A Clinician’s Guide to Perioperative Bridging for Patients on Oral Anticoagulation

2010 ◽  
Vol 23 (4) ◽  
pp. 303-312 ◽  
Author(s):  
Michelle T. Martin ◽  
Ann M. Kuchta ◽  
Edith A. Nutescu
Keyword(s):  
Risk Stratification ◽  
Oral Anticoagulation ◽  
Oral Anticoagulant Therapy ◽  
Bleeding Risk ◽  
Careful Consideration ◽  
Invasive Procedures ◽  
Bridging Therapy ◽  
Thrombosis Risk ◽  
Perioperative Anticoagulation ◽  
Risk Of Hemorrhage

Updates in recent clinical guidelines have led to a change in the management of perioperative anticoagulation for patients on oral anticoagulant therapy. No standardized bridging consensus exists in the literature. The necessity for bridging therapy is determined based on careful consideration of the thrombosis risk versus the bleeding risk of the procedure. Risk stratification will aid the decision to bridge or not to bridge. Patients are bridged with agents with appropriate kinetics to allow for their elimination prior to the time of the procedure in order to decrease the risk of hemorrhage during invasive procedures. This intent of this article is to discuss perioperative bridging therapy and provide a practical guide for the clinician.

scholarly journals Perioperative management of anticoagulant therapy

2019 ◽  
Vol 4 (4) ◽  
pp. 144-151
Author(s):  
Johanna Wagner ◽  
Johan F. Lock ◽  
Carolin Kastner ◽  
Ingo Klein ◽  
Katica Krajinovic ◽  
...  
Keyword(s):  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Invasive Procedure ◽  
Bleeding Risk ◽  
Coumarin Derivative ◽  
Bridging Therapy ◽  
Perioperative Bleeding ◽  
Increased Risk ◽  
Risk For Bleeding

AbstractAbout 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an increased risk for peri-interventional or perioperative bleeding. Depending on the risk for thromboembolism and the risk for bleeding, the physician has to decide whether the anticoagulant therapy should be interrupted or continued. Patient characteristics such as age, renal function and drug interactions must be considered. The perioperative handling of the oral anticoagulant therapy differs according to the periprocedural bleeding risk. Patients requiring a procedure with a minor risk for bleeding do not need to pause their anticoagulant therapy. For procedures with an increased risk for perioperative bleeding, the anticoagulant therapy should be adequately paused. For patients on a coumarin derivative with a high risk for a thromboembolic event, a perioperative bridging therapy with a low molecular weight heparin is recommended. Due to an increased risk for perioperative bleeding in patients on a bridging therapy, it is not recommended in patients with a low risk for thromboembolism. For patients taking a non-vitamin K oral anticoagulant, a bridging therapy is not recommended due to the fast onset and offset of the medication.

Bleeding risk of submuscular ICD implantation with continued oral anticoagulation versus heparin bridging therapy

2017 ◽  
Vol 33 (4) ◽  
pp. 441-446 ◽  
Author(s):  
Simon Pecha ◽  
Ayhan Ayikli ◽  
Iris Wilke ◽  
Samer Hakmi ◽  
Yalin Yildirim ◽  
...  
Keyword(s):  
Oral Anticoagulation ◽  
Bleeding Risk ◽  
Bridging Therapy ◽  
Icd Implantation

Oral Anticoagulation in the Prevention of One-Year Vein Graft Occlusion after Aortocoronary Bypass Surgery: Optimal Therapeutic Range and Practical Limitations

1994 ◽  
Vol 72 (05) ◽  
pp. 676-681 ◽  
Author(s):  
J van der Meer ◽  
H L Hillege ◽  
P H J M Dunselman ◽  
B J M Mulder ◽  
H R Michels ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Major Bleeding ◽  
Oral Anticoagulation ◽  
Vein Graft ◽  
Oral Anticoagulant Therapy ◽  
Coronary Bypass ◽  
Graft Patency ◽  
Graft Occlusion ◽  
Coronary Bypass Grafts ◽  
One Year

