perioperative antiplatelet therapy management - angiology.beangiology.be/onewebmedia/bwga...
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Perioperative antiplatelet therapymanagement
Dr Borgoens Philippe
Cardiologist
CHR Citadelle Liège
Perioperative antiplatelet therapy management
• 1 000 000 patients undergo coronary stent implantation per year in UE and USA
• 15% and 25% patients undergo invasive or surgical procedurewithin 1 and 5 y post coronary stenting
Urgent surgery
• Surgery required within 48h
• Avoid platelets transfusion 4-6h after thienopyridine and 10-12 h after last intake ticagrelor
Thrombotic risk in elective surgery
Optimal antiplatelet therapy CAD
Optimal antiplatelet therapy PAD
Not only cardiologist point of view…Multidisciplinar approach…
https://itunes.apple.com/us/app/stent-surgery/id551350096?mt=8.
GIHP 2017
Stent <1moStent for MI<6moStent increased ischemic risk <6m
---> HIGH THROMBOTIC RISK
Adapted from GIHP consensus 2017 and Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Hemorrhagic risk and surgery
• LOW: DAPT →continue
• INTERMEDIATE: ASPIRIN →continue
• HIGH: ASPIRIN → stop (very high risk)
Aspirin or P2Y12- monotherapy
Low intermediate high
Primary preventionASA
stop stop stop
Secondaryprevention
ASA or Clopidogrel
continue Continue ASAStop clopidogrel 7d and start ASA
(Stop aspirin 3-5d)Stop clopidogrel 5d+2d if intracranialsurgeryBe carefull si CVA or TIA<1m, CABG<6w
Hemorrhagic risk
Adapted from GIHP consensus 2017
LOW INTERMEDIATE HIGH
LOW AspirinP2Y12-
AspirinP2Y12-
AspirinP2Y12-
INTERMEDIATE AspirinP2Y12-
AspirinP2Y12-
If nondeferrable
AspirinP2Y12-
If nondeferrable(IIbIIIa -?)
HIGH AspirinP2Y12-
(Aspirin)P2Y12-
If nondeferrable
((Aspirin))P2Y12-
If nondeferrable(IIbIIIa -?)
Thrombotic risk
Bleeding
Bitherapy
POSTPONE INTERVENTION IF POSSIBLE
Adapted from GIHP consensus 2017 and Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
ContinueStop
Prasugrel 7d, Clopidogrel 5d, Ticagrelor (3 -5d), ASA 3dIf intracanian surgery: +2 d for all GIHP french consensus 2017
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
Rossini and al, JACC cardiovascular interventions Vol 11 NO S 2018 March 12 2018 4 17-34
• ♂ 75 yo
• PCI DES RCA 3 m ago for ACS
• PCI LAD 5 y ago for stable angina
• GFR 40ml/min
• Diabetes type II
• Asa 100mg od, Brilique 90mg bid
• Acute lithiasic non perforated cholecystis. No septic shock, no migration
Question
1. Stop Brilique 3 d, continue ASA for cholecystectomy
2. Stop Brilique 7 d, continue ASA for cholecystectomy
3. Stop Brilique 5 d, stop ASA 3d for cholecystectomy
4. Continue aspirine and Brilique for cholecystectomy
5. Postpone surgery with antibiotics to at least 1y post ACS
Question
1. Stop Brilique 3 d, continue ASA for cholecystectomy
2. Stop Brilique 7 d, continue ASA for cholecystectomy
3. Stop Brilique 5 d, stop ASA 3d for cholecystectomy
4. Continue aspirine and Brilique for cholecystectomy
