Anticoagulation

Question 1

What questions must be considered for peri-procedural management

Answer 1

does warfarin need to be held for procedure?
if warfarin needs to be held does the patient require bridging anticoag?

Question 2

What types of procedures do not need a stop in warfarin therapy?

Answer 2

Dental, derm, and ophthalmologic procedures

Question 3

What mechanical heart valves have a high thromboembolism risk during interruption of warfarin?

Answer 3

mitral valve replacements

multiple mechanical heart valves

stroke, TIA, or cardioembolic event in last 6 months

Question 4

What cardio conditions have a high thromboembolism risk (or lead to Afib) during interruption of warfarin?

Answer 4

Severe valvular heart disease

CHADS2 score= 5-6

Stroke or TIA in last 3 months

Question 5

What can cause a high risk of VTE during interruption of warfarin?

Answer 5

VTE in last 3 months

Severe thrombophilia

Question 6

Refer to slide 16 for the table on thromboembolism during interruption of warfarin therapy

Answer 6

know the high risks for sure

Question 7

what are the options for periprocedural management of anticoagulation ? include dosing

Answer 7

enoxaparin: 1 mg/kg BID or 1.5 mg/kg once daily
dalteparin: 100 IU/kg BID or 200 IU/kg once daily
heparin (UFH): to attain an aPTT 1.5-2 x the control
– those w CrCl < 30 ml/min or in hospitalized patients

Question 8

When would you use heparin for pre-op anticoag over other options?

Answer 8

those w CrCl < 30 ml/min or in hospitalized patients

Question 9

How long should you stay off warfarin prior to procedure?

Answer 9

will need to stay off warfarin for 5 days prior to help reduce risk of bleeding

Question 10

How should the plan for periprocedural management of anticoagulation be implemented?

Refer to slide 23 for full answer

Answer 10

2 options:

1) 1.5 mg/kg once daily
– day before surgery, take 1/2 usual dose of enoxaparin
2) 1 mg/kg BID
– no PM dose night before surgery
– Cantrell prefers this for ease of 1/2 dose night before

for both:
no enox. day of surgery
restart warfarin night of surgery
continue both warf and enox for 5 days after surgery and stop enox if INR ≥ 2.5

Question 11

what are the monitoring parameters for warfarin therapy after surgery/procedure

Answer 11

monitor for sx of bleeding and blood clots

follow up after re-initiation of warfarin
- INR at 5 days
- continue enox until INR therapeutic

Question 12

What is the adverse effect of dopamine agonists (pramipexole, ropinirole)

Answer 12

5% of susceptible patients experience impulse control disorders prone to riskier behaviors: pathological gambling, spending, sexuality

Question 13

What are other options for RLS management to avoid/lessen impulse control disorders

Answer 13

gabapentin (neurontin)
pregabalin (lyrica)
BZDZ
Opioids (less common)
iron supplementation if deficient

Question 14

___ may be considered for primary prevention of ASCVD among adults 40-70 yo who are at higher risk of ASCVD risk but not at _____

Answer 14

low dose aspirin (75-100 mg orally daily)

increased bleeding risk

Question 15

Who should NOT get aspirin for primary prevention?

Answer 15

People over 70 and those with bleeding risk

Question 16

What is the concern with NSAIDs and warfarin?

what would be preferred instead?

Answer 16

increase the risk of bleeding (gastric bleeding)

Recommendation: 500 mg APAP TID or topical diclofenac