SummaryTo assess the optimal level of oral anticoagulation to prevent occlusion of vein coronary bypass grafts, 318 patients from a graft patency trial were analysed retrospectively. Oral anticoagulant therapy was started one day before surgery and continued for one year, after which graft occlusion was assessed by angiography. The aimed level of anticoagulation was 2.8-1.8 International Normalized Ratio (INR). Clinical outcome was assessed by the incidence of myocardial infarction, thrombosis and major bleeding.The observed anticoagulation level was 2.8-4.8 INR for 54%, and 1.8-3.8 INR for 75% of time per patient. Occlusion rates in patients who spent <35, 35-70, and ≥70% of time within INR range 2.8-1.8 were 10.5%, 10.8% and 11.8%, respectively (differences not statistically significant). Patients who spent ≥70% of time within INR range 1.8-3.8 versus 2.8-4.8 showed comparable occlusion rates. The risk of graft occlusion was not related to quality of anticoagulation early (0-3 months) or late (3-12 months) after surgery. Myocardial infarction, thrombosis and major bleeding occurred in 1.3%, 2.0% and 2.9% of patients.To maintain vein graft patency in the first postoperative year by oral anticoagulation, a level within INR range 1.8-3.8 for ≥70% of time seems to be sufficient.

Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

2021 ◽  
Vol 42 (02) ◽  
pp. 183-198
Author(s):  
Georgios A. Triantafyllou ◽  
Oisin O'Corragain ◽  
Belinda Rivera-Lebron ◽  
Parth Rali
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Prediction Models ◽  
Bleeding Risk ◽  
Hemodynamic Instability ◽  
Reperfusion Therapy ◽  
Mortality Prediction ◽  
Risk Scores ◽  
Short Term Mortality ◽  
Urgent Patient

AbstractPulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

The current treatment and predictors of outcome in elderly patients with non-ST-elevation myocardial infarction in an all comers population: the POPular Age registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M.E Gimbel ◽  
D.R.P.P Chan Pin Yin ◽  
R.S Hermanides ◽  
F Kauer ◽  
A.H Tavenier ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Elderly Patients ◽  
Major Bleeding ◽  
Oral Anticoagulation ◽  
Dual Antiplatelet Therapy ◽  
Bleeding Risk ◽  
Cardiovascular Death ◽  
St Elevation ◽  
One Year

Abstract Background Elderly patients form a large and growing part of the patients presenting with non-ST-elevation myocardial infarction (NSTEMI). Choosing the optimal antithrombotic treatment in these elderly patients is more complicated because they frequently have characteristics indicating both a high ischaemic and high bleeding risk. Purpose We describe the treatment of elderly patients (&gt;75 years) admitted with NSTEMI, present the outcomes (major adverse cardiovascular events (MACE) and bleeding) and aim to find predictors for adverse events. Methods The POPular AGE registry is an investigator initiated, prospective, observational, multicentre study of patients aged 75 years or older presenting with NSTEMI. Patients were recruited between August 1st, 2016 and May 7th, 2018 at 21 sites in the Netherlands. The primary composite endpoint of MACE included cardiovascular death, non-fatal myocardial infarction and non-fatal stroke at one-year follow-up. Results A total of 757 patients were enrolled. During hospital stay 76% underwent coronary angiography, 34% percutaneous coronary intervention and 12% coronary artery bypass grafting (CABG). At discharge 78.6% received aspirin (non-users mostly because of the combination of oral anticoagulant and clopidogrel), 49.7% were treated with clopidogrel, 34.2% with ticagrelor and 29.6% were prescribed oral anticoagulation. Eighty-three percent of patients received dual antiplatelet therapy (DAPT) or dual therapy consisting of oral anticoagulation and at least one antiplatelet agent for a duration of 12 months. At one year, the primary outcome of cardiovascular death, myocardial infarction or stroke occurred in 12.3% of patients and major bleeding (BARC 3 or 5) occurred in 4.8% of the patients. The risk of MACE and major bleeding was highest during the first month and stayed high over time for MACE while the risk for major bleeding levelled off. Independent predictors for MACE were age, renal function, medical history of CABG, stroke and diabetes. The only independent predictor for major bleeding was haemoglobin level on admission. Conclusion In this all-comers registry, most elderly patients (≥75 years) with NSTEMI are treated with DAPT and undergoing coronary angiography the same way as younger NSTEMI patients from the SWEDEHEART registry. Aspirin use was lower as was the use of the more potent P2Y12 inhibitors compared to the SWEDEHEART which is very likely due to the concomitant use of oral anticoagulation in 30% of patients. The fact that ischemic risk stays constant over 1 year of follow-up, while the bleeding risk levels off after one month may suggest the need of dual antiplatelet therapy until at least one year after NSTEMI. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca

