Perioperative Anticoagulation

Question 1

Challenges to Perioperative Anticoagulation?

Answer 1

 Risk of bleed vs benefit of continuing anticoagulant
 Long half-life of warfarin
 Slow onset of anticoagulant effects when restarting warfarin
 Variability in half-life of NOAGs

Question 2

CHEST High Risk for TE

Answer 2

MVR
A Fib + CHADS2 of 5 or 6
Stroke TIA within last 3 months
VTE within 3 months

Question 3

CHEST Moderate Risk for TE

Answer 3

CHADS of 3 or 4
VTE in past 3-12 months
Recurrent VTE
Active cancer

Question 4

CHEST Lower Risk for TE

Answer 4

CHADS2 of 0-2

VTE > 12 months ago and no other risk factors

Question 5

AHA High Risk for TE

Answer 5

Mechanical valve
Prior stroke
CHADS2DS2VASc >/= 2

Question 6

High Bleed Risk Procedures

Answer 6

CABG
Heart valve replacement
Pacemaker
Orthopedic (knee/hip)
Kidney liver or spleen surgery

Question 7

Low Bleed Risk Procedures

Answer 7

Minor dental procedures
Minor dermatologic procedures
Minor ophthalmologic procedures

Question 8

When to stop warfarin prior to procedure

Answer 8

Hold for 5 days prior to procedure

Question 9

When to stop rivaroxaban prior to procedure

Answer 9

At least 24 hours prior to procedure

Question 10

When to stop apixaban prior to procedure

Answer 10

At least 24 hours prior to procedure if low risk

At least 48 hours if moderate or high risk

Question 11

When to stop edoxaban prior to procedure

Answer 11

At least 24 hours prior to procedure

Question 12

When to stop dabigatran prior to procedure

Answer 12

CrCl > 50 mL/min: 1-2 days prior to procedure

CrCl less than 50 mL/min: 3-5 days prior to procedure

Question 13

Bridging CHEST Recommendations

Answer 13

o High risk for TE → Bridge (therapeutic dose SC LMWH or IV UFH)
o Moderate risk for TE → decision based on patient specific/procedure specific factors (therapeutic SC LMWH, IV UFH or low dose SC LMWH)
o Low risk for TE → Don’t bridge

Question 14

ACC/AHA A Fib Guidelines

Answer 14

o Recommended for patients with Afib and mechanical heart valve undergoing procedures requiring interruption of warfarin
o No mechanical heart valve, but has Afib, decision to bridge during interruption of warfarin or target specific oral anticoagulants should balance risks of stroke and bleeding and duration of time patient will not be anticoagulated

Question 15

***INR before Surgery

Answer 15

• Reasonable to check INR at least once before surgery (preferably 1-2 days)
• If INR still elevated >1.5 1-2 days before procedure, consider administering low-dose oral vitamin K (1-2 mg)

Question 16

After procedure + High bleeding risk + LMWH

Answer 16

Restart LMWH 48-72 hours post-procedure

Question 17

After procedure + Low bleeding risk + LMWH

Answer 17

Restart LMWH 24 hours post procedure

Question 18

After procedure + Warfarin

Answer 18

Restart generally 12-24 hours after procedure

Question 19

Reversal of warfarin for urgent surgical or other invasive procedure needed:

Answer 19

Low dose (2.5 to 5mg ) IV or PO vitamin K

Question 20

Reversal of warfarin for urgent surgical or other invasive procedure needed more rapid version

Answer 20

 Treat with fresh-frozen plasma (FFP) or another prothrombin concentrate plus low-dose IV or PO vitamin K
 * FFP or other prothrombin concentrate only temporarily overrides but does not eliminate anticoagulant effect