Faculty Disclosures Perioperative Management of Warfarin Interruption There are no actual or potential conflicts of interest associated with Victoria Lambert, PharmD, CACP this presentation. Medication Management Pharmacist William W. Backus Hospital What’s the hype about Learning Objectives interrupting warfarin therapy? Review recommendations for when to interrupt warfarin therapy Anticoagulation serves an important role in reducing the risk of thromboembolism or stroke Review guidelines for determining thromboembolic risk A number of patients are at risk of developing arterial or venous thromboembolism if warfarin therapy needs to be withheld. Review recommendations for bridging therapy implementation Patients will eventually need to undergo some type of procedure. Review cases for appropriate method to manage Perioperative management is a common clinical warfarin interruption based on risk stratification problem. What do we do? Identify case-specific monitoring parameters for anticoagulation bridge therapy Ask the Audience What is bridging therapy? Warfarin therapy must be interrupted for all surgical procedures? “In the absence of a universally accepted definition, we define bridging a. True anticoagulation as the admininstration of a b. False short-acting anticoagulant, for an ~ 10-12 c. Not sure day period during interruption of VKA therapy when the INR is not within a therapeutic range”. Chest 2012; 141; e326S-e350S 1
Who is a candidate for bridging? Does warfarin need to be withheld? Ask yourself 3 questions… Continue warfarin: Dental procedures (2C) * CAUTION: spinal/epidural Does warfarin need to be withheld? Cataract Removal (2C) procedures + anticoagulants INCREASE risk of hematoma Endoscopy (diagnostic) = possible paralysis What is the patient’s risk for clotting? Joint injections* Knees, wrist, hip Minor dermatologic procedures (2C) What is the patient’s risk for bleeding? Consider procedures that do not pose increased bleeding risk while on warfarin CHEST 2008, CHEST 2012 Grant PJ, Brotman DJ, Jaffer AK. Perioperative Anticoagulant Management. Med Clin N Am 93 (2009) 1105-1121 Discontinue warfarin: Ask the Audience Orthopedic surgeries To assess the risk of clotting, we TKR, THR need to review? Biopsy a. The patient's warfarin indication Breast, Lung b. The type of procedure Neurosurgery c. Co-morbidities Hernia Surgery d. All of the above Colonoscopy Family history of cancer/polyps CHEST 2008, CHEST 2012 What is the patients’ risk of clotting? There are no validated risk stratification tools to determine the risk of perioperative thromboembolism. Considerations “Only limited data exist to aid clinicians in classifying which patients Underlying indication for warfarin therapy are sufficiently high risk for thromboembolism to warrant the risk Patient’s risk factors for thromboembolism and cost of full (therapeutic) doses of heparin products perioperatively”. Morbid obesity, hypercoagulable state, immobility Duration of anticoagulation cessation “Standardizing periprocedural anticoagulation management for VTE patients has not been adequately defined by either randomized, MHV – TE risk 0.046%/day controlled trial data or observational cohorts”. A fib – TE risk 0.013%/day Now what?.......... CHEST 2008; 304S. CHEST 2012 Grant PJ, Brotman DJ, Jaffer AK. Perioperative Anticoagulant Management. Med Clin N Am 93 (2009) 1105-1121 Jaffer AK, Brotman DJ, Bash LD. The American Journal of Medicine 2010; 123:141-150 CHEST 2008; 311S,312S Mcbane RD, Wysokinski WE, Daniels PR. Arterioscler Thromb Vasc Biol. 2010; 30:442-448 2
Strength of the Recommendations Grading Thrombosis Risk System Chest guidelines Grade of Recommendation Benefit vs Risk and Burdens Methodologic Strength Supporting Evidence Evidence based practice guidelines which Strong - 1A High quality evidence Benefit>risk/burden or vice versa RCT, exceptionally strong evidence from observational studies incorporate data from existing literature. Strong - 1B Moderate quality evidence Benefit>risk/burden or vice versa RCT with limitations, strong evidence Atrial fibrillation from observational studies Mechanical Heart Valves Strong - 1C Low or very low quality evidence Benefit>risk/burden or vice versa Evidence for at least one critical outcome with serious flaws or indirect evidence VTE Weak - 2A High quality evidence Benefit closely balanced with risks + burdens RCT, exceptionally strong evidence from observational studies Weak - 2B Moderate quality evidence Benefit closely balanced with risks + burdens RCT with limitations, strong