Periopera,ve&Management&of&Pa,ents& …...2015/11/05 · James&D.&Douke,s&MD,&FRCP(C)& Dept.&of&Medicine,&St.&Joseph’s&Healthcare&and&& McMaster&University,&Hamilton,&Canada& Periopera,ve&Management&of&Pa,ents

James D. Douke,s MD, FRCP(C)

Dept. of Medicine, St. Joseph’s Healthcare and McMaster University, Hamilton, Canada

Periopera,ve Management of Pa,ents on Warfarin or NOACs:

Is heparin bridging needed? Periopera1ve NOAC management?

Disclosures for: James Douke,s

Research Support/P.I. Canadian Ins,tutes of Health Research, Heart and Stroke Founda,on of Canada, Boehringer-‐Ingelheim

Employee No relevant conflicts of interest to declare

Consultant Actelion, AGEN Biomedical, Bio,e, Boehringer-‐

Ingelheim, Cytori, Ortho, Janssen, Portola

Major Stockholder No relevant conflicts of interest to declare

Speakers Bureau No relevant conflicts of interest to declare

Honoraria Honouraria received from these sources deposited in

university-‐based research accounts

Scien,fic Advisory Board Astra-‐Zeneca, Bayer, Bristol-‐Myers-‐Squibb, Leo

Pharma, Medicines Co., Pfizer, Sanofi

Learning Objec,ves

•  To iden,fy warfarin-‐treated pa,ents in whom heparin bridging an,coagula,on is needed and not needed.

•  To describe safe prac,ces for bridging in pa,ents who require bridging an,coagula,on.

•  To consider the use of bridging in NOAC-‐treated pa,ents.

Periopera,ve An,coagula,on…lessons learned

•  IV unfrac,onated heparin SC LMWH

•  Full-‐dose LMWH on day -‐1 ½-‐dose LMWH

•  Resume bridging <24 h delay resump,on 48-‐72 h post-‐op in all pa,ents if high bleed risk

•  Resume usual dose double-‐dose warfarin

warfarin post-‐op post-‐op for 1-‐2 days

Douke,s J, et al. Arch Intern Med 2004 Dunn AS, et al. J Thromb Haemost 2006 Kovacs MJ, et al. Circula1on 2004 Douke,s J, et al. Thromb Haemost 2004 Spyropoulos A, et al. J Thromb Haemost 2006 Schulman S, et al. J Thromb Haemost 2014

•  Periopera,ve management of pa,ents on VKA is common… 315,000-‐1,275,000 pa,ents/yr in North America need warfarin interrup,on (based on 2.5 million users)

•  RE-‐LY study (warfarin vs. dabigatran for AF) 26% of pa,ents had at least 1 an,coagulant interrup,on during 2-‐yr follow-‐up

Healey JS, et al. Circula1on 2012;126:343 Douke,s J, et al. Chest 2008;133:399

What is the scope of this problem?

Warfarin will remain…despite NOACs

•  Atrial fibrilla,on: warfarin widely used in 2015 •  40-‐60% in USA and some EU countries •  >80% in La,n American countries

•  Atrial fibrilla,on or venous thromboembolism •  excellent INR control (>70% within therapeu,c range) •  CrCl <30 mL/min •  NOAC cost issues

•  Mechanical heart valves •  warfarin only op,on

Xu Y, et al. CMAJ Open 2013;1:E115-‐9 Desai NR, et al. Am J Med 2014;127:1075 Olesen JB, et al. Europace 2015;17:187

• 75-‐year old female with atrial fibrilla,on (AF) is receiving warfarin (target INR: 2.0-‐3.0)

-‐ hypertension, diabetes -‐ CHADS2 = 3

• Scheduled for elec,ve colon resec,on for incidentally found colon cancer…

One doctor told her she needs to be assessed for heparin bridging.

Another doctor told her she does not need bridging.

