Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft...
Transcript of Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft...
![Page 1: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/1.jpg)
Current Anticoagulation Management in Special Groups and Future TrendsJameela Sathar
Hospital Ampang
7 Aug 2010
![Page 2: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/2.jpg)
Special groups
Surgery
Pregnancy
Paediatrics
![Page 3: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/3.jpg)
Warfarin and Surgery
![Page 4: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/4.jpg)
Overview
Perioperative management of
anticoagulation
Evidence
Risk stratification
![Page 5: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/5.jpg)
Perioperative management
Lack of good clinical trials
Is the risk of thromboembolic (TE)
complications with interruption of
warfarin overstated?
![Page 6: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/6.jpg)
Balance
Bleeding
Thrombosis-
warfarin
witheld
Thrombosis-
warfarin
witheld
Bleeding-
surgery
Bleeding-
surgery
![Page 7: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/7.jpg)
Some increase in the risk of
thromboembolism is
unavoidable
![Page 8: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/8.jpg)
Surgery increases the risk of venous thromboembolism
Flanc C, Br J Surg 1968
Carter CJ, Prog Cardiovasc Dis 1994
![Page 9: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/9.jpg)
But
there is no evidence that surgery
increases the risk of arterial
embolism in patients with AF or
MHV
![Page 10: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/10.jpg)
Assessment of periop TE risk
Clinical indications for anticoagulation
Additional TE risk factors
Clinical consequences of a TE event
![Page 11: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/11.jpg)
Clinical indications
Mechanical heart valves
Chronic atrial fibrillation
Venous thromboembolism
![Page 12: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/12.jpg)
Mechanical Heart Valves
![Page 13: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/13.jpg)
Mechanical Heart Valves (MHV)
Estimated incidence of TE not receiving
warfarin: 9 - 22% per year
Mortality rate 15% with valve thrombosis
Absolute incidence of TE when warfarin
interrupted during 6 – 8 days: 0.17 – 0.42%
Martinelli J 1991
![Page 14: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/14.jpg)
Bridging anticoagulant therapy in
MHV
Various studies: 1 - 18% risk of TE
events
Need for large, well designed prospective
studies
Risk stratify- high, moderate or low risk
![Page 15: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/15.jpg)
Single tilting disc
Bjork-Shiley
Ball in cage
Starr Edwards
Bi-leaflet tilting disc
St Jude/Carbomedics
Aortic position Mitral position
Large Small
Increasing thrombogenicity
Not all valves are the same
![Page 16: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/16.jpg)
Risk Patient characteristics Bridging
anticoagulant
High Recent (<1 month) stroke/TIA,
Any mitral valve,
Aortic valve: caged-ball or
single-leaflet tilting disc
Strongly recommended
Moderate Aortic valve: bileaflet tilting
disc + ≥2 stroke risk factors Should be considered
Low Aortic valve: bileaflet tilting
disc + <2 stroke risk factors
Optional
Duoketis JD 2003
Risk stratification in MHV
![Page 17: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/17.jpg)
Stroke risk factors
AF
Previous stroke, TIA or systemic embolism
LV dysfunction
Age> 75 years
HT
DM
![Page 18: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/18.jpg)
Chronic Atrial Fibrillation
![Page 19: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/19.jpg)
Chronic atrial fibrillation (AF)
Incidence of recurrent stroke
• Low risk: <1% per year
– Lone AF
– <65 years
– No additional stroke risk factors
• Moderate risk: 3-7% per year
(≥2 risk factors without h/o stroke)
• High risk: 12-15% per year
(with previous stroke)
EAFT Lancet 1993
Albert GW et al Chest 2001
![Page 20: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/20.jpg)
Chronic AF: warfarin
interruption
Estimated risk for stroke during 6- 8 days:
High: 0.28- 0.38%
Moderate: 0.06- 0.15%
Low: 0.02- 0.04%
However, no real data
![Page 21: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/21.jpg)
Risk stratification for chronic AF
Risk Patient
characteristics
Bridging
anticoagulant
High Recent (<1 month)