5. Postpone surgery with antibiotics to at least 1y post ACS
Complication…
• Choledochal lithiasis migration and acute pancreatitis
-> non deferrable ERCP + sphincterotomy
Question
1. Stop Brilique 3 d, continue ASA
2. Stop Brilique 7 d, continue ASA
3. Stop Brilique 5 d, stop ASA 3d
4. Stop Brilique 3d, stop ASA 3d
5. Stop Brilique 5d, continue ASA
6. Stop Brilique 5d, continue ASA, start IIbIIIa inhibitor
7. Stop Brilique, continue ASA, start LWMH
Questions
1. Stop Brilique 3 d, continue ASA
2. Stop Brilique 7 d, continue ASA
3. Stop Brilique 5 d, stop ASA 3d
4. Stop Brilique 3d, stop ASA 3d
5. Stop Brilique 5d, continue ASA
6. Stop Brilique 5d, continue ASA, start IIbIIIa inhibitor
7. Stop Brilique, continue ASA, start LWMH
Digestive endoscopy
• ♀ 65 yo
• DES LAD for STEMI 2 m ago
• Efient 10mg od, ASA 100mg od
• Discovery malignant brain’s tumor
-> intracranial surgery
Question
1. Stop ASA 5 days and Efient 7 days
2. Continue ASA and stop Efient 7days
3. Stop ASA 7 days, Efient 7 days and bridge LWMH
4. Stop ASA 5 days and Efient 7 days, bridge IIbIIIa inhibitors 3 days before->4h before surgery
Question
1. Stop ASA 5 days and Efient 7 days
2. Continue ASA and stop Efient 7days
3. Stop ASA 7 days, Efient 7 days and bridge LWMH
4. Stop ASA 5 days and Efient 7 days, bridge IIbIIIa inhibitors 3 days before->4h before surgery
Neurosurgery
• ♂68yo
• 2 DES proximal LAD and proximal CX for stable angina 5m ago
• STEMI PCI RCA 5y ago
• LVEF 50%
• Clopidogrel, ASA
• Anemia 9,6gr/l
• Gastroscopy and coloscopy…
Question
1. Stop clopidogrel 5 d continue ASA
2. Stop clopidogrel 7d and stop ASA 3 d
3. Stop ASA 3d, continue clopidogrel
4. Continue clopidogrel and ASA
5. Postpone exams
Question
1. Stop clopidogrel 5 d continue ASA
2. Stop clopidogrel 7d and stop ASA 3 d
3. Stop ASA 3d, continue clopidogrel
4. Continue clopidogrel and ASA
5. Postpone exams
Digestive endoscopy
• ♂68yo
• BMS PTA iliac 2m ago
• Clopidogrel ASA
• Prostatic cancer -> radical prostatectomy
Question
1. Stop clopidogrel 7d and continue ASA
2. Continue clopidogrel ASA
3. Stop clopidogrel 5d and continue ASA
4. Stop clopidogrel 5 d and stop ASA 3d
5. Stop clopidogrel 5d and ASA 5d
6. Stop clopidogrel 5d and ASA 7d
Question
1. Stop clopidogrel 7d and continue ASA
2. Continue clopidogrel ASA
3. Stop clopidogrel 5d and continue ASA
4. Stop clopidogrel 5 d and stop ASA 3d
5. Stop clopidogrel 5d and ASA 5d
6. Stop clopidogrel 5d and ASA 7d
• ♀ 75 yo
• Carotid endarterectomy 1 y ago for stroke and limb amputation 6 m ago
• Clopidogrel 75mg od
• Gastric cancer ->gastrectomy
Question
1. Stop clopidogrel 5d
2. Continue clopidogrel
3. Stop clopidrogel 7d and start aspirin, continue aspirin
4. Stop clopidogrel 7d
Question
1. Stop clopidogrel 5d
2. Continue clopidogrel
3. Stop clopidrogel 7d and start aspirin, continue aspirin
4. Stop clopidogrel 7d
• ♀75 yo
• Stable angina and multivessels disease
• No history MI
• Aspirin
-> CABG
Question
1. Stop ASA 3d
2. Stop ASA 5d