Case Presenta1on

How to manage this pa,ent’s an,coagulants?

1)  stop warfarin 5 days pre-‐op, give bridging with LMWH (e.g. enoxaparin, 1 mg/kg BID) pre-‐op and post-‐op, first dose star,ng <24 hrs post-‐op

2)  stop warfarin 5 days pre-‐op, give bridging with LMWH pre-‐op and post-‐op, first dose star,ng 48-‐72 hrs post-‐op

3)  stop warfarin 5 days pre-‐op, administer LMWH (e.g. enoxaparin, 40 mg daily) pre-‐ and post-‐op

4)  stop warfarin 5 days pre-‐op and resume arer procedure

What do the prac1ce guidelines tell us?

High Risk (consider bridging):

Atrial fibrilla,on

•  recent (<3 mos) stroke/TIA

•  CHADS 5-‐6 •  rheuma,c heart Mechanical heart valve •  caged-‐ball or ,l,ng disc valve •  mitral valve •  recent (<6 mos) stroke/TIA

VTE •  recent (<3 mos) VTE •  severe thrombophilia (protein C, S or

AT deficiency, APLA)

Moderate Risk: Atrial fibrilla,on •  CHADS 3-‐4 Mechanical heart valves •  bileaflet AVR + major risks VTE •  VTE within 3-‐12 months or cancer

Low Risk (consider NO bridging): Atrial fibrilla,on •  CHADS 0-‐2 (no prior stroke) Mechanical heart valves •  bileaflet AVR without risks VTE •  VTE >12 months ago

Thromboembolic Risk Stra1fica1on and Need for Bridging during Warfarin Interrup1on

Douke,s J, et al. Chest 2012;141(Suppl):e326S

Pa,ents on Warfarin who need a Surgery or Procedure: Bridging or No Bridging?

•  Recommenda1on: In pa,ents with a MHV or AF or VTE at low risk for thromboembolism, we suggest low-‐dose SC LMWH or no bridging instead of bridging with therapeu,c-‐dose SC LMWH or IV UFH. (Grade 2C)

•  Recommenda1on: In pa,ents with a MHV or AF or VTE at high risk for TE, we suggest bridging with therapeu,c-‐dose SC LMWH instead of no bridging. (Grade 2C)

Douke,s J, et al. Chest 2012;141(Suppl):e326S

What about Pa,ents at Moderate Risk for Thromboembolism (like our example)?

Recommenda1on: There is NO recommenda,on!

“In pa1ents with a MHV, AF or VTE at moderate risk for thromboembolism, the bridging or no-‐bridging approach chosen is based on an assessment of individual pa1ent-‐ and surgery-‐related factors.”

Periopera,ve Risk for Thromboembolism: Bridging vs. No Bridging Strategies (observa,onal studies)

No significant risk reduc,on for TE with heparin bridging…BUT, major poten,al confounding effect

Siegal D, et al. Circula1on 2012;126:1630

Periopera,ve Risk for Bleeding: Bridging vs. No Bridging Strategies (observa,onal studies)

Bridging associated with 3-‐ to 4-‐fold increase in major bleeding…is it an acceptable trade-‐off to prevent TE?

Siegal D, et al. Circula1on 2012;126:1630

BRUISECONTROL Randomized Trial

Pa,ents on warfarin who need a pacemaker/ICD Randomized to:

(a) con,nue warfarin (ensure INR <3.0 at procedure) (b) interrupt warfarin + bridge (enoxaparin 1 mg/kg BID), star,ng within 24 hours post-‐procedure

Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interrup,on of an,coagula,on. N Engl J Med 2013;368:2084-‐93.

BRUISECONTROL Randomized Trial Results: incidence of pacemaker hematoma

con,nue warfarin…………………….3.5% interrupt warfarin + bridging……….16.0% (P <0.01)

But…higher rates of bleeding with bridging likely because bridging started too soon arer procedure!

