Anticoagulation Bridging

7/28/2019 Anticoagulation Bridging

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Anticoagulation

Bridging: New

Paradigms

Michael Benjamin, M.D.

February 2013

(And a little bit about reversing new anticoagulants)


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1. Bridging

anticoagulants


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Warfarin

Lovenox/Heparin/Arixtra

/Dalteparin

Warfarin


/Dalteparin

SURGERY

5 days 1d


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Hospital-Acquired Conditions

1. Foreign Object Retained After Surgery

2. Air Embolism

3. Blood Incompatibility

4. Stage III and IV Pressure Ulcers

5. Falls and Trauma

6. Manifestations of Poor Glycemic Control

7. Catheter-Associated Urinary Tract Infection (UTI)

8. Vascular Catheter-Associated Infection

9. Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):

10. Surgical Site Infection Following Bariatric Surgery for Obesity

11. Surgical Site Infection Following Certain Orthopedic Procedures

12. Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)

13. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic

Procedures:

Total Knee Replacement

Hip Replacement

14. Iatrogenic Pneumothorax with Venous Catheterization

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html


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A case of bridging gone wrong

1. Hypercoaguable state

2. Thrombosis

3. Overlap coumadin and

lovenox

4. Renal insufficiency

5. Bleeding


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Warfarin


/Dalteparin

Warfarin


/Dalteparin

SURGERY

5 days 1d


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Warfarin


/Dalteparin

Warfarin


/Dalteparin

SURGERY

5 days 1d


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Forest plot of thromboembolic events. Review of bridging studies.

Siegal D et al. Circulation 2012;126:1630-1639

Copyright American Heart Association


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Forest plot of overall bleeding events.

Siegal D et al. Circulation 2012;126:1630-1639

Copyright American Heart Association


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A case of bridging gone wrong

1. Hypercoaguable state

2. Thrombosis

3. Overlap coumadin and

lovenox

4. Renal insufficiency

5. Bleeding

ect veness o r g ng nt coagu at on or urgery e


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ect veness o r g ng nt coagu at on or urgery eStudy)

This study is currently recruiting participants.

Verified January 2013 by Duke University

Sponsor:

Duke University

Collaborator:National Heart, Lung, and Blood Institute (NHLBI)

Information provided by (Responsible Party):

Duke University

ClinicalTrials.gov Identifier:

NCT00786474

First received: November 5, 2008

Last updated: January 17, 2013

Last verified: January 2013

Estimated Enrollment: 3626

Study Start Date: July 2009Estimated Study Completion Date: March 2015

Estimated Primary Completion Date: January 2015

(Final data collection date for primary outcome measure)


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Longer LOS


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Longer LOS

More bleeding Fewer clots?


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Bridge warfarin?

NO

Cataract surgery

Dental

cleaning/extraction

Colonoscopy

Dr Samuel Z Goldhaber(Brigham

and Women's Hospital, Boston, MA)

AHA 2011


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Bridge warfarin?

YES

AF CHADS > 3

Multi-valve disease

Orthopaedic surgery

hip/knee

CONSIDER

1. Bleeding risk2. Thrombosis risk

Dr Samuel Z Goldhaber(Brigham

and Women's Hospital, Boston, MA)

AHA 2011


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Circulation.

2006; 114: e84-

e231


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Longer LOS

More bleeding Fewer clots?


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2. What about the new

anticoagulants?


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$245.97 /m $206.00/m $250.36 /m

AF AF AFHip/Knee repl.

DVT/PE

??????


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???

N Engl J Med 2011; 365:883-891

???


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3. Reversing the new

anticoagulants(If theyre bleeding, either way, itll be

$7,000)


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Beriplex P/N = Four factor PCC (not US!)


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Profilnine has II, IX, X and low levels

Factor VII = US version Three factor


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Dose = 7090mcg/kg


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Factor II

Factor IX

Factor XActivated Factor VII

Dose? Hemophilia = 50100 U /kg = 3000U in 60kg pt


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4. $$$


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Ann Intern Med. 4 January 2011;154(1):1-11

Daily cost =

$8.199

Statins in low risk

CHD prophylaxis

$9,900/QALY

Mammography 50-75 $50,000/QALY

Left main CABG $8,768/QALY


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Date of do nload Cop right The American College of Cardiolog

From: Efficacy and Safety of Dabigatran Compared to Warfarin in Patients With Paroxysmal, Persistent, and

Permanent Atrial Fibrillation: Results From the RE-LY (Randomized Evaluation of Long-Term

Anticoagulation Therapy) Study

J Am Coll Cardiol. 2012;59(9):854-855. doi:10.1016/j.jacc.2011.10.896

Event Rates and Hazard Ratios

Shown are the rates of stroke and systemic embolism and the rates of major bleeding with dabigatran etexilate (DE) 110 mg bid ,

dabigatran 150 mg bid, and warfarin (W) for the different types of atrial fibrillation (AF). The hazard ratios with 95% confidence limits

(CI) for the 2 doses of dabigatran compared to warfarin are also illustrated. RE-LY = Randomized Evaluation of Long-Term

Anticoagulant Therapy With Dabigatran Etexilate.

Figure Legend:

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Anticoagulation Bridging