3. Continue ASA
4. Stop ASA 7d
5. Stop ASA 10d
Question
1. Stop ASA 3d
2. Stop ASA 5d
3. Continue ASA
4. Stop ASA 7d
5. Stop ASA 10d
Management of antithrombotic therapy in patients
undergoing elective invasive procedures
Serge Motte
– 21.04.18 -
ANTICOAGULANTS
63
Fondaparinux
DanaparoïdeXa
IIa
TF/VIIa
X IX
IXa
VIIIa
FibrineFibrinogène
AT
Adapté de Weitz & Bates, J Thromb Haemost 2005
Héparines
AT
AT
AVK [II,VII,IX,X]
Rivaroxaban(Xarelto®)
Apixaban(Eliquis®)
Edoxaban(Lixiana®)
Dabigatran(Pradaxa®)
MANAGEMENT OF ANTITHROMBOTIC THERAPY IN PATIENTS
UNDERGOING ELECTIVE INVASIVE PROCEDURES
64
Case 1
76 year-old female
Associated diseases:
Hypertension
Diabetes non-insulin treated
Moderate renal insufficiency (CrCL: 55 ml/min. )
Atrial fibrillation since 10 years, treated with
Sintrom®
Changes in bowel behavior
Planned colonoscopy
MANAGEMENT OF ANTITHROMBOTIC THERAPY IN PATIENTS
UNDERGOING ELECTIVE INVASIVE PROCEDURES
Last intake of Sintrom® on D – 4 and bridging with
therapeutic dose of LMWH
Last intake of Sintrom® on D – 4 and bridging with
prophylactic dose of LMWH
Last intake of Sintrom® on D – 4 and no bridging
Continue Sintrom®, monitor the INR and carry out
the colonoscopy with INR 1,5-2,0
Last intake of Sintrom® on D – 4 and bridging with
therapeutic dose of unfractionated heparin
65
Which option ?
ANTICOAGULANT TREATMENT AND PLANNED INVASIVE PROCEDURES:
WHAT ARE THE RISKS?
66
ANTICOAGULANT TREATMENT AND PLANNED INVASIVE
PROCEDURES: WHAT ARE THE RISKS?
67Rechenmacher SJ et Fang JC. J Am Coll Cardiol 2015;66:1392–403
Periprocedural event rates by oral anticoagulation indication
MANAGEMENT OF AF PATIENTS:
TO BRIDGE OR NOT TO BRIDGE ?
The BRIDGE study: 1884 AF patients
68JD Douketis et al. N Engl J Med. 2015;373:823-33
* P value for non inferiority; † P value for superiority.
BRIDGING RESULTS IN PERIPROCEDURAL BLEEDING WITHOUT
REDUCTION IN THROMBOEMBOLISM
69Rechenmacher SJ et Fang JC. J Am Coll Cardiol 2015;66:1392–403
Periprocedural event rates by bridging strategy
IN CLINICAL PRACTICE
In patients treated with VKAs:
Individualized bridging anticoagulation in specific high-
risk patients with a low bleeding risk procedure
70
WHICH PATIENTS ARE AT HIGH RISK OF THROMBOEMBOLISM
IN CASE OF TEMPORARY INTERRUPTION OF ORAL
ANTICOAGULATION ?
Mechanical mitral heart valve
Multiple mechanical heart valves
Mechanical aortic heart valve and additional risk
factors (history of thromboembolism, AF, heart failure,
dilated cardiomyopathy, intracardiac thrombus)
AF with history of stroke or TIA, left atrial appendage
thrombus
Venous thromboembolism 3 months
71
PROCEDURES CARRYING A HIGH RISK OF BLEEDING
Cardia surgery, major vascular surgery
Neurosurgery
Major surgery for cancer
Urology surgery: prostatectomy, nephrostomy,
nephrectomy, cystectomy
Colonoscopy with polypectomy
Endoscopic sphincterotomy
Vitrectomy, blepharoplasty,..
72
EXAMPLE OF ALGORITHM FOR THE MANAGEMENT OF
SINTROM®
73
High risk of thromboembolism?