In another study where bridging started within 24 hrs of high-‐bleed risk surgery (Dunn AS, et al. JTH 2004;5:2211), rate of major bleed = 20%

BRIDGE Trial

Pa,ents on warfarin who need elec,ve surgery/procedure, interrupt warfarin and randomized to:

(a) bridging (dalteparin 100 IU/kg BID) pre-‐/post-‐procedure

(a) no bridging

Douke,s JD, Spyropoulos AC, Kaatz S, et al. Periopera,ve bridging in pa,ents with atrial fibrilla,on. N Engl J Med 2015;373:823

Study Hypotheses

1)  Forgoing bridging an,coagula,on would be non-‐inferior to bridging with LMWH for the preven,on of periopera,ve arterial thromboembolism (ATE) 1% ATE in bridging group, 1% ATE in no bridging group

-‐ and -‐

2)  Forgoing bridging an,coagula,on would be superior to bridging with respect to major bleeding (MB)

3% MB in bridging group, 1% MB in no bridging group

Study Methods •  Randomized, double-‐blind, placebo-‐controlled trial

•  Pa,ents: AF with CHADS2 ≥1 (excluded if mechanical heart valve or CrCl <30 mL/min)

•  Warfarin stopped 5 days pre-‐procedure, resumed ≤24 hrs arerwards

•  Pa,ents randomized to: – bridging with dalteparin, 100 IU/kg BID or matching placebo for 3 days pre-‐ and 5–10 days post-‐procedure

•  Follow-‐up for 30 days post-‐procedure

BRIDGE Trial Design

Pa,ent Characteris,cs Characteris,c No Bridging (N=950) Bridging (N=934)

Age, yr 71.8±8.74 71.6±8.88 Male sex, no. (%) 696 (73.3) 686 (73.4) Race, no. (%) White 860 (90.5) 849 (90.9) Nonwhite 88 (9.3) 82 (8.8) Unknown 2 (0.2) 3 (0.3) Weight, kg 96.2±24.87 95.4±23.50 CHADS2 score Mean 2.3±1.03 2.4±1.07 DistribuPon, no. (%) 0 1 (0.1) 1 (0.1) 1 216 (22.7) 212 (22.7) 2 382 (40.2) 351 (37.6) 3 229 (24.1) 232 (24.8) 4 96 (10.1) 106 (11.3) 5 23 (2.4) 27 (2.9) 6 3 (0.3) 5 (0.5)

Surgeries and Procedures* Surgery/Procedure Type No Bridging Bridging Minor, no. (%) (n=781) (n=758)

GastrointesPnal 391 (50.1) 357 (47.1)

Cardiothoracic 139 (17.8) 151 (19.9)

Orthopedic 54 (6.9) 47 (6.2)

Urologic 41 (5.3) 45 (5.9)

Other 156 (19.9) 158 (20.9)

Major, no. (%) (n=94) (n=89)

Orthopedic 29 (30.9) 29 (32.6)

Urologic 26 (27.7) 20 (22.5)

General surgery 16 (17.0) 14 (15.7)

Other 23 (24.5) 26 (29.2)

*Ini,al classifica,on of surgery/procedure not always aligned to bleeding risk designa,on.

Periopera,ve An,coagulant Management

Variable No Bridging (N=950)

Bridging (N=934)

P Value

Warfarin treatment

Pre-‐procedure ,me not taking warfarin

PaPents with data 872 839 0.28

mean, days 5.2±1.4 5.3±1.8

Time to first post-‐procedure warfarin dose


mean, days 1.5 (1.3) 1.4 (1.0)

Aspirin treatment, no./total no. (%)

Interrup,on ≥7 days pre-‐procedure 92/324 (28.4) 92/329 (28.0)

0.53 Interrup,on <7 days pre-‐procedure 41/324 (12.7) 33/329 (10.0)

No interrup,on 191/324 (59.0) 204/329 (62.0)

Periopera,ve An,coagulant Management Variable

No Bridging (N=950)

Bridging (N=934)

P value

LMWH or placebo

Pre-‐procedure dose PaPents with data, no.

