CURRENT CONCEPTS Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures

From the Divisions of Gastroenterology and Hepatology (T.H.B., P.S.K.), Cardiovascular Diseases (R.D.M.), and Hematology (R.D.M.), Mayo Clinic, Rochester, MN.
New England Journal of Medicine (Impact Factor: 55.87). 05/2013; 368(22):2113-2124. DOI: 10.1056/NEJMra1206531
Source: PubMed


When patients receiving anticoagulation therapy undergo invasive procedures, management requires an individualized assessment of the risk of bleeding versus the risk of thrombosis. This review explains management, including bridging anticoagulation for patients receiving warfarin.

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    • "The management of those patients requires an involvement of all participating teams (general practitioners, surgeons, anesthesiologists , and other healthcare professionals involved in invasive procedures). Their cessation is indisputable in most elective procedure, but the risk between thrombosis and bleeding should be balanced [12]. In some settings, the therapeutic window is bridged by low molecular weight heparin (LMWH) or unfractionated heparin (UFH) to prevent thromboembolic risk [13] [14]. "
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    ABSTRACT: The field of oral anticoagulation has evolved with the arrival of non-vitamin K antagonist oral anticoagulants (NOACs) including an anti-IIa agent (dabigatran etexilate) and anti-Xa agents (rivaroxaban and apixaban). The main specificities of these drugs are predictable pharmacokinetics and pharmacodynamics but special attention should be paid in the elderly, in case of renal dysfunction and in case of emergency. In addition, their perioperative management is challenging, especially with the absence of specific antidotes. Effectively, periods of interruption before surgery or invasive procedures depend on half-life and keeping a permanent balance between bleeding and thromboembolic risks. In addition, few data regarding the link between plasma concentrations and their effects are provided. Routine laboratory tests are altered by NOACs and quantitative measurements are not widely performed. This paper provides a review on the management of NOACs in the perioperative setting, including the estimation of the bleeding and thrombotic risk, the periods of interruption, the indication of heparin bridging, the usefulness of laboratory tests before surgery or invasive procedure, and the time of resuming. Most data are based on expert’s opinions.
    BioMed Research International 09/2014; 2014(385014):16. DOI:10.1155/2014/385014 · 2.71 Impact Factor
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    • "7) Conservative discontinuation and reinitiation of anticoagulation therapy to prevent postprocedural bleeding.21 "
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    ABSTRACT: Periprocedural management of antithrombotics for gastroenterological endoscopy is a common clinical issue. To decide how to manage the use of antithrombotics in patients undergoing endoscopy, the risk for hemorrhage and thromboembolism during the procedure must be considered. For low-risk procedures, no adjustments in antithrombotics are needed. For high-risk procedures with a low thromboembolic risk, discontinuation of warfarin at 5 days, and clopidogrel at 5 to 7 days before the procedure has been recommended. However, it is better to continue aspirin use even during high-risk procedures. A heparin bridging therapy may be considered before endoscopy in patients with a high thromboembolic risk. The management of patients taking antithrombotics remains complex, especially in high-risk settings.
    Clinical Endoscopy 07/2014; 47(4):320-3. DOI:10.5946/ce.2014.47.4.320
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    • "Unfortunately, there is a lack of consensus regarding the different bridging procedures. These differences between national recommendations make safety studies difficult [78–82]. "
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    ABSTRACT: Dabigatran etexilate (DE), rivaroxaban, and apixaban are nonvitamin K antagonist oral anticoagulants (NOACs) that have been compared in clinical trials with existing anticoagulants (warfarin and enoxaparin) in several indications for the prevention and treatment of thrombotic events. All NOACs presented bleeding events despite a careful selection and control of patients. Compared with warfarin, NOACs had a decreased risk of intracranial hemorrhage, and apixaban and DE (110 mg BID) had a decreased risk of major bleeding from any site. Rivaroxaban and DE showed an increased risk of major gastrointestinal bleeding compared with warfarin. Developing strategies to minimize the risk of bleeding is essential, as major bleedings are reported in clinical practice and specific antidotes are currently not available. In this paper, the following preventive approaches are reviewed: improvement of appropriate prescription, identification of modifiable bleeding risk factors, tailoring NOAC’s dose, dealing with a missed dose as well as adhesion to switching, bridging and anesthetic procedures.
    BioMed Research International 06/2014; 2014(Article ID 616405). DOI:10.1155/2014/616405 · 3.17 Impact Factor
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