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Is a Bridge Needed Along This Road?

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Presentation on theme: "Is a Bridge Needed Along This Road?"— Presentation transcript:

1 Is a Bridge Needed Along This Road?
From the Publishers of Consult Guys Is a Bridge Needed Along This Road? COPYRIGHT © 2016, ALL RIGHTS RESERVED

2 Terms of Use The Consult Guys® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys® slide sets constitutes copyright infringement. Copyright © 2016

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%

17 the Consult Guys

18 Produced by and COPYRIGHT © 2016, ALL RIGHTS RESERVED


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