Indications for Perioperative Bridging

Ann McBride, M.D.Ann McBride, M.D.

UW Anticoagulation ServiceUW Anticoagulation Service

• No financial disclosuresNo financial disclosures

Objectives

• Brief review of literature regarding bridgingBrief review of literature regarding bridging• Identify risks of pt groups for increased risk of Identify risks of pt groups for increased risk of

thromboembolism when warfarin is interruptedthromboembolism when warfarin is interrupted• Identify pts for whom bridging AC should be Identify pts for whom bridging AC should be

consideredconsidered• Identify pt groups at increased risk for Identify pt groups at increased risk for

postoperative bleedingpostoperative bleeding

PATIENT RISK FACTORSPATIENT RISK FACTORS SURGICAL RISK FACTORSSURGICAL RISK FACTORS

ThrombosisThrombosis BleedingBleeding

1.1. Atrial fibrillation/flutterAtrial fibrillation/flutter

3.3. MHVMHV

5.5. VTE -PE, DVTVTE -PE, DVT

Patients chronically anticoagulated

Dunn, Turpie 2003

overall events 29/1868 1.6overall CVA 7/1868 0.4

Periprocedural Bridging with LMWHThree Prospective Studies, 2004

1.1. PROSPECT 260 ptsPROSPECT 260 pts

pre and post-op single dose enoxaparin pre and post-op single dose enoxaparin

major surgery (>1 hr), minor, inv. proceduremajor surgery (>1 hr), minor, inv. procedure

Pts: high risk AF (~ 2/3)Pts: high risk AF (~ 2/3)

Previous DVT (~ 1/3)Previous DVT (~ 1/3)

Periprocedural Bridging with LMWHThree Prospective Studies, 2004 cont’d

1.1. Kovacs 224 ptsKovacs 224 pts

pre-op single dose LMWHpre-op single dose LMWH

Post-op high risk bleed prophylactic LMWHPost-op high risk bleed prophylactic LMWH

Others single therapeuticOthers single therapeutic

Pts: MHV (~ ½)Pts: MHV (~ ½)

AF – high risk (~ ½)AF – high risk (~ ½)

3 month follow up3 month follow up

Periprocedural Bridging with LMWHThree Prospective Studies, 2004 cont’d

1.1. Douketis 650 ptsDouketis 650 pts

Pre and post-op bid LMWHPre and post-op bid LMWH

Pre-op LMWH bidPre-op LMWH bid

Post-op high risk bleed—no LMWHPost-op high risk bleed—no LMWH

Other – bid therapeutic doseOther – bid therapeutic dose

0.7% * (5.9%)

1.8%

2/542 (0.4%)

2/108 (1.8%)

(deaths)

1. Douketis

Non high risk bleeding

High risk bleeding

6.7%8/224 (3.6%)

(incl. 5 MI + 1 DVT)

1. Kovacs

3.5%4/260 (1.5%)1. PROSPECT

Major BleedsTE EventsResults

REGIMEN RegistrySpyropoulos 2006

Major Bleeds 5.5% 3.3%TE Rate 2.4% 0.9%

Atrial FibrillationRisk of Stroke in Patients

with Atrial Fibrillation

CHAD

S2

Congestive Heart Failure (LV ejection less than 40%)

HypertensionHypertension

Age greater than 75Age greater than 75

DiabetesDiabetes

Stroke/TIAStroke/TIA

12-18%5-6

4-8%2-4

1-3%0-1

% Annual CVA RiskCHADS Score

Risk Stratification—Patients with Chronic Atrial Fibrillation

Low—Bridging OptionalLow—Bridging OptionalCHADS score = 0 or 1CHADS score = 0 or 1

Moderate--? BridgingModerate--? BridgingCHADS score=2-4CHADS score=2-4

High—Bridging RecommendedHigh—Bridging RecommendedCHADS score =5-6CHADS score =5-6Recent (within 3 months) CVA/TIARecent (within 3 months) CVA/TIARheumatic Mitral Valve DiseaseRheumatic Mitral Valve Disease

Thrombotic risk with prosthetic heart valves

St. Jude valveBjork-Shiley valveCaged-ball valve

Double wing valvesTilting disc >Caged ball >

Mitral >> Aortic Position

Decreasing thrombotic risk

Heit JA. J Thromb Thrombolysis. 2001;12:81-87.

Risk Stratification—Patients with Mechanical Heart Valves

Low—Bridging OptionalLow—Bridging OptionalBileaflet AV (St. Jude or CarboMedics) and less than 2 CVA risk factorsBileaflet AV (St. Jude or CarboMedics) and less than 2 CVA risk factors

Moderate—Bridging should be consideredModerate—Bridging should be consideredBileaflet AV and more than 2 CVA risk factorsBileaflet AV and more than 2 CVA risk factors

(here Risk Factors refer to Atrial fibrillation, CHF, age greater than 75, HTN, (here Risk Factors refer to Atrial fibrillation, CHF, age greater than 75, HTN, DM)DM)

High—Bridging advisedHigh—Bridging advisedMitral Valve ReplacementMitral Valve Replacement

Recent (within past 3 months) CVA/TIARecent (within past 3 months) CVA/TIACaged-ball (Starr-Edwards) or tilting disc AV (Bjork-Shiley, Medtronic)Caged-ball (Starr-Edwards) or tilting disc AV (Bjork-Shiley, Medtronic)

