PERIPROCEDURAL

ANTICOAGULATION
Why is Perioperative Anticoagulant
Management Relevant?
Perioperative management of patients on chronic warfarin is common
 400,000-500,000 patients per year in North America alone
 ~1 in 6-10 patients receiving long-term warfarin are assessed for
periprocedural management annually
ANTICOAGULANT OVERVIEW

 Warfarin
 Direct Oral Anticoagulants (DOAC)
 Pradaxa (Dabigatran)
 Xarelto (Rivaroxaban)
 Eliquis (Apixaban)
 Common DOAC characteristics
 More consistent effects at fixed doses
 Lack of routine laboratory testing
 Rapid onset of effects (anticoagulation achieved ~2 hours)
 Rapid loss of activity (e.g. when doses missed)
Clinical Decision Support that guides:

 Whether to interrupt anticoagulation for a procedure by balancing:

 Risk of bleeding from procedure
 Risk of thrombosis from underlying indication
 Timing of interruption of anticoagulation
 Peri-procedural “bridging” when appropriate
 Clinical monitoring
 Timing and dosing for resumption of anticoagulants
Pisters R, Lane DA, Nieuwlaat R, et al. A novel userfriendly
score (HAS-BLED) to assess 1-year risk of major bleeding in
patients with atrial fibrillation: the Euro Heart Survey. Chest.
2010;138:1093–100.
Minimal Bleeding risk:
Continue OAC

Low Bleeding risk:

Allow residual AC effect pre-op
(i.e. 2-3 half lives)
Restart within 24 hours

High Bleeding Risk:

No residual AC effect (i.e. 4-5
half lives)
Restart within 48-72 hours
Consequences of Thromboembolism and
Major Bleeding
 Arterial thromboembolism
 15% case fatality for heart valve thrombosis
 70% rate of death or disability in stroke

 Venous thromboembolism
 6% rate of death or permanent disability for DVT; 25% rate for PE

 Major bleeding
 8-9% case-fatality
Key Questions regarding Perioperative
Management of Patients on Chronic OACs
 Should oral anticoagulant therapy be discontinued?

 When VKA is discontinued, should the patient have perioperative “bridging” therapy with heparin
(UFH or LMWH)?
 The goal of bridging therapy with parenteral heparin (either UFH or LMWH), usually in therapeutic doses,
is to allow for continued anticoagulation during temporary discontinuation of vitamin K antagonist (VKA)
therapy, usually for an elective procedure or surgery

 What is the optimal periprocedural management of patients on DOACs needing interruption?

Key Questions regarding Perioperative
Management of Patients on Chronic OACs
 Should oral anticoagulant therapy be discontinued?
Minimal Bleed Risk Procedures

Minor dermatologic, cutaneous, dental, opthalmologic procedures (cataract

surgery), pacemaker/cardioverter-defibrillator device implantation

DO NOT INTERRUPT OAC!

*May consider interrupting DOAC on day of procedure

BRUISE CONTROL 1 AND 2
 Oral anticoagulant use is common among patients requiring pacemakers or defibrillator surgery
 Bridge or Continue Coumadin for Device Surgery Randominsed Controlled (BRUISE CONTROL) trial
demonstrated 80% fewer device pocket hematomas when surgery was performed without interruption of
warfarin, compared to warfarin treated patients who had their anticoagulation interrupted and received
heparin bridging
 Since the publication of the first BRUISE CONTROL trial the use of DOACs has drastically increased and
they are now used in the majority of patients with atrial fibrillation, leading to the Strategy of Continued
Versus Interrupted Novel Oral Anti-coagulant at Time of Device Surgery in Patients With Moderate to High
Risk of Arterial Thromboembolic Events (BRUISECONTROL 2) trial.
 BRUISECONTROL 2 showed that the rates of clinically significant haematoma were the same in both
continued and interrupted DOAC groups.

In a multivariate analysis including both BRUISE CONTROL 1 and BRUISE CONTROL 2 patients and
adjusted for antiplatelet use, there was no difference in clinically significant hematoma between direct oral
anticoagulants (DOACs) and warfarin
Key Questions regarding Perioperative
Management of Patients on Chronic OACs

 When VKA is discontinued, should the patient have perioperative “bridging” therapy with heparin
(UFH or LMWH)?
Siegel D et al Circulation 2012;126:1630 39
Siegel D et al Circulation 2012;126:1630 39
Key Questions regarding Perioperative
Management of Patients on Chronic OACs

 What is the optimal periprocedural management of patients on DOACs needing interruption?

Suggested Periprocedural Strategies of VKA and
DOACs Based on Procedural Bleed Risk

Spyropoulos AC et al J of Thromb
Haemost 2016;14(5):875 -85
Resuming Anticoagulation
 Hemostasis should be established prior to resumption of any anticoagulation
 Warfarin resumption after procedures thought to have moderate bleeding risk may be deferred
for 1-2 days if unexpected perioperative bleeding occurs
 For patients at high/ very high risk, it may be appropriate to resume LMWH or IV UFH therapy 24
hours after the procedure
 Even in the scenario that “bridging” is not indicated, post-procedure DVT prophylaxis should still
be considered in procedures that require routine prophylaxis
 For moderate risk thromboembolic risk patients with a moderate procedural bleeding risk: A
prophylactic LMWH dose may be used to bridge post-procedure to reduce risk of bleeding even if
therapeutic dose LMWH is used prior to procedure
 For High risk TE patients with a High procedural bleeding risk other options include:
 Post-procedure bridging with prophylactic LMWH until bleeding risk minimized then transition back to
therapeutic dose LMWH
 Post-procedure bridging with prophylactic LMWH only
 Resumption of warfarin alone with no LMWH/IV UFH

REFERENCES
 Doherty, J.U., Gluckman, T.J., Hucker, W.J. et al, 2017 ACC expert consensus decision
pathway for periprocedural management of anticoagulation in patients with nonvalvular
atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus
Document Task Force. J Am Coll Cardiol. 2017;69:871–898.
 Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in
Patients with Atrial Fibrillation. N Engl J Med 2015; 373:823.
 Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant
therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College
of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012.
 Olesen JB, Lip GYH, Hansen ML, et al. Validation of risk stratification schemes for
predicting stroke and thromboembolism in patients with atrial fibrillation: Nationwide
cohort study BMJ. 2011.
 Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative Management of
Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest.
2012;141(2 Suppl):e326S-e350S. doi:10.1378/chest.11-2298.