CHEST 2012: Bridging

Question 1

VKA interruption

Answer 1

5 days before surgery

Question 2

VKA resumption when temporarily interrupted prior to surgery

Answer 2

12 to 24 hours after surgery when adequate hemostasis (evening of or following morning)

Question 3

If mechanical heart valve, AF, or VTE at low risk for thromboembolism, decision should be to

Answer 3

Do Not bridge

Question 4

If minor dental procedure

Answer 4

Continue VKA with coadministration of a prohemostatic agent (ex. fibrinogen, factor 7a) OR stop VKA 2-3 days prior to procedure

Question 5

If only takes ASA and minor dental or skin procedure

Answer 5

Keep taking ASA

Question 6

If minor skin procedure and taking VKA

Answer 6

Local hemostasis and continue VKA

Question 7

If cataract surgery and has VKA

Answer 7

Continue VKA

Question 8

If taking only ASA and needing non-cardiac surgery

1) at moderate to high risk of CV events
2) at low risk of CV events

Answer 8

1) Continue ASA

2) Stop ASA 7 - 10 days before surgery

Question 9

If taking ASA and require CABG

Answer 9

Continue ASA

Question 10

If DAPT and require CABG

Answer 10

Continue ASA

Stop clopidogrel/prasugrel 5 days before surgery

Question 11

If DAPT and stented and require surgery

And if those are not options

Answer 11

Defer 6 weeks after BMS stent placement
Defer 6 months after DES stent placement

If those are not options, continue DAPT

Question 12

If getting therapeutic IV UFH for bridging, when to stop

Answer 12

4 - 6 hours before surgery

Question 13

If getting therapeutic LMWH for bridging, when to stop preoperative LMWH

Answer 13

24 hours before

Question 14

High Risk for VTE per risk stratification

Answer 14

VTE within 3 months or severe thrombophilia

Question 15

Low risk for VTE per risk stratification

Answer 15

VTE more than 12 months ago and no other risk factors

Question 16

Dabigatran interruption (when to stop and when to restart)
CrCl 30 - 50
CrCl > 50

Answer 16

CrCl 30 - 50:
Last dose 3 days before the procedure if low bleed risk, 4-5 days before the procedure if high bleed risk
CrCl > 50:
Last dose 2 days before the procedure if low bleed risk,
3 days before procedure if high bleed risk

Resume 24 hours after procedure if low bleed risk
Resume 2-3 days after procedure if high bleed risk

Question 17

Rivaroxaban or Apixaban interruption for procedure

CrCl 15 - 30
CrCl > 30

Answer 17

CrCl 15 - 30: individualized

CrCl > 30:
Last dose 2 days before procedure for low bleeding risk
Last dose 3 days before procedure for high bleeding risk

Resume 24 hours after procedure for low bleeding risk
Resume 2-3 days after procedure for high bleeding risk

Question 18

Edoxaban interruption for procedure

CrCl > 50

Answer 18

Last dose 2 days before procedure if low bleeding risk
Last dose 3 days before procedure if high bleeding risk

Resume 24 hours after if low bleeding risk
Resume 2-3 days after if high bleeding risk

Question 19

When to restart UFH for bridging procedure

Answer 19

Restart within 12 hours after procedure

Question 20

When to restart LMWH for bridging procedure

Answer 20

Restart within 24 hours after procedure

Question 21

UFH aPTT goal for procedure

Answer 21

1.5 to 2 x control

Question 22

When to start parenteral anticoagulation for bridging

Answer 22

Approximately 3 days before procedure

Question 23

When to stop warfarin for bridging

Answer 23

Approximately 5 days before procedure

Question 24

When to give oral vitamin K prior to procedure (INR and how much to give)

Answer 24

When INR is > 1.5

Consider 1 - 2.5 mg PO

Question 25

When to restart warfarin post procedure

Answer 25

Consider either the evening of procedure or the morning after the procedure

Question 26

When to avoid restarting an anticoagulant post procedure

Answer 26

If high bleeding risk