Evaluation of Bleeding Risk Prior to Invasive Procedures

2021 ◽  
pp. 411-422
Author(s):  
Andrea Lewin ◽  
Katelyn W. Sylvester ◽  
Jean M. Connors
Keyword(s):  
Bleeding Risk ◽  
Invasive Procedures

Thromboprophylaxis in atrial fibrillation: device therapy and surgical techniques

ESC CardioMed ◽  
2018 ◽  
pp. 2198-2204
Author(s):  
Thorsten Lewalter ◽  
Clemens Jilek ◽  
Klaus Tiemann
Keyword(s):  
Antiplatelet Therapy ◽  
Oral Anticoagulation ◽  
Left Atrial ◽  
Surgical Techniques ◽  
Bleeding Risk ◽  
Surgical Approaches ◽  
Antiplatelet Medication ◽  
High Bleeding Risk ◽  
Bleeding History

The concept of left atrial appendage (LAA) occlusion is to mainly prevent stroke by excluding the most relevant source of embolism from the blood circulation. The LAA can be occluded by a number of interventional or surgical approaches. Following a successful LAA occlusion implant procedure or surgical LAA exclusion, oral anticoagulation is typically terminated, followed by antiplatelet therapy, which is routinely used in the post-implant phase for 3–6 months. The need for chronic antiplatelet therapy is still unclear. Most patients are maintained on a single antiplatelet medication, but patients with a particularly high bleeding risk receive no chronic drug therapy. Currently, the main indication for LAA occluder implantation or LAA exclusion is stroke prevention in patients at high stroke risk, with contraindications for long-term oral anticoagulation due to a bleeding history or an otherwise elevated risk for major bleeding.

4037Nurse counseling of patients with atrial fibrillation to improve compliance to oral anticoagulation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
R Chilian-Hof ◽  
S Schnupp ◽  
C Mahnkopf ◽  
J Brachmann ◽  
C Kleinecke
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Oral Anticoagulation ◽  
Vitamin K Antagonists ◽  
Randomised Trial ◽  
Female Gender ◽  
Bleeding Risk ◽  
Telephone Counseling ◽  
Bleeding Events

