1. Mike Kolber BSc, MD, CCFP, MSc AAPCE Nov. 3, 2012

2. Conflict of Interest  Family physician with additional skills GI medicine training  Funded U of A Department of Family Medicine  Research and Speaking Fees Non-Profit Sources (ACFP, PCN etc) No funding from Industry

4. Life is a risk / benefit calculation

5. Endoscopy is a risk / benefit calculation

6. Anticoagulants and Antiplatelets  Procedure: Assume performing a polypectomy  Meds: and why? ASA: 1’ or 2’ CV prevention (NSAIDs) Clopidogrel: 2’ CV prevention Coumadin: AF, VHD, VTE treatment NOACs: Dabi, Riva, Apixa

7. Anticoagulants and Antiplatelets  Risks of stopping vs continuing agents?

8. Case 1: Mr. A.E. Newman  A 60 yo AF on warfarin booked for colon for rectal bleeding.  No PHx of CVA, or CHF, but DM+ and hypertensive.  What is your peri-operative anti- coagulation strategy?

9. Case 1: Mr. A.E. Newman A. Continue coumadin through procedure B. Discontinue coumadin 7 days prior and BRIDGE with LMWH C. Discontinue coumadin 7 days prior WITHOUT BRIDGING D. Discontinue coumadin 5 days prior and BRIDGE with LMWH E. Discontinue coumadin 5 days prior WITHOUT BRIDGING

10. Case 2: MR. CF  A 55 yo on DAPT (ASA + clopidogrel) for previous PCI 3 years ago, presents for colon for rectal bleeding  Meds: metformin, ramipril, HCTZ, allopurinol, monocor, Astatinstatin  What is your peri-operative anti-platelet strategy?

11. Case 2: MR. CF A. Continue DAPT B. D/C ASA 7-10 days prior, continue clopidogrel C. D/C clopidogrel 7-10 days prior, continue ASA D. D/C clopidogrel 10-14 days prior, continue ASA E. Phone your friendly neighborhood cardiologist (as he states no one should d/c plavix without his blessing)

12. Risk of post endoscopy bleeding Aspirin or NSAIDs  694 patients gastro / colon: post endo survey 1 ASA / NSAIDs: NO DIFF major bleeding (hospital visit) ○ All 4 major bleeds had polypectomy Minor bleeding (blood on TP): 6% ASA vs 2% no ASA  20,000 patients colonoscopy + polypectomy 2 Case-control clinically significant PPB ASA or NSAID use ASA and NSAID bleed rates similar to no ASA (0.5%) No diff. instability, transfusions, hospitalizations, interventions 1 Yousfi, Am J Gastro 2004;99:1785 2 Shiffman, Gastro Endosc 1994;40:458

13. Clopidogrel and Polypectomies Case-control #1  142 patients on plavix with polypectomy  70% on plavix > 1 year, 54% on DAPT  Sig. bleeds (hospital, ↓ Hb, prbcs, intervention) ○ 2.1% plavix vs 0.4% no plavix, NNH = 63 ○ All sig bleeds on DAPT ○ 2xs endo clip rate in plavix arm  “PPB rate sig. ↑ in patients undergoing polypectomy while taking clopidogrel and ASA / NSAIDs; however, risk is small and outcome is favorable. Routine cessation of clopidogrel before colonoscopy / polypectomy not necessary” Singh, Gastrointest Endosc 2010;71:998

14. Clopidogrel and Polypectomies Case-control study # 2  118 patients on clopidogrel had polypectomy  1/118 PBB on clopidogrel 0.85%, 0.32% control ARD = 0.5%  NNH 200  “We speculate that cardiovascular risks of routinely discontinuing clopidogrel before elective colonoscopy may exceed any excess risk of PPB”. Feagins, Dig Dis Sci (2011) 56:2631–2638

15. DAPT Length of therapy  RCT of 2701 DES patients 1 1 year post stent: RCT: ASA vs plavix + ASA At 2 years: ○ No diff. non-fatal MI, CV death (1.2% vs 1.8%) ○ Trend ↑ MI, CVA, death any cause (1.8% vs 3.2%) ○ Major bleeds: 1 vs 3 (NSS)  1970 stent patients (DES, bare metal), RCT to 6 or 24 months of DAPT 2 CV events (2 years): 10% vs 10.1% Major bleeds ↑: 6 vs 16 (SS) 1 Park, NEJM 2010;362:1374 2 Valgimigli,Circulation 2012;125:2015

16.  ACS and any stent: (bare metal or DES)  DAPT x 1 year  ASA after  Elective PCI Bare metal stent: DAPT x 1 month DES: DAPT x 3-6 months CHEST 2012; 141(2)(Suppl):e637S–e668S

17. Anti-platelets, clopidogrel and DAPT Summary  ASA for 1’ prevention: stop x 7 days  NSAIDs: stop x 7 days if able  ASA for 2’ prevention: continue  Plavix alone: switch to ASA 7-10 days  DAPT  d/c Plavix (7-10 days), continue ASA  Unable to stop DAPT  delay elective procedure Gastro Endoscopy 2009; 70 (6) Am J Gastro 2009; 104:3085 Gut 2008;57;1322 Can J of Cardio 2011; 27: 74 Circulation 2008, 117:261

