LMWH Others single therapeutic Pts: MHV (~ ½) AF – high risk (~ ½) 3 month follow up

Periprocedural Bridging with LMWH Three Prospective Studies, 2004 cont’d 3.Douketis 650 pts Pre and post-op bid LMWH Pre-op LMWH bid Post-op high risk bleed—no LMWH Other – bid therapeutic dose

Results TE Events Major Bleeds 1.PROSPECT 4/260 (1.5%) 3.5% 2.Kovacs 8/224 (3.6%) (incl. 5 MI + 1 DVT) 6.7% 3.Douketis Non high risk bleeding Non high risk bleeding High risk bleeding High risk bleeding 2/542 (0.4%) 2/108 (1.8%) (deaths) 0.7% * (5.9%) 0.7% * (5.9%)1.8%

REGIMEN Registry Spyropoulos 2006 Major Bleeds 5.5% 3.3% TE Rate 2.4% 0.9%

Atrial Fibrillation Risk of Stroke in Patients with Atrial Fibrillation C H A D S2

Congestive Heart Failure (LV ejection less than 40%) Hypertension Age greater than 75 DiabetesStroke/TIA

CHADS Score % Annual CVA Risk % % %

Risk Stratification—Patients with Chronic Atrial Fibrillation Low—Bridging Optional CHADS score = 0 or 1 Moderate--? Bridging CHADS score=2-4 High—Bridging Recommended CHADS score =5-6 Recent (within 3 months) CVA/TIA Rheumatic Mitral Valve Disease

Thrombotic risk with prosthetic heart valves Mitral >> Aortic Position Caged ball > Tilting disc > Double wing valves Caged-ball valve Bjork-Shiley valve St. Jude valve Decreasing thrombotic risk Heit JA. J Thromb Thrombolysis. 2001;12:81-87.

Risk Stratification—Patients with Mechanical Heart Valves Low—Bridging Optional Bileaflet AV (St. Jude or CarboMedics) and less than 2 CVA risk factors Moderate—Bridging should be considered Bileaflet AV and more than 2 CVA risk factors (here Risk Factors refer to Atrial fibrillation, CHF, age greater than 75, HTN, DM) High—Bridging advised Mitral Valve Replacement Recent (within past 3 months) CVA/TIA Caged-ball (Starr-Edwards) or tilting disc AV (Bjork-Shiley, Medtronic)

Risk Stratification—Patients with VTE High—Bridging Strongly Recommended Recent episode of VTE (within past 3 months) Moderate—Bridging should be considered VTE within the past 6 months History of VTE after surgery Active Cancer—metastatic, recent treatment Prot C, Prot S, Antithrombin Deficiency Low—Bridging Optional None of these risk factors outlined above present **Pt with previous VTE recurrence when warfarin was interrupted

Postoperative Bleeding Risks Non-surgicalUremiaThrombocytopenia Coagulation Factor Deficiency Recent Bleed (i.e., GI)

Surgical Low—no interruption of OAC needed CataractDermatology Simple dental Joint and Soft Tissue Aspiration/Injection Laparascopic Cholescystectomy, Hernia Repair ***

Surgical, cont’d Moderate Screening Colonoscopy or Diagnostic EGD at UW Complicated Dental surgery Bronchoscopy Other Orthopedic Surgery Other intra thoracic surgery Other intra-abdominal surgery

Surgical, cont’d High Major vascular Permanent pacemaker Internal defibrillator Prostatectomy Bladder Tumor resection Lung resection Hip/Knee Joint Replacement Intestinal Anastomosis Bowel Polypectomy Kidney or Prostate Bx Cervical Cone Bx Bronchoscopy with Bx

Surgical, cont’d Very High Risk Intracranial Surgery CABG Heart Valve Spinal Surgery

Example of Patient Instructions Warfarin Holding/LMWH Plan for DateLovenoxMorningLovenoxEveningWarfarinDose Lab Test 2/03HOLDHOLDHOLD 2/04HOLDHOLDHOLD 2/05 70 mg HOLD 2/06 HOLD 2/07 HOLDHOLD INR and Platelets 2/08ProcedureHOLD 70 mg 4 mg 2/09 70 mg 4 mg 2/10 70 mg 4 mg 2/11 70 mg 4 mg 2/12 70 mg To be Determined INR and Platelets

Points to Consider If target INR , pt to be WITHIN target range at time of withholding warfarinIf target INR , pt to be WITHIN target range at time of withholding warfarin If INR = , after 3-4 warfarin doses held, INR level will be less than 1.5If INR = , after 3-4 warfarin doses held, INR level will be less than 1.5 Most surgeries/procedures can be performed reasonably safely when INR less than 1.5Most surgeries/procedures can be performed reasonably safely when INR less than 1.5 After surgery, when pt resumes warfarin, most pts resume their pre-op dose (some give loading dose, we tend not to). After 4 to 5 days of resuming warfarin, INR will typically be greater than 2.0After surgery, when pt resumes warfarin, most pts resume their pre-op dose (some give loading dose, we tend not to). After 4 to 5 days of resuming warfarin, INR will typically be greater than 2.0

Cases 75 yo pt atrial fibrillation—dental work75 yo pt atrial fibrillation—dental work 70 yo pt atrial fibrillation, no hx CVA/TIA—colonoscopy at UW70 yo pt atrial fibrillation, no hx CVA/TIA—colonoscopy at UW 82 yo MVR scheduled for cystocele repair82 yo MVR scheduled for cystocele repair 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopy50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopy 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopy, with protein C deficiency50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopy, with protein C deficiency

Cases, cont’d 44 yo M with unprovoked DVT RLE 4 yrs earlier; + heterozygous FV Leiden, scheduled for lap hernia repair44 yo M with unprovoked DVT RLE 4 yrs earlier; + heterozygous FV Leiden, scheduled for lap hernia repair 68 yo with atrial fibrillation and AVR scheduled for colonoscopy68 yo with atrial fibrillation and AVR scheduled for colonoscopy 65 yo met lung ca, DVT 9 months ago, scheduled for laparotomy65 yo met lung ca, DVT 9 months ago, scheduled for laparotomy 77 yo with atrial fibrillation, HTN, DM, CHF scheduled for prostate bx77 yo with atrial fibrillation, HTN, DM, CHF scheduled for prostate bx 77 yo with atrial fibrillation, HTN, CHF, DM, no hx TIA/CVA scheduled colonoscopy77 yo with atrial fibrillation, HTN, CHF, DM, no hx TIA/CVA scheduled colonoscopy