796 768 0.61

Mean no. of doses 5.0±0.7 5.0±1.4

Pa,ents in whom last dose was taken on the morning of the day before the procedure, no./total no.

778/796 (97.7)

734/768 (95.6)

0.01

Time to first post-‐procedure dose

Major surgery/procedure (high bleeding risk)


mean, hr 53.3±31.6 51.3±27.9

Minor surgery/procedure (low bleeding risk)


mean, hr 21.1±2.3 21.0±2.4

Post-‐procedure dose PaPents with data 764 721

0.47 Mean no. of doses 15.7±7.4 16.1±8.4

Primary Study Outcomes

Outcome No. (%)

No Bridging (N = 918)

Bridging (N = 895)

P-‐ value

ATE 4 (0.4) 3 (0.3) 0.01 (non-‐infer.) 0.73 (super.)

-‐ stroke 2 (0.2) 3 (0.3)

-‐ TIA 2 (0.2) 0 (0)

-‐ systemic embolism 0 (0) 0 (0)

Major bleeding 12 (1.3) 29 (3.2) 0.005 (super.)

•  Mean CHADS2 in pa1ents with TE event = 2.6 (range, 1-‐4) •  Median 1me to TE event = 19.0 days (IQR, 6.0-‐23.0) •  Median 1me to major bleed = 7.0 days (IQR, 4.0-‐18.0)

Secondary Study Outcomes

Outcome No. (%)

No Bridging (N = 918)

Bridging (N = 895) P-‐value

Death 5 (0.5) 4 (0.4) 0.88 (sup)

Myocardial infarc,on 7 (0.8) 14 (1.6) 0.10 (sup)

Deep vein thrombosis 0 (0) 1 (0.1) 0.25 (sup)

Pulmonary embolism 0 (0) 1 (0.1) 0.25 (sup)

Minor bleeding 110 (12.0) 187 (20.9) <0.001 (sup)

Study Limita,ons •  Few pa,ents had a high CHADS2 score (e.g., 5-‐6)

•  Most pa,ents had low bleed risk procedures, such as colonoscopy or ambulatory surgery

•  Overall rate of ATE was lower than expected

•  Findings should not be applied to pa,ents with mechanical heart valves or VTE…or on NOAC

Study Conclusion

•  For pa,ents with AF who require warfarin interrup,on for elec,ve surgery/procedure, a strategy of forgoing bridging was non-‐inferior to bridging with LMWH for preven,on of ATE

•  Forgoing bridging also decreased the risk of major bleeding compared to bridging with LMWH

• 75 yr-‐old woman with AF, hypertension and prior TIA (CHADS2 = 4) on dabigatran, 150 mg BID

• Scheduled for total hip replacement with spinal anesthesia (Monday, Nov 2, @1PM). • CrCl = 54 mL/min (wt = 80 kg, creat = 100 umol/L)

One doctor told her to take last dose of dabigatran on Friday PM (2 days off before surgery).

Another doctor told her to take last dose on Tuesday PM (5 days off before surgery) and receive bridging for 2-‐3 days.

Case Presenta1on

Douketis J et al. Perioperative Management of Antithrombotic Therapy. Chest 2012;141:e326S

Do not address perioperative management of NOACs

Samama CM, Gogarten L. European Society of Anaesthesiology 2012 Congress http://esra.ekonnect.co/ESRA_405/poster_46273/program.aspx

Stop all NOACs 4–5 days before a surgery/procedure and consider LMWH bridging in high-risk patients

Guidance on Periopera,ve Management Varies

Verma A et al. Canadian Cardiovascular Society Can J Cardiol 2014;30:1114

Stop NOACs 1–2 days before surgery with low bleeding risk and 2–3 days before surgery with high risk of major bleeding*