18. Oral anti-coagulants and Endoscopy

19. Risk of warfarin interruptions: Procedures (including endoscopy)  1024 patients on warfarin, 1293 interruptions 84% ≤ 5 days  Mean age 72, 57% male  AF (54%), VTE (14%), Valvular HD (13%) 7% high risk: prosthetic valve, recent VTE, cancer  Colonoscopy, dental, optho, biopsies  Bridging LMWH: 8% of cases Garcia, Arch Intern Med. 2008;168(1):63

20. Risk of warfarin interruptions Total N = 1293 Bridged N = 108 (8.3%) Not Bridged N = 1185 (91.7%) Notes TE Events7 (0.5%)0 (0%)7 (0.6%)2 high risk for TE (active ca, recent VTE) Significant Bleeds* 23 (1.7%)14 (13%)9 (0.8%) Garcia, Arch Intern Med. 2008;168(1):63 Thromboembolic risk: days off coumadin: ≤ 5 days = 0.4% ≥ 7 days = 2.2% *Hospital, ≥ 2 units prbcs, critical (brain)), death or unplanned intervention

21. AFIB Sub-group  N = 550 (690 interruptions)  97.5% not bridged Median CHADS 2 = 2  Thromboembolism = 4/690 (0.6%)  Bleeding = 6/690 (0.9%)  % bridged: CHADS 2 0 = CHADS 2 3

22. Effectiveness of Bridging Anticoagulation for Surgery: (BRIDGE) study  RCT of patients on warfarin AF or valvular HD (excludes prosthetic valve, recent CVA or VTE) CHADS 2 ≥ 1  Elective procedure or surgery (Not CV or neuro)  LMWH bridge vs. placebo (no bridge)  Outcomes: TE events, bleeding  Completion 2014

23. Thromb Haemost 2012; 108: 213–216 Douketis, CHEST 2012; 141(2)(Suppl):e326S

24. Warfarin Bottom Line: ASGE 2009

26. Warfarin Interruptions Summary  ST interruptions ≤ 5 days = low TE risk  Bridging ↓ TE risk, but ↑ bleeding  Reserve bridging to: CHADS 2 scores (≥ 3) mechanical valves or rheumatic valvular HD previous CVA Douketis, CHEST 2012; 141(2)(Suppl):e326S

28. NOACs and Endoscopy Dabigatran (Pradax)  Reversible direct thrombin inhibitor  Bid dosing (shorter T1/2)  Canada Indications Afib CHADS2 ≥ 1 VTE prevention post hip / knee replacement

29. Dabigatran interruptions RELY trial  4951 / 18,113 pts (27%) interrupted tx.  Pacer, dent, diagnostics, opth, colons (8.6%) 4 Healy, Circulation 2012;126:343

30. Dabigatran interruptions RELY trial  Major bleed @ 30 days*:  3.8% (D110), 5.1% (D150), 4.6% (warf) (NSS) Bridged: 110mg = 150mg (16%) < warfarin (29%)  Stroke or systemic embolism: 0.5% for all arms (7/1500) 4 Healy, Circulation 2012;126:343*Hospital, ↓ Hb 20, transfused ≥ 2 units or critical site

31. Peri-operative NOACs  Restart 4-6 hours (if hemostasis adequate)  Unlikely require bridging Schulman, Blood 2012 119: 3016, Cairns, Can J Cardio 2011; 27:74, FDA Pradaxa, accessed Oct. 8, 2012

32. Summary Anti-platelets and anti-coagulants  Endoscopy (polypectomies) are safe in patients on ASA or NSAIDs  DAPT  substitute with ASA  Most patients can have brief (≤ 5 days) interruptions of coumadin  Higher risk patients (CHADS 2 ≥3, VHD, previous CVA) consider bridging LMWH Bridging ↑ bleeding risk  NOACs: standard dc 1-2 days before (age, renal function and procedure)

33. Case 1: Mr. A.E. Newman  A 60 yo AF on warfarin booked for colon for rectal bleeding.  No PHx of CVA, or CHF, but DM+ and hypertensive.  What is your peri-operative anti- coagulation strategy?

34. Case 1: Mr. A.E. Newman A. Continue coumadin through procedure B. Discontinue coumadin 7 days prior and BRIDGE with LMWH C. Discontinue coumadin 7 days prior WITHOUT BRIDGING D. Discontinue coumadin 5 days prior and BRIDGE with LMWH E. Discontinue coumadin 5 days prior WITHOUT BRIDGING

35. Case 2: MR. CF  A 55 yo on DAPT (ASA + clopidogrel) for previous PCI 3 years ago, presents for colon for rectal bleeding  Meds: metformin, ramipril, HCTZ, allopurinol, monocor, Astatinstatin  What is your peri-operative anti-platelet strategy?

36. Case 2: MR. CF A. Continue DAPT B. D/C ASA 7-10 days prior, continue clopidogrel C. D/C clopidogrel 7-10 days prior, continue ASA D. D/C clopidogrel 10-14 days prior, continue ASA E. Phone your friendly neighborhood cardiologist (as he states no one should d/c plavix without his blessing)

37. Thank you!

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