1. Is a Bridge Needed Along This Road?
From the Publishers of
Consult Guys
Is a Bridge Needed Along This Road?
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3. I am a dedicated long time fan of the Consult Guys.
Early in your stellar series you discussed a case of a patient who was receiving a direct oral anticoagulant (DOAC) who needed epidural therapy and discussed how to manage it in the perioperative period. You have also discussed a case of a patient with a prosthetic valve and the management of his warfarin in the perioperative period. I need advice regarding perioperative anticoagulation management that is more complicated than either of these cases and I and my patient really need your help and advice. So here goes:
Guys:
Mr. J is 76 years old and has chronic atrial fibrillation. He also has hypertension and diabetes (Type II) and both are well controlled with medical therapy. Several months ago he developed hoarseness and was just found to have laryngeal carcinoma. Laryngectomy with cervical node dissection is planned.
He leads an active life and walks up the stairs at his home multiple times each day without difficulty. He has no known coronary artery disease. Ten years ago when he had the onset of atrial fibrillation a cardiac stress test was done and it revealed no evidence of myocardial ischemia.
Bp 120/70 right and left arm
JVP normal. No carotid bruit
Lungs clear
Rhythm irregular
S1 S2 normal. No murmur
Abdominal exam unremarkable
ECG: atrial fibrillation with ventricular response 80 bpm. No ischemia, injury, infarct
No edema. Distal pulses intact
As you discussed in an earlier Consult Guys session I assessed his risk of perioperative cardiac complication.
Cr. 1.3

4. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al; American College of Cardiology.
2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery:
a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.
J Am Coll Cardiol. 2014;64:e [PMID: ] doi: /j.jacc

5. 211, ,385 = 468,795 patients
Gupta PK, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, et al. Development and validation of a risk calculator for
prediction of cardiac risk after surgery. Circulation. 2011;124: [PMID: ] doi: /CIRCULATIONAHA

6. Our Patient Revised Cardiac Index
High risk surgery (Intraperitoneal, intrathoracic, suprainguinal vascular): No
History of or evidence of coronary artery disease: No
CHF: No
Cerebrovascular disease: No
Diabetes (insulin): No
Serum Cr > 2 mg/dl: No
Estimated risk for perioperative MI, pulmonary embolism, ventricular fibrillation,
cardiac arrest, complete heart block: 0.4%

7. 4315 + 1422 = 5737 patients High risk OR Hx CAD Hx CHF
Risk predictors
High risk OR
Hx CAD
Hx CHF
Cerebrovascular dx
Diabetic insulin
Cr > 2
= patients
Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al.
Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
Circulation. 1999;100: [PMID: ]

8. How do we determine stroke risk ?
CHADS2
Congestive heart failure - 1pt
Hypertension - 1pt
Age > pt
Diabetes - 1pt
Stroke or TIA pts
0 points – low risk ( strokes per 100 patient years)
1-2 points – moderate risk ( strokes per 100 patient years)
> 3 points – high risk ( strokes per 100 patient years)
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285: [PMID: ]

9. How do we determine stroke risk ?
CHA2DS2-VASc (Lip, et al.: Chest 2010)
Congestive heart failure/ LV dysf - 1pt
Hypertension - 1pt
Age > pt
Diabetes - 1pt
Stroke or TIA pts
Vascular disease (prior MI, PAD, aortic plaque) - 1pt
Age pt
Sex category (ie female gender) - 1pt
CHA2DS2-VASc = 4 (high risk)
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism
in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137:
[PMID: ] doi: /chest

10. No discussion of direct oral anticoagulants
Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al; American College of Chest Physicians.
Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Chest. 2012;141:e326S-50S. [PMID: ] doi: /chest

11. ACCP 2012: Bridging in Afib warfarin patient
Low risk of perioperative thromboembolism
No bridge
High risk of perioperative thromboembolism
Bridge
Moderate risk of thromboembolism (CHADS2: 3-4)
Consider individual and surgery related risks

12. Approximately 50% low risk GI procedures: endoscopy CHADS2 mean 2.3
Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, et al; BRIDGE Investigators.
Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015;373:
[PMID: ] doi: /NEJMoa

13. BRIDGE Trial Warfarin discontinued 5 days preop
LMWH (dalteparin) begun 3 days preop
Last dose LMWH morning 24 hours preop
Warfarin resumed evening of surgery or day after surgery
LMWH begun
Minor or low-risk bleeding procedure: hours postop
Major or high risk bleeding procedure: hours postop
LMWH continued until INR > 2
Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, et al; BRIDGE Investigators.
Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015;373:
[PMID: ] doi: /NEJMoa

14. From The New England Journal of Medicine, Douketis JD et al
From The New England Journal of Medicine, Douketis JD et al., Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation,
373, Copyright © 2015 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

15. No difference embolism Bridge: more bleeding
From The New England Journal of Medicine, Douketis JD et al., Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation,
373, Copyright © 2015 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

16. Can we use the Bridge Trial to decide?
Our patient CHADS2=3; CHADS2VASc=4 is higher thromboembolic risk than Bridge Trial (mean 2.3): CHADS2=3; CHADS2VASc=4 Laryngeal surgery with neck dissection has high bleeding risk: 2-3%

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