*For dabigatran when eGFR ≥80 mL/min/1.73 m2

2015 ASRA Guidelines on Periopera,ve NOAC Management

Narouze S, et al. Reg Anesth Pain Med 2015;40:182

NOAC Interrup,on Interval Post-‐op Resump,on dabigatran 4-‐6 days 24 hrs

apixaban 3-‐5 days 24 hrs

rivaroxaban 3 days 24 hrs

2015 ASRA Guideline Recommenda,ons for Interven,onal Spine and Pain Procedure

•  “We recommend a 5 half-‐life interval between discon1nua1on of a NOAC and a medium-‐ to high-‐risk procedure.”

•  “If the risk of VTE is high, we recommend LMWH bridging during the stoppage of the NOAC with the LMWH discon1nued 24 hours before the procedure.”

•  “We could not provide strength and grading of recommenda1ons as there are not enough well-‐designed studies concerning interven1onal pain procedures to support such grading.”

Narouze S, et al. Reg Anesth Pain Med 2015

Periopera,ve Dabigatran Cohort Study

Schulman S, et al. Circula1on 2015

•  Mul,-‐centre Canadian prospec,ve cohort study

•  541 pa,ents with AF on dabigatran who required an elec,ve surgery/procedure received standardized periop. management

•  Dabigatran stopped 1-‐4 days pre-‐procedure (as per algorithm) and resumed 24-‐72 hrs post-‐procedure (when hemostasis secured)

•  No heparin bridging given

•  Follow-‐up period: 5-‐7 days pre-‐ UNTIL 30 days post-‐procedure

Results: ▫  1 TIA (0.2%) ▫  10 major bleeds (1.8%) ▫  28 minor bleeds (5.2%)

Risks and Benefits of LMWH Bridging during NOAC Interrup,on: RE-‐LY Trial Sub-‐study

•  Prevalence of bridging during an,coagulant interrup,on •  warfarin……..28% •  dabigatran….15% (30-‐40% in NA and EU countries)

•  With dabigatran interrup,on, bridged pa,ents had more major bleeding than pa,ents not bridged:

6.5% vs. 1.8%; OR = 3.68 (CI: 2.2-‐6.0)

•  Bridged and not bridged groups did not differ for SSE: 0.5% vs. 0.3%; OR = 1.82 (CI: 0.37-‐9.1)

Douke,s J, et al. Thromb Haemost 2014;113

Blood Sub-‐study in 181 pa,ents: Plasma sample taken just before surgery/procedure

Coagula,on Test Normal Range Near-‐normal

PT 11-‐15 sec -‐

aPTT 25-‐35 sec 36-‐45 sec

TT 20-‐30 sec -‐

dilute TT -‐ Hemoclot® <20 ng/mL 20-‐40 ng/mL

Douke,s J, et al. J Thromb Haemost 2015 (online)

Laboratory Characteris,c Low Bleed Risk (n = 118)

High Bleed Risk (n = 63)

aPTT

mean, sec (SD) 35.5 (15.4) 30.7 (4.2) normal (22-‐35 sec), n (%) 91 (75.2) 54 (88.5) minimally elevated (36-‐45 sec), n (%) 20 (16.5) 5 (8.2) TT

mean, sec (SD) 55.9 (34.9) 34.8 (18.8) normal (20-‐30 sec), n (%) 24 (19.8) 36 (59.0) Dilute TT

mean (SD) 27.4 (28.1) 20.1 (4.3) normal (<20 ng/mL), n (%) 91 (75.2) 55 (90.2 )

minimally elevated (20-‐40 ng/mL), n (%) 18 (14.9) 5 (8.2)

Results: Effect of Dabigatran Interrup,on on Coag. Tests

Douke,s J, et al. J Thromb Haemost 2015 (online)

Effect of Dabigatran Interrup,on on: TT

(sec)