stroke or TIA,
rheumatic valve dis
Strongly
recommended
Moderate Chronic AF + ≥2 stroke risk factors
Considered
Low Chronic AF + <2
stroke risk factors
Optional
Duoketis JD, Throm Res 2003
![Page 22: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/22.jpg)
Venous Thromboembolism
![Page 23: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/23.jpg)
Venous thromboembolism (VTE)
• No data on recurrence of VTE when warfarin is
interrupted
• Highest recurrence <3 weeks from acute VT
• Idiopathic: 10- 27% per year
• Transient risk factor: 2- 5% per year
• Increased risk:
– cancer
– chronic disease- cardiac or pulmonary
– APLSDouketis JD 2000
![Page 24: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/24.jpg)
Risk stratification for VTE
Risk Patient characteristics Bridging
anticoagulant
High Recent (within 3 weeks)
episode of VTE, active
cancer, APLS, major
chronic disease
Strongly
recommended
Moderate VTE within past 6
months, VTE recurring
with previous warfarin
interruption
Considered
Low None of above Optional
Duoketis JD 2003
![Page 25: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/25.jpg)
Perioperative management of anticoagulation
![Page 26: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/26.jpg)
Stopping antithrombotic
drug• Anti-platelet drugs stopped at least 7 days
before surgery
• Warfarin stopped 5 days
• INR on day before surgery
• If INR >1.5, give oral vit K 1- 2mg
ACCP 2008
![Page 27: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/27.jpg)
Bridging anticoagulant therapy
Indication: high risk category; consider for moderate risk
Start LMWH 2 days after stopping warfarin
Last therapeutic dose of LMWH 12h before op with bd dose or 24h before op with once-daily dose
iv UFH stopped 4-6h before op
ACCP 2008
![Page 28: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/28.jpg)
Safe INR
Most surgical procedures: < 1.5
Neurosurgery: < 1.2
Ansell J, Chest 2001
White RH, Ann Intern Med 1995
![Page 29: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/29.jpg)
Neuraxial anaesthesia
Insertion of epidural needle:
Prophylactic LMWH dose stopped 12 h before
Treatment LMWH dose stopped 24h before
Removal of epidural catheter:
10-12h after last dose of LMWH
Resume LMWH 2h after catheter removal
Horlocker RA, Reg Anesth Pain Med 2003
![Page 30: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/30.jpg)
Resumption of anticoagulation
![Page 31: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/31.jpg)
Resumption of anticoagulant
Adequate post-op hemostasis
Surgical procedure and bleeding risk
![Page 32: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/32.jpg)
Assessment of bleeding risk
Type of surgery
Post-op haemostasis
Clinical consequences
![Page 33: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/33.jpg)
Bleeding risk stratification
• High risk:
– Neurosurgery, genito-urinary, renal biopsy
– Heart valve replacement, CABG
– Major cancer surgery, bowel polypectomy
• Moderate risk:
– Major intra-abdominal, intra-thoracic, orthopedic
– Pacemaker insertion
• Low risk:
– Cataract extraction, cutaneous surgery
– Lap cholecystectomy, hernia repair
– Coronary angiography
![Page 34: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/34.jpg)
Resumption of anticoagulation
Bleeding risk Suggested anticoagulant management
Warfarin Low dose
LMWH
Full dose
LMWH
High Evening of day
after surgery
24- 48h after
surgery
48- 72h after
surgery
Moderate Evening of day
of surgery
Evening of day
of surgery
24- 48h after
surgery
Low Evening of day
of surgery
Evening of day
of surgery
24h after
surgery
Stop LMWH once INR in therapeutic range Duoketis JD 2003
![Page 35: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/35.jpg)
Case VN
40 years old lady
L DVT 3 months ago- idiopathic
On warfarin; target INR 2.5
Fell and hurt her knee ?meniscus tear
Plan for arthroscopy
No other risk factors or medical illness
![Page 36: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/36.jpg)
Case VN
What is the VTE risk?
Moderate risk: VTE within 6 months
How would you manage her?
![Page 37: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/37.jpg)
Case VN
Stop warfarin 5 days
Admitted for LMWH- was it necessary?
INR 1.6 the day before op
What will you do?
![Page 38: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/38.jpg)
Case VN
What actually happened..
2 u FFP requested for op- was it necessary?
