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Anticoagulation
Bridging: New
Paradigms
Michael Benjamin, M.D.
February 2013
(And a little bit about reversing new anticoagulants)
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1. Bridging
anticoagulants
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Warfarin
Lovenox/Heparin/Arixtra
/Dalteparin
Warfarin
Lovenox/Heparin/Arixtra
/Dalteparin
SURGERY
5 days 1d
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Hospital-Acquired Conditions
1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma
6. Manifestations of Poor Glycemic Control
7. Catheter-Associated Urinary Tract Infection (UTI)
8. Vascular Catheter-Associated Infection
9. Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
10. Surgical Site Infection Following Bariatric Surgery for Obesity
11. Surgical Site Infection Following Certain Orthopedic Procedures
12. Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
13. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic
Procedures:
Total Knee Replacement
Hip Replacement
14. Iatrogenic Pneumothorax with Venous Catheterization
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html
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A case of bridging gone wrong
1. Hypercoaguable state
2. Thrombosis
3. Overlap coumadin and
lovenox
4. Renal insufficiency
5. Bleeding
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Warfarin
Lovenox/Heparin/Arixtra
/Dalteparin
Warfarin
Lovenox/Heparin/Arixtra
/Dalteparin
SURGERY
5 days 1d
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Warfarin
Lovenox/Heparin/Arixtra
/Dalteparin
Warfarin
Lovenox/Heparin/Arixtra
/Dalteparin
SURGERY
5 days 1d
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Forest plot of thromboembolic events. Review of bridging studies.
Siegal D et al. Circulation 2012;126:1630-1639
Copyright American Heart Association
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Forest plot of overall bleeding events.
Siegal D et al. Circulation 2012;126:1630-1639
Copyright American Heart Association
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A case of bridging gone wrong
1. Hypercoaguable state
2. Thrombosis
3. Overlap coumadin and
lovenox
4. Renal insufficiency
5. Bleeding
ect veness o r g ng nt coagu at on or urgery e
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ect veness o r g ng nt coagu at on or urgery eStudy)
This study is currently recruiting participants.
Verified January 2013 by Duke University
Sponsor:
Duke University
Collaborator:National Heart, Lung, and Blood Institute (NHLBI)
Information provided by (Responsible Party):
Duke University
ClinicalTrials.gov Identifier:
NCT00786474
First received: November 5, 2008
Last updated: January 17, 2013
Last verified: January 2013
Estimated Enrollment: 3626
Study Start Date: July 2009Estimated Study Completion Date: March 2015
Estimated Primary Completion Date: January 2015
(Final data collection date for primary outcome measure)
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Longer LOS
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Longer LOS
More bleeding Fewer clots?
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Bridge warfarin?
NO
Cataract surgery
Dental
cleaning/extraction
Colonoscopy
Dr Samuel Z Goldhaber(Brigham
and Women's Hospital, Boston, MA)
AHA 2011
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Bridge warfarin?
YES
AF CHADS > 3
Multi-valve disease
Orthopaedic surgery
hip/knee
CONSIDER
1. Bleeding risk2. Thrombosis risk
Dr Samuel Z Goldhaber(Brigham
and Women's Hospital, Boston, MA)
AHA 2011
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Circulation.
2006; 114: e84-
e231
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Longer LOS
More bleeding Fewer clots?
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2. What about the new
anticoagulants?
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$245.97 /m $206.00/m $250.36 /m
AF AF AFHip/Knee repl.
DVT/PE
??????
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???
N Engl J Med 2011; 365:883-891
???
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3. Reversing the new
anticoagulants(If theyre bleeding, either way, itll be
$7,000)
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Beriplex P/N = Four factor PCC (not US!)
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Profilnine has II, IX, X and low levels
Factor VII = US version Three factor
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Dose = 7090mcg/kg
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Factor II
Factor IX
Factor XActivated Factor VII
Dose? Hemophilia = 50100 U /kg = 3000U in 60kg pt
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4. $$$
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Ann Intern Med. 4 January 2011;154(1):1-11
Daily cost =
$8.199
Statins in low risk
CHD prophylaxis
$9,900/QALY
Mammography 50-75 $50,000/QALY
Left main CABG $8,768/QALY
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Date of do nload Cop right The American College of Cardiolog
From: Efficacy and Safety of Dabigatran Compared to Warfarin in Patients With Paroxysmal, Persistent, and
Permanent Atrial Fibrillation: Results From the RE-LY (Randomized Evaluation of Long-Term
Anticoagulation Therapy) Study
J Am Coll Cardiol. 2012;59(9):854-855. doi:10.1016/j.jacc.2011.10.896
Event Rates and Hazard Ratios
Shown are the rates of stroke and systemic embolism and the rates of major bleeding with dabigatran etexilate (DE) 110 mg bid ,
dabigatran 150 mg bid, and warfarin (W) for the different types of atrial fibrillation (AF). The hazard ratios with 95% confidence limits
(CI) for the 2 doses of dabigatran compared to warfarin are also illustrated. RE-LY = Randomized Evaluation of Long-Term
Anticoagulant Therapy With Dabigatran Etexilate.
Figure Legend: