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220 Anticoagulation Therapy
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35. Crowther MA, Ageno W, Garcia D, et al. Oral vitamin K versus placebo to correct
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symptomatic intracerebral hemorrhage. Arch Neurol. 2010;67:965-969.
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treated with vitamin K antagonists. Anesthesiology. 2008;109:918-926.
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10
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Chapter
TRANSITIONS IN CARE—
PERIPROCEDURAL BRIDGING
AND TRANSITIONS BETWEEN
AGENTS
Jessica Rimsans, Katelyn W. Sylvester, and John Fanikos
INTRODUCTION
Patients receiving long-term antiplatelet (AP) therapy or oral anticoagulation (OAC)
with vitamin K antagonists (VKA) or a direct-acting oral anticoagulant (DOAC)
commonly transition from the ambulatory setting to the hospital and back again.
This clinical scenario often requires antithrombotic therapy changes. Each transition
point (hospital admission, procedure, unit transfer, discharge to home, or longterm care) represents an opportunity to assess medication regimens for errors,
omissions, and treatment adjustments. Emphasis on abbreviating hospital stay
and reducing costs further magnifies the need for seamless conversion between
oral and parenteral antithrombotic therapies. As these patients transition, either
electively or urgently, the diagnosis and indications for anticoagulant therapy
should be evaluated. Surgical and invasive procedures add additional levels of
complexity where OAC and AP therapy may be continued, interrupted, or replaced
with short-term parenteral or bridge therapy. Since there is not a standardized
definition of bridging, most regimens have been developed from observational and
retrospective studies, registry data, and more recently a randomized controlled trial.
Physician and patient preference will play a role in determining whether therapy
is continued, stopped, or replaced with an alternative agent.
PERIPROCEDURAL BRIDGING PRINCIPLES
•
Determine thromboembolism risk with interruption of anticoagulant (AC) and/or AP
therapy.
•
Assess bleeding risk associated with:
Parenteral AC/AP therapy
Surgical or invasive procedure
Continuation of AC/AP therapy
•
Weigh risk versus benefits of bridging
•
Consider patient and physician’s goals and preferences
223
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PERIPROCEDURAL THROMBOEMBOLIC RISK
ASSESSMENT
•
Patients should undergo a thorough assessment for thromboembolism using a
standardized risk stratification evaluation.
•
Identify level of thromboembolism risk based on underlying disease and comorbidities.
•
Previous literature and current guidelines historically risk stratified patients using
Cardiac Failure, Hypertension, Age, Diabetes, and Stroke (doubled) (CHADS
however, CHA
validated and adopted into clinical practice.
-VASc (vascular disease and sex category) has since been
2DS2
1
2-4
);
2
PERIPROCEDURAL BLEEDING RISK
ASSESSMENT
•
Patients should undergo a thorough assessment for bleeding risk.
•
The procedure itself is one of the most important risk factors for bleeding.
•
Consider patient risk factors and comorbidities that may impact oral or parenteral anticoagulation and increase procedural and postprocedural bleeding risk.
•
Various prognostic and scoring indices for bleeding exist for initiating VKA
therapy, in-hospital risk, and postprocedural risk.
•
Consider using an appropriate bleeding index to identify patient’s risk level
for bleeding.
5-9
10-13
DETERMINING PROCEDURAL RISK OF
HEMORRHAGE
•
Assess the risk of bleeding from the procedure.
•
Incidence of hemorrhage will depend on the procedure and occurs in as many
as 11.9% of patients during routine surgery. Published bleeding rates include
the following:
Thoracic surgery 33.7%
Abdominal surgery 11.4%
Other major surgery 14.3%
•
Two thirds of bleeding events will occur within 48 hours after the intervention.
•
Procedures in closed areas or cavities carry a high risk for hemorrhagic complications (Table 10-1), including:
Pericardial region (related to pacemaker/internal cardiac defibril-
lator [ICD] insertion)
Spinal (related to trauma from lumbar puncture or epidural place-
ment)
Urologic procedures (involving the retroperitoneum or bladder
lumen)
•
Assess patient specific risk factors for bleeding (Table 10-2).
5,6
4,7
TRANSITIONS IN CARE 225
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TABLE 10-1: Procedural Risk of Hemorrhage in the Setting of
Perioprocedural Anticoagulation
When assessing the risk of periprocedural bleeding in the setting of anticoagulation, it is important to evaluate the bleeding risk in relation to the dose of anticoagulation (i.e., therapeutic
anticoagulation vs. prophylactic doses of anticoagulation).
High Bleeding Risk Invasive Procedure or
Surgery
Cardiothoracic
• Thoracic aortic aneurysm repair, heart
valve replacement/repair, coronary
artery bypass, cardiac biopsy, heart
transplantation, coronary angiography
+/- PCI
Lung surgery: lobectomy, wedge
•
resection, segmentectomy,
pneumonectomy
• Implantable cardiodefibrillator device
implantation or pacemaker insertion
Urological
• Transurethral prostate resection,
prostectomy, prostate surgery/biopsy,
bladder resection or tumor ablation,
nephrectomy, kidney biopsy/surgery,
urogynecological surgery
Gastrointestinal
• Intra-abdominal surgery, appendectomy,
bowel resection, intestinal anastomosis,
PEG tube placement, cholecystectomy,
polypectomy, colonoscopy with biopsy
>2 cm
Orthopedic
•
Joint arthroplasty, hip/knee replacement,
other major orthopedic surgery
Vascular
• AAA repair, endarterectomy, carotid
bypass surgery, port placement, other
major vascular surgery
Cancer
• Urologic, gynecologic, head and neck,
colorectal, breast
Neurosurgical
• Intracranial or spinal surgery,
laminectomy, other major neurosurgery
1,5-9
1
Low Bleeding Risk Invasive Procedure or
Surgery
Abdominal hernia repair
Abdominal hysterectomy
Axillary node dissection
Arthrocentesis
Ablation
Arthroscopy
Biopsy if low vascularity of site (bladder,
thyroid, lymph node, pancreas)
Bronchoscopy without biopsy
Cataract eye surgery
Central venous catheter removal
Cutaneous surgeries
Dental hygiene or extraction (uncomplicated)
Dermatologic procedures (minor)
Dilation and curettage
Electrophysiologic testing
Hemorrhoid surgery or hydrocele repair
Joint and soft tissue injections/aspirations
Non-coronary angiography
Gastrointestinal endoscopy or colonoscopy
without biopsy
Skin cancer excision
(continued)
226 Anticoagulation Therapy
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TABLE 10-1: (Continued)
High Bleeding Risk Invasive Procedure or
Surgery
Surgery and procedures/biopsies in highly
vascular organs
• Kidney, liver, spleen, breast
Reconstructive plastic surgery with
extensive tissue injury
Other
•
Complicated dental surgery (multiple
tooth extractions)
Sternotomy wire removal
•
•
Endoscopy guided fine-needle aspira-
tion
Any major surgery >45 min in duration
•
AAA: abdominal aortic aneurysm, PCI: percutaneous coronary intervention, PEG: percutaneous
endoscopic gastrostomy
Low Bleeding Risk Invasive Procedure or
Surgery
PERIPROCEDURAL MANAGEMENT OF
ANTIPLATELET THERAPY
•
Evidence supporting periprocedural management of AP therapy is limited.
TRANSITIONING FROM VKA TO PARENTERAL
THERAPY
•
There are limited high quality data to guide clinicians on how to devise a bridge
strategy, if necessary, based on thromboembolism and bleeding risk (Table
1
10-3).
•
Optimal bridge therapy for temporary warfarin interruption for invasive procedures has been shown to increase the risk of bleeding in atrial fibrillation patients
without a corresponding decrease in thromboembolism risk (BRIDGE trial); it
is also associated with an increased risk of bleeding, without a corresponding
decrease in thromboembolism risk in patients receiving VKA for prior venous
thromboembolism (VTE).
•
In patients on VKA, low dose vitamin K 1 mg orally can be given to normalize INR
the day before surgery without conferring warfarin resistance postoperative.
BRIDGING WITH LOW MOLECULAR WEIGHT
HEPARIN
•
Registry data suggests bridging may be unnecessary for the vast majority of
patients in an anticoagulation management service even with interruptions in
warfarin therapy (continued, lower-intensity, or interrupted).
14-19
20
19-25
TRANSITIONS IN CARE 227
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TABLE 10-2: Major Patient Risk Factors and Comorbidities
Increasing Bleeding Risk with Anticoagulation
Risk Factor or
Comorbidity
Increasing age Risk increases as age increases >55 years
History of bleeding Higher risk with more recent bleeding event (e.g., gastrointestinal,
Vascular disease Prior stroke or peripheral vascular disease
Renal dysfunction Creatinine clearance
Hepatic dysfunction Associated with altered coagulation function and a higher risk of
Congestive heart
failure
Anemia Hematocrit <30% or hemoglobin <13 g/dL males, <12 g/dL females is
Cancer Bleeding risk correlates with the type and extent of cancer
Hypotension Systolic blood pressure <100 mm of Hg
Hypertension Systolic blood pressure >200 mm of Hg
Female Predictor of higher risk; exact mechanism is unknown
Explanation
intraocular, hematuria)
a
associated with higher risk
bleeding with worsening liver function
Exacerbations may alter anticoagulant response and pharmacodynamics
associated with higher risk
<90 mL/min or serum creatinine >1.2 mg/dL
4–7
Diabetes mellitus Impacts many risk factors that increase bleeding risk
Labile INRs Poorly controlled INR, <60% time in therapeutic range
Alcohol
consumption
Concomitant drugs Antiplatelet agents and nonsteroidal anti-inflammatory agents
a
Calculated using Cockcroft-Gault formula.
INR: international normalized ratio
•
Low molecular weight heparin (LMWH) prophylactic doses have never been
studied in the arena of preventing thromboembolism. Thus, when bridging
for atrial fibrillation and mechanical heart valves, therapeutic dosing is usually
preferred.
