1/18/2016 1 Perioperative Management of Anticoagulation Rapid Fire Session Hospital Medicine 2016 San Diego 8 March 2016 Scott Kaatz, DO, MSc, FACP, FHM Hurley Medical Center Flint, MI Associate Professor of Medicine Michigan State University • Grant support to institution – Boehringer-Ingelheim – Bristol Myer Squibb – Bayer/Jansen/Johnson and Johnson – Eisai – Iverson Genetics Diagnostics/Medicare – National Institute of Health – Canadian Institute of Health Research – Blue Cross/Blue Shield of Michigan • Speaker honorarium – Janssen – Boehringer-Ingelheim – Bristol Myer Squibb/Pfizer – CSL Behring – Daiichi Sankyo • Consultant – Boehringer Ingelheim – Bristol Myer Squibb/Pfizer – Janssen – Daiichi Sankyo – Portola • Board membership (non-profit) – Thrombosis and Hemostasis Societies of North America – AC Forum – National Certification Board of Anticoagulation Providers – National Blood Clot Alliance Medical and Scientific Advisory Board Full Disclosure
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1/18/2016
1
Perioperative Management of Anticoagulation
Rapid Fire Session
Hospital Medicine 2016
San Diego
8 March 2016
Scott Kaatz, DO, MSc, FACP, FHM
Hurley Medical Center
Flint, MI
Associate Professor of Medicine
Michigan State University
• Grant support to institution– Boehringer-Ingelheim– Bristol Myer Squibb– Bayer/Jansen/Johnson and Johnson– Eisai– Iverson Genetics Diagnostics/Medicare – National Institute of Health– Canadian Institute of Health Research– Blue Cross/Blue Shield of Michigan
• Board membership (non-profit)– Thrombosis and Hemostasis Societies of North America– AC Forum– National Certification Board of Anticoagulation Providers– National Blood Clot Alliance Medical and Scientific Advisory Board
Full Disclosure
1/18/2016
2
PERIOPERATIVE MANAGEMENT OF ANTICOAGULATION
• Bridging anticoagulation
– Mechanical valves
– Atrial fibrillation
– Venous thromboembolism
• Anticoagulation reversal
– Warfarin
– Dabigatran
– Rivaroxaban, Apixaban, Edoxaban
• Anticoagulation measurement
4Case
• 76 yo woman with a mechanical mitral valve, chronic atrial fibrillation, and a previous stroke 2 years ago
• To undergo (open) subtotal colectomy for resection of adenocarcinoma of the colon
• What would you do?
A. Don’t interrupt warfarin, perform procedure at therapeutic INR
• 2.4. In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest• bridging anticoagulation instead of no bridging during interruption
of VKA therapy (Grade 2C)
• In patients with a mechanical heart valve, atrial fibrillation, or VTE at low risk for thromboembolism, we suggest • no bridging instead of bridging anticoagulation during interruption
of VKA therapy (Grade 2C)
• In patients with a mechanical heart valve, atrial fibrillation, or VTE at moderate risk for thromboembolism, • the bridging or no-bridging approach chosen is, as in the higher-
and lower risk patients, based on an assessment of individual patient- and surgery-related factors
6 Risk Stratification for Perioperative Thromboembolism