Periprocedural Antithrombotic Strategies

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Decision trees for periprocedural interruption of chronic oral anticoagulation (top) and for periprocedural bridging anticoagulation (bottom)

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Reference:

Rechenmacher, S., & Fang, J. (2015). Bridging Anticoagulation. Journal Of The American College Of Cardiology66(12), 1392-1403. doi: 10.1016/j.jacc.2015.08.002

Checklist: Perioperative Meds That Affect Haemostasis

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References

Hart, B., Ferrell, S., Motejunas, M., Bonneval, L., Cornett, E., Urman, R., & Kaye, A. (2018). New anticoagulants, reversal agents, and clinical considerations for perioperative practice. Best Practice & Research Clinical Anaesthesiology, 32(2), 165-178. doi: 10.1016/j.bpa.2018.06.008

DOACs vs NOACs?

Timeline

  • 2011 – dabigatran approved by FDA for stroke prevention in nonvalvular Afib and for VTE prophylaxis and treatment
  • 2011-2015 – factor Xa inhibitors rivaroxaban (2011), apixaban (2012) edoxaban (2015) approved by FDA for various indications including nonvalvular Afib, VTE prophylaxis and treatment and VTE recurrence
  • 2017 – betrixaban indicated for VTE prophylaxis in patients hospitalized for medical illness

Originally, these agents were called “novel oral anticoagulants” – new mechanism for oral anticoagulation – acronym NOAC.  There is at least one documented error where NOAC was mistaken to mean “no anticoagulation.”

In 2015, the International Society on Thrombosis and Haemostasis conducted a survey across North America and Europe discussing the terminology for these novel agents.  This society recommended against the use of the term NOAC, and for the use of DOAC to describe Factor Xa inhibitors and direct thrombin inhibitors.

Reference:

Hart, B., Ferrell, S., Motejunas, M., Bonneval, L., Cornett, E., Urman, R., & Kaye, A. (2018). New anticoagulants, reversal agents, and clinical considerations for perioperative practice. Best Practice & Research Clinical Anaesthesiology, 32(2), 165-178. doi: 10.1016/j.bpa.2018.06.008

NOACs – To bridge or not to bridge?

Periprocedural management of NOACs

 

See tables below to determine need for briding and/or interrupting NOACs:

 

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Simplified version:  (always interrupt if mod to high HR, consider bridging if high TR)d.JPG

 

a

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Reference:

Raval, Amish N. et al. “Management Of Patients On Non–Vitamin K Antagonist Oral Anticoagulants In The Acute Care And Periprocedural Setting: A Scientific Statement From The American Heart Association”. Circulation (2017): CIR.0000000000000477.

FXa and “Universal” Reversal Agent Drug Targets

TWO REVERSAL AGENTS IN DEVELOPMENT:
  • Andexanet alfa = recombinant modified FXa decoy molecule
    • see previous blog
  • Ciraparantag = reverse many anticoagulants including the FXa inhibitors
    • developed by Perosphere
    • formerly known as “aripazine” or “PER977”
    • di-arginine piperazine
    • small (512 Da) synthetic molecule
    • binds to UFH, LMWH, fondaparinux, DOACs
    • inactivates anticoagulants via noncovalent hydrogen binding, blocks binding to target sites of FIIa and FXa
FXa and “Universal” Reversal Agent Drug Targets:
capture

Reference:

Milling, Truman J. and Scott Kaatz. “Preclinical And Clinical Data For Factor Xa And “Universal” Reversal Agents”. The American Journal of Emergency Medicine 34.11 (2016): 39-45.

Anticoagulation in Patients with Brain Metastases

Treatment:

  • Anticoagulate in patients with brain tumors and VTE except if risk of ICH is high: i.e.
    • melanoma mets
    • renal cell carcinoma mets
    • choriocarcinoma mets
    • thyroid carcinoma mets
  • treat x 3-6 months; long term if malignant gliomas
  • LMWH recommended versus warfarin
  • If risk of ICH high:
    • IVC filter if significant residual brain mets
    • if mets already removed / treated effectively and medical condition too unstable – anticoagulate

DVT Prophylaxis:

  • do not anticoagulate except in post-operative period
  • use SCDs with post-op LMWH or UFH 12-24 hours after surgery
  • cotninue prophylaxis until ambulation resumed

 

REFERENCE:

Uptodate. “Anticoagulant and antiplatelet therapy in patients with brain tumors.” Accessed 08/12/2016.

Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 2007; 25:5490.