Risk Stratification—Patients with VTE

High—Bridging Strongly RecommendedHigh—Bridging Strongly RecommendedRecent episode of VTE (within past 3 months)Recent episode of VTE (within past 3 months)

Moderate—Bridging should be consideredModerate—Bridging should be consideredVTE within the past 6 monthsVTE within the past 6 monthsHistory of VTE after surgeryHistory of VTE after surgeryActive Cancer—metastatic, recent treatmentActive Cancer—metastatic, recent treatment

Prot C, Prot S, Antithrombin DeficiencyProt C, Prot S, Antithrombin Deficiency

Low—Bridging OptionalLow—Bridging OptionalNone of these risk factors outlined above presentNone of these risk factors outlined above present

**Pt with previous VTE recurrence when warfarin was interrupted**Pt with previous VTE recurrence when warfarin was interrupted

Postoperative Bleeding Risks

Non-surgicalNon-surgical

UremiaUremia

ThrombocytopeniaThrombocytopenia

Coagulation Factor DeficiencyCoagulation Factor Deficiency

Recent Bleed (i.e., GI)Recent Bleed (i.e., GI)

Surgical

Low—no interruption of OAC neededLow—no interruption of OAC needed

CataractCataract

DermatologyDermatology

Simple dentalSimple dental

Joint and Soft Tissue Aspiration/InjectionJoint and Soft Tissue Aspiration/Injection

Laparascopic Cholescystectomy, Hernia Repair ***Laparascopic Cholescystectomy, Hernia Repair ***

Surgical, cont’d

ModerateModerateScreening Colonoscopy or Diagnostic EGD at UWScreening Colonoscopy or Diagnostic EGD at UW

Complicated Dental surgeryComplicated Dental surgery

BronchoscopyBronchoscopy

Other Orthopedic SurgeryOther Orthopedic Surgery

Other intra thoracic surgeryOther intra thoracic surgery

Other intra-abdominal surgeryOther intra-abdominal surgery

Surgical, cont’d

HighHigh

Major vascularMajor vascularPermanent pacemakerPermanent pacemakerInternal defibrillatorInternal defibrillatorProstatectomyProstatectomyBladder Tumor resectionBladder Tumor resectionLung resectionLung resectionHip/Knee Joint ReplacementHip/Knee Joint ReplacementIntestinal AnastomosisIntestinal AnastomosisBowel PolypectomyBowel PolypectomyKidney or Prostate BxKidney or Prostate BxCervical Cone BxCervical Cone BxBronchoscopy with BxBronchoscopy with Bx

Surgical, cont’d

Very High RiskVery High Risk

Intracranial SurgeryIntracranial Surgery

CABGCABG

Heart ValveHeart Valve

Spinal SurgerySpinal Surgery

Example of Patient Instructions

Warfarin Holding/LMWH Plan for

INR and Platelets

To be Determined

To be Determined

70 mg2/12

4 mg70 mg70 mg2/11

4 mg70 mg70 mg2/10

4 mg70 mg70 mg2/09

4 mg70 mgHOLD2/08

Procedure

INR and Platelets

HOLDHOLD70 mg2/07

HOLD70 mg70 mg2/06

HOLD70 mg70 mg2/05

HOLDHOLDHOLD2/04

HOLDHOLDHOLD2/03

Lab Test

Warfarin

Dose

Lovenox

Evening

Lovenox

MorningDate

Points to Consider

• If target INR 2.0-3.0, pt to be WITHIN target range at time of If target INR 2.0-3.0, pt to be WITHIN target range at time of withholding warfarinwithholding warfarin

• If INR = 2.0-3.0, after 3-4 warfarin doses held, INR level will be less If INR = 2.0-3.0, after 3-4 warfarin doses held, INR level will be less than 1.5than 1.5

• Most surgeries/procedures can be performed reasonably safely when Most surgeries/procedures can be performed reasonably safely when INR less than 1.5INR less than 1.5

• After surgery, when pt resumes warfarin, most pts resume their pre-op 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 dose (some give loading dose, we tend not to). After 4 to 5 days of resuming warfarin, INR will typically be greater than 2.0resuming 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 70 yo pt atrial fibrillation, no hx CVA/TIA—colonoscopy at UWat 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 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopywithout recurrence; scheduled for screening colonoscopy

• 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs 50 yo hx recurrent VTE (DVT LLE x2); on OAC x 6 yrs without recurrence; scheduled for screening colonoscopy, without recurrence; scheduled for screening colonoscopy, with protein C deficiencywith protein C deficiency

Cases, cont’d

• 44 yo M with unprovoked DVT RLE 4 yrs earlier; + 44 yo M with unprovoked DVT RLE 4 yrs earlier; + heterozygous FV Leiden, scheduled for lap hernia repairheterozygous FV Leiden, scheduled for lap hernia repair

• 68 yo with atrial fibrillation and AVR scheduled for 68 yo with atrial fibrillation and AVR scheduled for colonoscopycolonoscopy

• 65 yo met lung ca, DVT 9 months ago, scheduled for 65 yo met lung ca, DVT 9 months ago, scheduled for laparotomylaparotomy

• 77 yo with atrial fibrillation, HTN, DM, CHF scheduled 77 yo with atrial fibrillation, HTN, DM, CHF scheduled for prostate bxfor prostate bx

• 77 yo with atrial fibrillation, HTN, CHF, DM, no hx TIA/77 yo with atrial fibrillation, HTN, CHF, DM, no hx TIA/CVA scheduled colonoscopyCVA scheduled colonoscopy