Effect of Dabigatran Interrup,on on: aPTT

(sec)

Effect of Dabigatran Interrup,on on: dilute TT

(ng/mL)

Laboratory Characteris,c Low Bleed Risk (n = 37)

High Bleed Risk (n = 22)

aPTT

mean, sec (SD) 32.8 (5.6) 29.7 (2.4) normal (22-‐35 sec), n (%) 29 (78.4) 22 (100) minimally elevated (36-‐45 sec), n (%) 7 (18.9) -‐ TT

mean, sec (SD) 37.7 (17.6) 29.1 (10.6) normal (20-‐30 sec), % (n) 14 (37.8) 17 (77.3) Dilute TT

mean (SD) 20.4 (6.7) 19.6 (2.6) normal (<20 ng/mL) % (n) 34 (91.9) 21 (95.4)

minimally elevated (20-‐40 ng/mL) % (n) 2 (5.4) 1 (4.6)

Results: Effect of Dabigatran Interrup,on on Coagula,on Tests with Longer Interrup,on (PAUSE Study Protocol)

Douke,s J, et al. Reg Pain Med Analg 2015 (submi}ed)

PAUSE Study • Aim: To establish a safe, standardized protocol for the periopera,ve management of pa,ents with atrial fibrilla,on (AF) who are taking a NOAC and need an elec,ve surgery/procedure.

• Design: Mul,-‐centre prospec,ve cohort study

• Pa,ents: 3,300 pa,ents with AF (1,100 per NOAC)

• NOAC interrup,on interval: 4-‐5 half-‐lives (3-‐6% residual an,coagulant effect)

High-‐bleed risk surgery/procedure (CrCl >50 mL/min)

When to Interrupt Dabigatran?

TIME Thursday Friday Saturday Sunday Monday (surgery)

AM Ø

PM Ø Ø

Ø

Low-‐bleed risk surgery/procedure (CrCl >50 mL/min)

High-‐bleed risk surgery/procedure

When to Interrupt Dabigatran (CrCl <50 mL/min)?


AM Ø Ø Ø

PM Ø Ø Ø Ø

Ø

Low-‐bleed risk surgery/procedure


When to interrupt apixaban?


AM Ø

PM Ø Ø

Ø



When to interrupt rivaroxaban?


AM Ø Ø


When to Interrupt NOACs before Surgery?

NOAC Surgery Type

Low Bleed Risk High Bleed Risk

dabigatran (do not take NOAC on surgery day)

-‐ CrCl ≥50 skip 1 day skip 2 days

-‐ CrCl <50 skip 2 days skip 4 days

rivaroxaban skip 1 day skip 2 days

apixaban skip 1 day skip 2 days

www.thrombosiscanada.ca

…back to the Learning Objec,ves

•  To iden,fy warfarin-‐treated pa,ents in whom heparin bridging an,coagula,on is needed and not needed. •  DON’T bridge most pa,ents with AF (CHADS2 <5)

•  DO bridge pa,ents with mechanical mitral valves or older aor,c valves

•  DON’T bridge pa,ents needing pacemaker/ICD

•  To describe safe prac,ces for bridging in pa,ents who require bridging an,coagula,on. •  BRIDGE trial provides ‘bridging protocol’ with low rates of thromboembolism and bleeding

…back to the Learning Objec,ves

•  To consider the use of bridging in NOAC-‐treated pa,ents •  bridging not needed…more research is needed …including the PAUSE study

•  empiric, easy-‐to-‐use protocols available:

www.thrombosiscanada.ca

Documents

Periopera,ve&Management&of&Pa,ents& …...2015/11/05 · James&D.&Douke,s&MD,&FRCP(C)& Dept.&of&Medicine,&St.&Joseph’s&Healthcare&and&& McMaster&University,&Hamilton,&Canada& Periopera,ve&Management&of&Pa,ents