After op, FFP transfused
Patient developed urticaria
INR on op day: 1.3
![Page 39: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/39.jpg)
Thachil J, Br J Surg 2008
Peri-op
anticoagulation
plan list
![Page 40: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/40.jpg)
Summary
Patients on warfarin undergoing surgery should
have a planned management
Risk stratify them into low, moderate or high
risk group
Balance risk of thrombosis and risk of bleeding
![Page 41: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/41.jpg)
Warfarin in Pregnancy
![Page 42: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/42.jpg)
Anticoagulation in Pregnancy
Acute VTE
Thromboprophylaxis
Mechanical heart valves
Management of labour and delivery
![Page 43: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/43.jpg)
Selection of Prosthetic Heart Valves
In women of childbearing age
Tissue valves
High risk of structural valve deterioration
Mechanical valves
Long-term durability
High risk of valve-thrombosis
![Page 44: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/44.jpg)
Mechanical Heart Valves in
Pregnancy
Interests of the mother and the fetus are in conflict
Warfarin is safest for mother
UH / LMWH is safest for fetus
![Page 45: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/45.jpg)
Problems with warfarin
• Teratogenic (5%)
• Increased risk of miscarriage
• Increased risk of stillbirth
• Maternal bleeding
• Fetal intracerebral haemorrhage
Cotrufo et al. Obst & Gynecol 2002; 99: 35-40
![Page 46: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/46.jpg)
Warfarin
N= 792
Heparin-
warfarin-
heparin
N= 230
Heparin
N= 21
Fetal loss 33.6% 26.5% 16.3%
Embryopathy 6.4% 3.4% 0%
Thrombo-
embolism
3.9% 9.2% 33.3%
Maternal
mortality
1.8% 4.2% 15.0%
Chan, Arch Intern Med 2000
Warfarin vs. UH
![Page 47: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/47.jpg)
LMWH vs UH
TEC MM Fetal loss
UH (Chan) 33.3% 15.0% 16.3%
LMWH
(Oran) n=81
13.4% 1.5% 9.0%
Oran, Lee-Parritz & Ansell. Thromb Haemost 2004; 94: 747-751.
![Page 48: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/48.jpg)
LMWH
Monitor anti-Xa
Maintain 4-6 hours post-injection anti-Xa >1.0
U/ml
Adjunctive aspirin
Oran, Lee-Parritz & Ansell. Thromb Haemost 2004; 94: 747-751.
![Page 49: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/49.jpg)
Maternal mortality
Main cause: valve thrombosis
Risk factors:Valve type: single leaflet / ball in cage
Valve position: mitral
LA size
Heparin
Hx previous thrombosis
no. of mechanical valves
Vongpatanasin NEJM ’96, Sadler BJOG ‘00
Elkayam J ACC ’99, Oakley et al EHJ ‘03
![Page 50: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/50.jpg)
Fetal loss
Risk factors:
Mitral mechanical valve
Warfarin
Vongpatanasin NEJM ’96, Sadler BJOG ‘00
Elkayam J ACC ’99, Oakley et al EHJ ‘03
![Page 51: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/51.jpg)
Single tilting disc
Bjork-Shiley
Ball in cage
Starr Edwards
Bi-leaflet tilting disc
St Jude/Carbomedics
Aortic position Mitral position
Large Small
Increasing thrombogenicity
Not all valves are the same
![Page 52: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/52.jpg)
Which Anticoagulant Regimes
for Mechanical Valves?
Which Anticoagulant Regimes
for Mechanical Valves?
• Warfarin throughout
• Heparin until 12/40,
Warfarin until 36/40,
Heparin
• Heparin + aspirin throughout ?Large aortic
Bileaflet
Small mitral
Bjork Shiley
<5mg warfarin?
![Page 53: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/53.jpg)
ACCP 2008
1. Adjusted –dose bd LMWH throughout (keep
peak 4h anti-Xa >1.0 U/mL)
2. Adjusted-dose bd UH s/c throughout (keep 2x
APTT or anti-Xa 0.35 to 0.7 U/mL)
3. UH or LMWH until 13th week with warfarin
substitution
![Page 54: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/54.jpg)
ACCP 2008
Very high risk:
Older generation prosthesis in mitral
position
History of thromboembolism
� Warfarin + aspirin throughout; with UH or
LMWH close to delivery
![Page 55: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/55.jpg)
Informed choice
![Page 56: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/56.jpg)
Warfarin: reducing fetal risk
Full counselling
Stop before 6 weeks if changing to heparin
Optimum dose < 5mg/dayBUT
Maintain INR 2-4 depending on valve type
Detailed and serial fetal scans
Stop 10 days before delivery or 36 weeks
Restart at least 3 days post partum
![Page 57: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/57.jpg)
Any strategy carries risk
![Page 58: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/58.jpg)
Mechanical heart valves in pregnancy
Women should participate in the choice of anticoagulation
Women should be fully informed of risks and benefits of all options
