1. Antiplatelets, Anticoagulants What are the consequences Dr Jeremy Wright Cardiologist Hearts1st, Greenslopes Private Hospital

2. Outline  2 clinical cases  Overview of haemostasis  Antiplatelet medications  Anticoagulant medications  Strategy for peri-procedural management

3. Case 1  86yo female  RCA stent 6 months ago  Hb 55, large colorectal cancer  Transfusion, staged anterior resection  Pre-op phone assessment advised stop Aspirin and Clopidogrel 1 week prior to surgery  Anterior resection performed  In recovery - chest pain and intermittent bradycardia

5. Case 1  Multiple VF arrests  Aspirated  Intubated  Angio showed stent thrombosis  IV heparin, eptifibatide  Prolonged stay in ICU  Discharged home 1 month later

6. Case 2  83 yo female  2 days post stent to LAD  Aspirin and Clopidogrel  Pleural effusion  Pleural tap requested to exclude empyema  Large haemothorax  Deceased despite resuscitation

7. Haemostasis

8. Antiplatelets Anticoagulants

9. Antiplatelet medications  Aspirin -Cartia, Astrix, etc  Clopidogrel -Plavix, Iscover  Prasugrel -Effient  Ticagrelor -Brilinta  Fish Oil, Chinese Herbs  GP IIb/IIIa inhibitors – Reopro, Aggrastat

10. Coronary Artery Stents  Three ‘Generations’ 1.) Bare Metal (BMS) 2.) Drug Eluting (DES) (first generation) 3.) Drug Eluting (DES) (second generation)  BMS require dual antiplatelet therapy for at least 1 month  DES require dual antiplatelet therapy for at least 6 months  Aspirin must continue

11. Anticoagulants  Older agents -Oral: Warfarin -Injection: Heparin, Clexane, Danaparoid, Fondaparinux  New oral agents -Dabigatran (Pradaxa) -Rivaroxaban (Xarelto) -Apixaban (Eliquis)  New injection agents -Lepirudin (Refludan) -Bivalirudin (Angiomax) -Desirudin (Revasc)

12. Time required for medications to wear off  Antiplatelets: 7 days  Warfarin: 5 days  Injections: 6-24 hours  New oral agents -Dabigatran (Pradaxa) 2 days if eGFR>50, otherwise 5 days -Rivaroxaban (Xarelto) 1-2 days -Apixaban (Eliquis) 1-2 days

13. General Principles  Assess thromboembolic risk of stopping medication -Why taking the medication -How long ? -Previous bleeding problems  Assess bleeding risk associated with the procedure  Ultimate responsibility lies with the Dr performing the procedure, assisted by the referring Dr  Bridging medications may be required in some circumstances

14. Confused?  CSANZ 2009  Warfarin for prosthetic valves ?

15. Confused?  Society of Interventional Radiology Consensus Guidelines  J Vasc Interv Radiol 2009; 20:S240-S249

19. Take home messages  Critical to find out what the patient is taking – oral, SC, IV  There are many new medications -If not sure, look it up or ask  These decisions can be complex  Communication is the key