Abstract Background Atrial fibrillation (AF) is the most frequent arrhythmia with a prevalence of 1%–2% in the general population. Oral anticoagulation (OAC) is state-of-the art for preventions of thromboembolic events, in particular ischemic stroke, in patients with atrial fibrillation. Despite its proven benefit, numerous studies have documented under use of OAC for a variety of reasons. Purpose To establish a program of nurse counseling in patient with atrial fibrillation and treatment with oral anticoagulation. The program is designed to improve patients satisfaction, compliance to OAC, prevention of medication errors, ischemic and bleeding events. Methods Patients with atrial fibrillation and treatment with oral anticoagulation were prospectively identified at the department of cardiology of our clinic. They received a 30 minutes nurse counseling about oral anticoagulation during the hospital stay and another 30 minutes telephone counseling 3 months after inclusion. Furthermore, they received a brochure to inform about atrial fibrillation, oral anticoagulation and methods to improve medication compliance. Demographic characteristics with stroke and bleeding risk (CHA2DS2-VASc and HAS-BLED scores), as well as procedural data were systematically assessed in a predefined standardized way and captured in a dedicated database. Results Between June 2017 and January 2018, a total of 617 patients (female gender: 43.1%) with atrial fibrillation and oral anticoagulation received nurse counseling. Demographic and follow-up data of 204 patients (female gender: 85/204 (41.7%); mean age 69.7±17.3, CHA2DS2-VASc score 4.2±1.7, HAS-BLED score 2.8±0.37) were assessed in a dedicated database. Indication for OAC was paroxysmal and persistent/permanent AF in 110/204 (53.9%), 93/204 (45.6%) and others 17 (8.3%), respectively. 33/2014 (16.2%) were treated with vitamin K antagonists, and 172/204 (84.3%) with non-vitamin K antagonists. After a follow-up of 0.46±2.9 years and 187 patients-years the rates of cardiovascular death, major bleeding events and all-cause stroke and TIA were 1.07%, 2.14% and 1.61% per 100 patient-years. Conclusion Nurse counseling in patients with atrial fibrillation and treatment with oral anticoagulation has been established at the REGIOMED clinics, Germany. Its effectiveness in terms of quality of live, medication complications and cardiovascular events has to be proven in a randomised trial. Acknowledgement/Funding Daichi-Sankyo

scholarly journals How to define the relative contraindications to oral anticoagulant therapy

2017 ◽  
Vol 87 (2) ◽  
Author(s):  
Roberto F.E. Pedretti
Keyword(s):  
Risk Factors ◽  
Anticoagulant Therapy ◽  
Clinical Judgment ◽  
Oral Anticoagulant Therapy ◽  
Hierarchical Classification ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Clinical Settings ◽  
High Bleeding Risk ◽  
European Society Of Cardiology

<p>There is currently a lack of consensus on which anticoagulant therapy contraindications should be considered “absolute” and which should be considered “relative”. Guidelines do not clearly identify absolute and relative contraindications to anticoagulant therapy. Recent guidelines on AF of the European Society of Cardiology underline the relevance of several factors and their use in scores, leaving anyway space to the clinical judgment of the physician. A high bleeding risk score should generally not result per se in a contraindication to anticoagulant therapy. Rather, bleeding risk factors should be identified and treatable factors corrected. A combined use of a more hierarchical classification of the different bleeding risk factors and the risk scores probably represents the best approach to maximize the benefit of anticoagulant therapy in various clinical settings.</p>

scholarly journals Antithrombotic Therapy in Patients with Atrial Fibrillation and Acute Coronary Syndrome

2020 ◽  
Vol 9 (7) ◽  
pp. 2020
Author(s):  
Wilbert Bor ◽  
Diana A. Gorog
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Combination Therapy ◽  
Bleeding Risk ◽  
Careful Consideration ◽  
P2y12 Inhibitor ◽  
Coronary Syndrome ◽  
Antithrombotic Efficacy ◽  
Selection Of ◽  
Made In

Acute coronary syndrome and atrial fibrillation are both common and can occur in the same patient. Combination therapy with dual antiplatelet therapy and oral anticoagulation increases risk of bleeding. Where the two conditions coexist, careful consideration is needed to determine the optimal antithrombotic treatment to reduce the risks of future ischaemic events associated with both conditions. Choices can be made in intraprocedural anticoagulation, type and dosing of oral anticoagulant, duration of combination therapy, and selection of P2Y12 inhibitor including genetic testing. This review article provides an overview of the available evidence to support clinicians in finding the delicate balance between antithrombotic efficacy and bleeding risk in patients with acute coronary syndrome and atrial fibrillation.

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