Last intake of Sintrom® on D – 4
Yes
No bridging
No
Start Clexane when INR < 2**
Last dose 24 h
before procedure
Yes No
ClCR < 30 ml/min*
Start UFH when INR < 2**
Stop 6 h before procedure
** In practice, start D - 2
Clexane 1 mg/kg/12h; UFH iv , 15 UI/kg/h (no bolus)
EXAMPLE OF ALGORITHM FOR THE MANAGEMENT OF
SINTROM®
74
High risk of thromboembolism ?
After the procédure
Yes
No bridging
No
Start Sintrom J0 ou
later post-procédure
according to
bleeding risk
High risk of bleeding ?
Yes No
No Clexane or UFH
Start Sintrom J1 post-procedure
or later according to bleeding risk
Start Clexane SC 24 h ou
UFH IV 12 h after procedure*
Start Sintrom J0 or
J1 post-procedure
* Clexane 1 mg/kg/12 h
iv UFH : pre-op maintenance dose (no bolus)
MANAGEMENT OF ANTITHROMBOTIC THERAPY IN
PATIENTS UNDERGOING ELECTIVE INVASIVE PROCEDURES
Case 2
72 year-old male
Associated diseases:
Hypertension
Obesity (BMI 33 kg/m2)
Urinary catheter recently placed for acute urinary retention
Planned open surgery for large benign prostate adenoma
Diagnosis of proximal DVP, 2 weeks ago, treatmentwith Xarelto®
75
MANAGEMENT OF ANTITHROMBOTIC THERAPY IN PATIENTS
UNDERGOING ELECTIVE INVASIVE PROCEDURES
Last intake of Xarelto® on D – 3 and bridging with
therapeutic dose of LMWH
Last intake of Xarelto® on D – 3 and bridging with
prophylactic dose of LMWH
Last intake of Xarelto® on D – 3 and no bridging
Postpone surgery up to 3 months of anticoagulant
therapy
76
Which option ?
DIRECT ORAL ANTICOAGULANTS
MAIN PHARMACOKINETIC CHARACTERISTICS
77
CharacteristicsDabigatran
(Pradaxa®)
Rivaroxaban
(Xarelto®)
Apixaban
(Eliquis®)
Edoxaban
(Lixiana®)
T Cmax (h) 2 2-4 1-4 1-2
Half-life 14 à 17 h 7 à 13 h 10 à 14 h 9 à 11h
Renal elimination 80% 35% 27% 50%
EXAMPLE OF ALGORITHM FOR THE MANAGEMENT OF
PRADAXA® (DABIGATRAN)
78
Yes No
Restart 48 h-72 h after procedure
according to bleeding riskRestart 24 h after procedure
Last intake before procedure according ClCR
> 80 ml/min: 3 days 50 - 80 ml/min: 3 - 4 days > 30 - 50 ml/min: 5 days
Last intake before procedure according ClCR
> 80 ml/min: 2 days50 - 80 ml/min: 2 - 3 days > 30 - 50 ml/min: 3 - 4 day
High risk of bleeding ?
79
Yes No
Restart Anti-Xa 48 h-72 h after
procedure according to bleeding riskRestart Anti-Xa 24 h after procedure
Last intake 72 h before procedure Last intake 48 h before procedure
High risk of bleeding or
age > 75 years or ClCR < 50 ml/min ?
EXAMPLE OF ALGORITHM FOR THE MANAGEMENT OF
XA INHIBITORS
CONCLUSIONS 1
80
Periprocedural anticoagulation management often
leads to significant adverse events Bleeding is much more common than clotting
Bridging in patients treated with VKAs results in
periprocedural bleeding without reduction in
thromboembolism
80
CONCLUSIONS 2
In patients treated with VKAs:
Individualized bridging anticoagulation in specific high-risk
patients with a low bleeding risk procedure
In patients treated with DOACs:
No bridging unless oral anticoagulation resumption is
delayed after the procedure
81