1. Peri-Operative Management of Anticoagulation Edward T. A. Fry, MD, FACC, FSCAI Director, Interventional Cardiology St. Vincent Hospital, Indianapolis The Heart Center of Indiana The Care Group, LLC

2. Anticoagulation and Surgery Assess need to stop anticoagulation Passive vs active reversal Target INR pre-op Assess thromboembolic risk off vs bleeding risk on anticoagulation Need for �Bridging� pre- and post-op LMWH vs UFH

3. Not All Procedures Require Discontinuation of Anticoagulation

4. Risks of Thromboembolism off Anticoagulation Indication of anticoagulation, patient factors, time off therapy, +/- reversal. High risk 1 year risk of ATE >10% or 1 month risk of VTE > 10%. Intermediate risk 1 year risk of ATE = 5-10%, 1 month risk of VTE = 2-10% Low risk 1 year risk of ATE <5%, 1 month risk of VTE < 2%

5. Risks of Thromboembolism off Anticoagulation High Risk � Need �Bridging� Hypercoaguable: Protein C or S deficient, Factor V Leiden def., Anti-phospholipid Ab. Arterial or VTE < 3 mo Valvular Dz: Old mechanical valves, recent valve < 3 mo, Mechanical MVR, MS with Afib Atrial Fib.: Rheumatic Dz, Cardiac thrombus, AF with prior embolus, AF with other risks Intra-cardiac shunts

6. Risks of Thromboembolism off Anticoagulation Intermediate risk: Individualized �Bridging� > 2 prior CVA / TIA�s without risk of cardiac embolus. Low profile mechanical mitral valve Older mechanical AVR (eg Starr-Edwards) AF without prior ATE but with other risks VTE 3-6 month ago

7. Risks of Thromboembolism off Anticoagulation Low Risk � �Bridging� not necessary Low profile AVR Bioprosthetic valve Cerebrovascular Dz without recent CVA Single VTE > 6 mo Atrial fibrillation without other risks

8. Reversing Anticoagulation Pre-Op Passive � Stopping Warfarin INR will fall to < 1.5 in 5 days (longer if steady-state INR > 3.0) Most procedures can be done if < 1.5 (<1.2 if neuosurgical or cardiothoracic) Reversal (Emergent) FFP � Volume, Transfusion risks Vitamin K: PO vs IV/SC �Warfarin resistance� Direct Thrombin Inhibitors - Ximelagatran

9. �Bridging� with Enoxaparin: Anticoagulation Clinic Check baseline INR and CBC, stop warfarin 5-7 days before scheduled procedure Check daily INR, check CBC 1 day pre-op When INR <2.0, start Enoxaparin 1 mg/kg SC q12 hrs. Hold 24 hrs before procedure. When acceptable post-op, resume previous maintenance dose of warfarin. Check INR qD Start Enoxaparin 1mg/kg SC q12 hrs, continue until INR >2.0.

10. Stent Patients on Clopidogrel Bleeding risk increased if within 5 days of last dose � CURE Post-op risk of stent thrombosis (MI) upto 10% if off clopidogrel and ASA in first 6 wk Need for ASA/clopidogrel with DES may be upto 3 months Risk of stent thrombosis is 10% for patients post stenting and coronary brachytherapy

12. Resources Jaffer AK, et al. Cleveland Clinic J. of Med. 2003;70:973. Kearon C and Hirsch J, NEJM 1997;336:1506 Indiana Hemostasis and Thrombosis Center 317-871-0000 TCG Pre-Op Evaluation Center 317-338-5050 TCG Protime-Clinic