Transcript Bridging Talk M. Blostein

Case #1
• 83 year old male
• Mechanical aortic valve
• Hernia repair
Estimated Rates of Thromboembolism Associated with Various Indications for Oral
Anticoagulation, and the Reduction in Risk Due to Anticoagulant Therapy
Kearon C and Hirsh J. N Engl J Med 1997;336:1506-1511
JGH protocol
5000 u
Fragmin for
High risk bleeding
procedures
High Risk Bleeding Procedures
Low Risk Bleeding Procedure
Major Orthopedic Surgery
Genitourinary surgery
Neurosurgery
Oacemaker insertion
Vascular Surgery
Endoscopy with possibility of biopsy
Abdominal Hysterectomy
Non-cancer Abdominal surgery
Cholecystectomy
Hernia Repair
Node dissection
Vaginal Hysterectomy
Hand surgery
Skin procedure
Line insertion
Case #2
• 76 year old female
• Colonoscopy
PMHx: AODM, HBP
To bridge or not to bridge?
Validation of Clinical Classification Schemes for Predicting Stroke
Results From the National Registry of Atrial Fibrillation
Brian F. Gage, MD,MSc; Amy D. Waterman, PhD; William Shannon, PhD; Michael Boechler, PhD; Michael W.
Rich, MD; Martha J. Radford, MD
JAMA. 2001;285:2864-2870.
CHADS2
CHF
HBP
Age>75
AODM
CVA/TIA
2 points
2008 ACCP GUIDELINES
2.4. In patients with a mechanical heart valve or atrial fibrillation or VTE
at high
risk for thromboembolism, we recommend bridging
anticoagulation with therapeutic-dose SC LMWH
or IV UFH over no bridging during temporary
interruption of VKA therapy (Grade 1C); we suggest
therapeutic-dose SC LMWH over IV UFH (Grade 2C). In patients with a
mechanical heart valve or atrial fibrillation or VTE at moderate
risk
for thromboembolism, we suggest
bridging
anticoagulation with therapeutic-dose SC
LMWH, therapeutic-dose IV UFH, or low-dose SC
LMWH over no bridging during temporary
interruption of VKA therapy (Grade 2C); we suggest
therapeutic-dose SC LMWH over other management options (Grade 2C).
In patients with a mechanical heart valve or atrial fibrillation or VTE at
low risk for thromboembolism, we suggest low-dose SC LMWH or no
bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade
2C).
ACCP RISK STRATIFICATION
Case #3
• 43 year old male
PMHx:
1996 idiopathic DVT
1999 secondary PE
2003 idiopathic DVTOn lifelong coumadin
Due for carpel tunnel surgery repair
CASE #4
•
•
•
•
Intracranial bleed on 7W
51 year old female- from France
Mechanical aortic valve
Presented with seizures secondary to an
intracranial bleed- INR = 7.0
Case #5
•60 year old male
•1993 DVT
•Lupus anticoagulant
•Thyroid needle biopsy
Estimated Rates of Thromboembolism Associated with Various Indications for Oral
Anticoagulation, and the Reduction in Risk Due to Anticoagulant Therapy
Kearon C and Hirsh J. N Engl J Med 1997;336:1506-1511
8
(
4
%
)
p
a
t
Kovacs et al, Circulation 2004;110:1658-1663
CIHR: PERIOP2
CHADS 1
NIH TRIAL- similar to PERIOP2 BUT
PATIENTS ARE RANDOMIZED TO
FRAGMIN vs PLACEBO FOR ENTIRE
TRIAL- USING CHADS ≥ 1