Antithrombotics Flashcards
Interruption of anticoagulation temporarily increases what?
Thromboembolic risk
Continuing anticoagulation increases risk of what?
Bleeding
What 2 things do you estimate to determine if and when to interrupt anticoagulation?
- Thromboembolic risk
2. Bleeding risk
3 high risk thrombotic risk stratification of mechanical heart valves?
- Any mitral valve prosthesis
- Older aortic valve prosthesis
- Recent (w/n 6mths) stroke or TIA
Moderate risk thrombotic risk stratification of mechanical heart valves?
- Bileaflet aortic valve and at least one of:
2. Afib, prior stroke or TIA, HTN, DM, CHF, >75
Low risk thrombotic risk stratification of mechanical heart valves?
- Bileaflet aortic valve w/o afib and no other risk factors for stroke
3 high risk thrombotic risk stratification of afib?
- CHA2DS2-VASc score >7
- Recent (w/n 3mths) thromboembolism
- Rheumatic valvular heart disease
2 moderate risk thrombotic risk stratification of afib?
- CHA2DS2-VASc score 5-6
2. Prior thromboembolism > 3mths previously
2 low risk thrombotic risk stratification of afib?
- CHA2DS2-VASc score 0-4
2. No prior thromboembolism
What 2 things cause CHA2DS2-VASc score of 2?
> 75 and stroke/TIA/thromboembolism
2 high risk thrombotic risk stratification of venous thromboembolism?
- Recent VTE (<6mths)
2. Severe thrombophilia (antiphospholipid antibodies)
4 moderate risk thrombotic risk stratification of venous thromboembolism?
- VTE within past 3-12 months
- Non-severe thrombophilia (heterozygous factor V mutation)
- Recurrent VTE
- Active cancer (treated w/n 6mths or palliative)
Low risk thrombotic risk stratification of venous thromboembolism?
Priori VTE >12 mths ago and no other risk factors
Annual stroke risk for high, moderate, and low risk?
High ( >10%)
Moderate (5-10%)
Low (<5%)
Annual risk of VTE for high, moderate, and low?
High (>10%)
Moderate (5-10%)
Low (<5%)
8 low/very low risk periop bleeding
- Dental extraction
- Subgingival scale/cleaning
- Cataract
- Dermatological
- Gastroscopy/colonoscopy with and without biopsy
- Coronary angiography
- Pacemaker/defibrillator
- Select procedures (thoracentesis, paracentesis, arthrocentesis)
8 moderate risk periop bleeding
- Intra-abdominal surgery
- General surgery (breast)
- Intrathoracic surgery
- Orthopedic surgery
- Vascular surgery
- Non-cataract ophthalmologic surgery
- Selected procedures (bone marrow biopsy, lymph node biopsy)
- Complex dental (multi tooth extraction)
11 high risk periop bleeding
- Neuraxial anesthesia
- Neurosurgery
- Cardiac surgery
- Major intra abdominal surgery
- Major vascular surgery
- Major orthopedic surgery
- Lung resection surgery
- Urological surgery
- Extensive cancer surgery
- Reconstructive plastic surgery
- Selected procedures (kidney biopsy, prostate biopsy, cervical cone biopsy, pericardiocentesis, colonic polypectomy)
When should an anticoagulation be interrupted?
Intermediate high surgical bleeding risk
What does interrupt therapy mean?
Limit the period without anticoagulation to the shortest possible interval
- especially thromboembolic risk is high
- if high risk of thromboembolism is transient within 1 mth
When do you consider interruption?
Low surgical bleeding risk AND presence of pt related bleeding factors
When do you not interrupt anticoagulation?
Low bleeding risk surgery AND absence of pt related bleeding factors
Discontinue >5 days before procedure depending on current INR, time to procedure; and desired INR for procedure; recheck INR 24 hrs before procedure
Supratherapeutic INR measure 5-7 days prior to procedure
Discontinue 5 days before procedure depending on current INR, time to procedure and desired INR for procedure; recheck INR 24 hrs before procedure
Goal level of INR (2-3)