•
There is no randomized controlled trial in patients with atrial fibrillation or heart
valves that shows therapeutic LMWH has any benefit in reduction in stroke risk.
•
Standardized LMWH “bridge” regimens often result in significant residual
anticoagulant activity shortly before surgery.
•
Patients with impaired renal function are likely to have delayed LMWH clearance.
•
Residual LMWH activity, as measured by anti-factor Xa testing, can last 24 hours
after a dose.
≥8 units alcoholic consumption per week
26
228 Anticoagulation Therapy
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•
Duration of LMWH bridging may be significantly longer (12 days) than is reported
in clinical trials.
•
In those patients undergoing pacemaker or ICD placement, a strategy of continued warfarin reduced the incidence of clinically significant pocket hematoma
compared with those being bridged with intravenous unfractionated heparin
(IV UFH).
27
16
RE-INITIATION OF VKA
•
Patients receiving higher weekly warfarin doses are likely to eliminate the drug
faster and return to baseline INR earlier than those patients on lower weekly
warfarin doses.
•
Consider any events during the intraoperative and immediate postoperative
period (excessive bleeding or bleeding vessels which required intervention) that
may impact reinitiating anticoagulation.
•
The decision to restart anticoagulation after a procedure must be made in
consultation with the surgeon or proceduralist, taking into account procedure,
presence of neuraxial anesthesia, and risk of bleeding/thromboembolism.
•
When warfarin is restarted, often the maintenance dose is reinitiated. When there
is a desire for earlier “measured” INR response, another option is to start with
an increased dose for the initial 2 days (≈50-100% increase in the maintenance
dose), then follow with the usual maintenance dose.
28,29
TRANSITIONING BETWEEN DIRECTACTING ORAL ANTICOAGULATION OR TO
PARENTERAL THERAPY
•
DOACs have a fast onset and offset. The use of a pre-operative parenteral
bridging agent is not needed. Use of a parenteral bridging (generally IV UFH)
may be necessary after surgery in high bleeding risk situations due to its short
duration and ability to reverse.
•
For low bleeding risk procedures (i.e., dental, ophthalmology, superficial surgeries) in patients with normal renal function, the DOAC may be continued uninterrupted at the discretion of the interventionalist.
•
When a DOAC is restarted, renal function, procedure, presence of neuraxial
anesthesia, risk of bleeding/thromboembolism, and onset of the agent should
be taken into account.
•
The effect of the DOAC on the UFH monitoring strategy (aPTT, anti-factor Xa
testing) must be considered; alternative monitoring strategies could be needed
to avoid lags in anticoagulation (Table 10-6).
•
In some situations (high bleeding risk/low thrombosis risk, delayed DOAC clearance due to acute kidney injury), heparin initiation may be delayed beyond
standard recommendations until the DOAC has largely cleared; appropriate
laboratory measures may help guide when to initiate UFH (Table 10-6).
30-33
18
30
bridging group and 0.3% in the bridging group (CI 0.6–0.8,
https://t.me/med1917
P = 0.01 for noninferiority)
group and 3.2% in the bridging group (CI 0.2 to 0.78, P =
0.005 for superiority)
12 of 343 patients (3.5%) in the continued warfarin group,
compared with 54 out of 338 (16%) in the heparin-bridging
group (RR 0.19 P <0.001)
significantly
• Incidence of arterial thromboembolism was 0.4% in the no-
• Incidence of major bleeding was 1.3% in the no-bridging
• Clinically significant device pocket hematoma occurred in
• Major surgical and TE complications did not differ
TRANSITIONS IN CARE 229
(continued)
0.2% in bridge vs. no bridge (CI 3.9–75.1)
vs. 3.9% clinically relevant bleeding events
procedural complications and 33.3% were directly related to
the bridging agent
groups (P = 0.56)
30 day rates of clinically relevant bleeding were 2.7% and
For therapeutic and prophylactic LMWH, there were 2.2%
Of the 15 bleeding events in the bridge cohort, 52.9% were
•
•
•
• Recurrent VTE were not significantly different between
Dalteparin 100 IU/kg SQ
AF patients (n = 1,884)
Randomized
Trial Study Design Population Intervention Outcome
TABLE 10-3: Summary of Evidence from Bridging Trials
BRIDGE trial
BID vs placebo 1-3 days
before procedure to 24 hr
before then 5–10 days post
procedure
Warfarin continued through
procedure vs. IV UFH or
LMWH before and/or after
-VASc 2–3,
2
DS
2
<10% with stroke/TIA
Majority CHA
controlled trials
)
15
(Douketis et
al.
Pacemaker or ICD
placement (n = 643), annual
risk of TE >5% or more
Randomized
controlled trial
trial (Birnie et
BRUISE
CONTROL
procedure
)
16
al.
Use of bridge vs. no bridge
during warfarin interruption
Therapeutic LMWH (89%)
and heparin (11%)
History of VTE (n = 1,178),
majority >12 months prior,
low recurrent VTE risk
category
Retrospective
cohort
14
Clark et al.
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