Decision should be individualized and ideally made pre-pregnancy
Care should be multidisciplinary
![Page 59: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/59.jpg)
Breastfeeding
Both warfarin
and heparin are
safe
![Page 60: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/60.jpg)
Summary
Warfarin in pregnancy is only indicated with
mechanical heart valve
Higher risk of embryopathy and fetal loss
Lower risk for valve thrombosis
![Page 61: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/61.jpg)
Summary
Several choices- each with it’s own risk
Informed choice- mum decides
![Page 62: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/62.jpg)
![Page 63: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/63.jpg)
Anticoagulation in Paediatrics
![Page 64: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/64.jpg)
Paediatrics
VTE rare
Haemostasis is dynamic
AT levels low at birth (adult level at 3 mo)
Reduced and delayed thrombin generation (25% less
than adults)
Reduced vitamin K-dependent factors at birth
Distribution, binding, clearance are age-dependent
Response to anticoagulants differs
![Page 65: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/65.jpg)
Paediatrics
Illnesses vary with age
The need for GA to perform many diagnostic studies
Vascular access (drug administration, blood taking)
No specific pediatric formulation, weight-adjusted
dosing difficult
Dietary differences (breast milk and infant formulas
have different vitamin K levels makes oral a/c difficult)
![Page 66: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/66.jpg)
Paediatrics
Prolonged APTT in neonates
APTT therapeutic ranges are calculated using adult
plasma ?valid
Heparin doses are age-dependent; highest <2mo
Larger volume of distribution
Altered pharmacokinetics
Low AT levels
![Page 67: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/67.jpg)
Developmental Haemostasis:Coagulation
NORMAL VALUES
Test 21 wk 26 wk 35 wk Term
PT (secs) 32 32 23 17
PTT (secs)169 154 105 44
TT (secs) 34 26 21 20
Adult
13
33
14
![Page 68: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/68.jpg)
Developmental Haemostasis:vitamin K dependent factors
27%34%
46%
53%
Factor VII
in fetal life
10% 10% 12%
32%
21 26 35 40
Factor IX
21% 25%28%
40%
Factor X
17% 20%28%
44%
Factor II
21 26 35 40
Gestational age
(weeks)
I. Roberts
![Page 69: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/69.jpg)
Neonatal thrombosis
VTE in paediatrics most commonly occur in neonates
Often occur in sick and preterm infants
Risk factors:
Indwelling central line
Asphyxia
Septicaemia
Dehydration
Congenital heart disease
Maternal diabetes
![Page 70: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/70.jpg)
![Page 71: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/71.jpg)
S. Ibrahim
![Page 72: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/72.jpg)
Neonatal thrombosis
Diagnosis- contrast angiography remains gold standard
Treatment
Supportive- silent thrombosis
Anticoagulant- organ or limb dysfunction
Thrombolytic– limb viability threatened
Prophylactic a/c- indwelling umbilical artery catheters,
cardiac catheterisation
![Page 73: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/73.jpg)
Clinical
indication
Medication Traditional
dosing
Current
recommended dosing
Asymp or symp
thrombus non-
limb threatening
UH 75u/kg iv bolus,
then 28u/kg/h
<28 wk: 25u/kg iv bolus,
then 15u/kg/h
28-37 wk: 50u/kg iv bolus,
then 15u/kg/h
>37 wk: 100u/kg iv bolus,
then 28u/kg/h
Asymp or symp
thrombus non-
limb threatening
LMWH 1.5mg/kg SQ per
12h
Term neonates: 1.7mg/kg
SQ per 12h
Preterm: 2.0mg /kg SQ per
12h
Limb/life-
threatening
thrombus
r-tPA NA 0.06 mg/kg/h
UFH at 10u/kg/h
Neonatal anticoagulation
Saxonhouse MA, Journal of Perinatology 2009
![Page 74: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/74.jpg)
UH vs. LMWH
Short half-life BUT
Target-range achievement: poor
14% within 6 hrs; 68% at 24hrs
Increased bleeding risk: 12.5%
Increased HIT: 3%
Need iv acccess
Need frequent blood taking for monitoring
Andrew M, REVIVE Study 1994
![Page 75: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/75.jpg)
Future trends
![Page 76: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/76.jpg)
Future trends in anticoagulation
Alternatives to VKA; shorter-acting LMWH
No monitoring required
Safe and efficacious
Antidote for reversal
Paediatric formulation
Safe in pregnancy
![Page 77: Current Anticoagulation Management in Special Groups and ...ijncollege.edu.my/PDF/Microsoft PowerPoint - A_C special gps_Dr... · Current Anticoagulation Management in Special Groups](https://reader036.fdocuments.in/reader036/viewer/2022070615/5c81326b09d3f207418c0e71/html5/thumbnails/77.jpg)
Thank you