evidence from observational studies Most common indications Weak - 2C Low or very low quality evidence Uncertainty in estimates of benefits, risks, Evidence for at least one critical outcome for long term anticoagulation and burden; benefits, risk + burden may be closely with serious flaws or indirect evidence balanced CHEST 2012 Risk Stratification for Perioperative TE What is CHADS 2 Scoring? Risk Mechanical Heart Atrial Venous Valve Fibrillation Thromboembolism Clinical prediction rule for estimating the High Any Mitral Valve CHADS 2 : 5-6, VTE within 3 months, Prosthesis. Caged-ball Stroke or TIA risk of stroke in patients with Severe thrombophilia or tilting disk aortic within 3 months, (protein C, S or antithrombin valve prosthesis. rheumatic deficiency, APA) nonrheumatic atrial fibrillation. Stroke/ TIA within valvular heart previous six months disease Intermediate Bileaflet aortic valve CHADS 2 : 3-4 VTE within past 3-12 months, prosthesis and any of recurrent VTE, Active cancer Used to determine the degree of the following: afib, (treated within 6 months), prior stroke/ TIA, HTN, Non-severe thrombophilia anticoagulation needed. DM, CHF , age > 75 (heterozygous Factor V Leiden mutation) Low Bileaflet aortic valve CHADS 2 : 0-2, Single VTE event greater prosthesis without afib than 12 months ago and no No prior stroke or and no other risk other risk factors TIA factors for stroke CHEST 2012 Ask the Audience CHADS 2 Score Which is the correct description of CHADS 2 CHADS 2 Risk Score Total Risk Level Stroke scoring? Criteria Score Rate a. CHF, hypertension, age > 65, DM, prior history of stroke 0-2 Low 1.9-4 b. Cardiomyopathy, hypertension, age > 75, DM, CHF 1 prior history of stroke Hypertension 1 Intermediate 3-4 5.9-8.5 c. CHF, hypertension, age > 75, DM, prior history of stroke Age > 75 1 d. CHF, hyperlipidemia, age > 75, DM, prior history DM 1 5-6 High 12.5- of stroke 18.2 Stroke/Tia 2 CHEST 2008 ACC/AHA/ESC 2006 Gage, BF 3
Risk Stratification for Perioperative TE What about CHA 2 DS 2 VASc? Risk Mechanical Heart Atrial Venous Valve Fibrillation Thromboembolism Refinement of CHADS 2 High Any Mitral Valve CHADS 2 : 5-6, VTE within 3 months, Prosthesis. Caged-ball Stroke or TIA Additional common stroke risk factors Severe thrombophilia or tilting disk aortic within 3 months, (protein C, S or antithrombin Female gender, vascular disease, age range 65-74 valve prosthesis. rheumatic deficiency, APA) Stroke/ TIA within valvular heart previous six months disease Max score is 9 Intermediate Bileaflet aortic valve CHADS 2 : 3-4 VTE within past 3-12 months, prosthesis and any of recurrent VTE, Active cancer More patients classified as high risk? the following: afib, (treated within 6 months), prior stroke/ TIA, HTN, Non-severe thrombophilia Score > /= 2 may benefit from anticoagulation DM, CHF , age > 75 (heterozygous Factor V Leiden mutation) therapy Low Bileaflet aortic valve CHADS 2 : 0-2, Single VTE event greater More patients require bridging for warfarin prosthesis without afib than 12 months ago and no No prior stroke or and no other risk other risk factors TIA interruption? factors for stroke CHEST 2012 Risk Stratification for Perioperative TE Case #1 – GH Risk Mechanical Heart Atrial Venous Valve Fibrillation Thromboembolism GH is a 66 year old male on indefinite High Any Mitral Valve CHADS 2 : 5-6, VTE within 3 months, warfarin therapy for a h/o multiple DVT’s Prosthesis. Caged-ball Stroke or TIA Severe thrombophilia or tilting disk aortic within 3 months, (protein C, S or antithrombin with an INR range of 2-3. PMH includes valve prosthesis. rheumatic deficiency, APA) Stroke/ TIA within valvular heart HTN, hyperlipidemia, diverticulitis. GH is previous six months disease scheduled for colon resection. Intermediate Bileaflet aortic valve CHADS 2 : 3-4 VTE within past 3-12 months, prosthesis and any of recurrent VTE, Active cancer 1) What is GH’s TE risk level when warfarin is the following: afib, (treated within 6 months), prior stroke/ TIA, HTN, Non-severe thrombophilia withheld? DM, CHF , age > 75 (heterozygous Factor V Leiden mutation) 2) What perioperative plan should be Low Bileaflet aortic valve CHADS 2 : 0-2, Single VTE event greater implemented? prosthesis without afib than 12 months ago and no No prior stroke or and no other risk other risk factors TIA factors for stroke GH’s risk? Risk level has been determined…. Thromboembolic Let’s review pre and post Intermediate procedure/surgical plan h/o recurrent DVT’s 4
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