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Management of Anticoagulation in Interventional Cardiology

Clinical Guideline

V1.0

November 2019

Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 2 of 21

Summary

Although of proven benefit in a range of indications, antithrombotics are associated with adverse effects, principally abnormal bleeding. When patients on anticoagulation require an invasive procedure, the risks and benefits of stopping or continuing anticoagulation must be considered. To maximise benefit over risks, the selection of patients for treatment with antithrombotics and their management should be evidence based.


1. Aim/Purpose of this Guideline

1.1. This document applies to all doctors (regardless of grade) and nurses who have the responsibility to identify patients (elective and inpatient) on medications that will increase the risk of bleeding during/after a cardiac procedure. 1.2. This guideline applies to patients taking oral anticoagulation or antiplatelet drugs who require an invasive procedure. It is designed to safely manage the discontinuation of the following medications and where appropriate the prescription of reversal agents or substitutes such as bridging therapy. It aims to standardise management across the cardiac wards in line with international guidelines and in so doing, to minimise morbidity and mortality from thrombosis or haemorrhage.

1.3. This guideline is designed to safely manage the discontinuation of the following medications listed in Appendix 5. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications.

1.4. This guideline is designed to safely manage the discontinuation of the following medications. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications. 1.5. This version supersedes any previous versions of this document. 1.6. Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in.

DPA18 is applicable to all staff; this includes those working as contractors and providers of services.

For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team [email protected]

2. The Guidance

2.1. Thrombotic risk The risk-benefit ratio of interrupting VKA therapy requires individual consideration. Continuation of anticoagulation during invasive procedures is likely to increase the bleeding risk. Whilst discontinuation is associated with a temporary increase in thrombosis risk. There is debate over the optimal approach to management in this situation and whether VKA therapy should be interrupted and, if so, whether there is a need for bridging therapy with the temporary

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introduction of an alternative antithrombotic, usually heparin. 2.2. The guidance for the Management of Anticoagulation in Interventional Cardiology is included in the tables of Appendix 3 and Appendix 4. 2.3. The guidance for the discontinuation of antiplatelet/anticoagulation is included in the tables of Appendix 5. 2.4. The guidance for the restarting of antiplatelet / anticoagulation medications is included in the tables of Appendix 6

3. Monitoring compliance and effectiveness

Element to be monitored

All elements to be monitored

Lead Cardiology Department

Tool Review of case notes, using the guidelines as the audit standard with Audit and review tool.

Frequency One year after implementation to complete first audit. Thereafter frequency will depend on our compliance

Reporting arrangements

Reporting into Cardiology Governance

Acting on recommendations and Lead(s)

The Cardiology Department Governance and Audit leads will be responsible for this. The report will be disseminated and an expectation to implement any recommendations of change immediately

Change in practice and lessons to be shared

The recommended actions will be cascaded to the nursing and medical staff involved in the clinical management of these patients, at presentations to the relevant departmental meetings.

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0

Date Issued/Approved: 20 September 2019

Date Valid From: November 2019

Date Valid To: November 2022

Directorate / Department responsible (author/owner):

Mohammed Abubakr, Consultant Cardiologist

Contact details: 07833 201879 or 01872 252911

Brief summary of contents

Guidance on the management of anticoagulation in interventional cardiology, and to safely manage the discontinuation of anticoagulation medications. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications.

Suggested Keywords: Anticoagulation, Antiplatelet, Cardiology, Antithrombotic

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: Initial version

This document replaces (exact title of previous version):

• Clinical Guideline for Management of Anticoagulation in Interventional Cardiology v1.0 • Clinical Guideline for Restarting Of Antiplatelet/Anticoagulation Medications V1.0 • Clinical Guideline for Discontinuation Of Antiplatelet/Anticoagulation Medications in Pacing and Intervention V1.0

Approval route (names of committees)/consultation:

Cardiology Governance Group

Care Group General Manager confirming approval processes

Sidwell Lawler

Name and Post Title of additional signatories

Not Required


Name and Signature of Care Group/Directorate Governance Lead confirming approval by specialty and care group management meetings

{Original Copy Signed}

Name: Becky Osborne

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Clinical / Cardiology

Links to key external standards None required

Related Documents: No

Training Need Identified? None

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

14.10.2019 V1.0 Initial version Mohammed Abubakr, Consultant Cardiologist

All or part of this document can be released under the Freedom of Information Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Management of Anticoagulation in Interventional Cardiology

Clinical Guideline V1.0

Directorate and service area: Cardiology

New or existing document: New

Name of individual completing assessment: Sian Pelton

Telephone: 07833201879

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

This guideline is aimed at all medical and nursing staff caring for patients awaiting interventional cardiology who require management of their anticoagulation. This guideline is designed to safely manage the discontinuation of anticoagulation medications. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications.

2. Policy Objectives*

To standardise clinical practice in the management of anticoagulation in patients awaiting cardiac procedures. To inform and educate all medical and nursing staff to ensure the management of anticoagulation for patients awaiting cardiac procedures is evidence based. This guideline is designed to safely manage the discontinuation of anticoagulation medications. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications.

3. Policy – intended Outcomes*

To reduce the number of patients cancelled or delayed in having their cardiac procedures due to incorrect/inconsistent management of anticoagulation. All clinical staff working in cardiology are knowledgeable and confident in their understanding of anticoagulation management in interventional cardiology To standardise care, ensure early, appropriate and timely interventions, better education and reduce morbidity and mortality.

4. *How will you measure the outcome?

Regular feedback from the booking team, wards, cardiac catheter labs and consultant body. Audit of the number of patients who are cancelled or delayed in having their cardiac procedure due to incorrect/inappropriate management of their anticoagulation.

5. Who is intended to benefit from the policy?

Both elective and inpatients on anticoagulation awaiting a cardiac procedure.


Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age X

Sex (male,

female, trans-gender / gender reassignment)

X

Race / Ethnic communities /groups

X

Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.

X

Religion / other beliefs

X

Marriage and Civil partnership

X

Pregnancy and maternity

X

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

X

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

X

Please record specific names of groups

Clinical leads for intervention and pacing have reviewed the guidelines and they have been presented at the Cardiology Audit Meeting.

Cardiology Consultants

What was the outcome of the consultation?

Agreed

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No X

9. If you are not recommending a Full Impact assessment please explain why.

Not indicated

Date of completion and submission

14.10.2019 Members approving screening assessment

Policy Review Group (PRG) ‘APPROVED’

This EIA will not be uploaded to the Trust website without the approval of the Policy Review Group. A summary of the results will be published on the Trust’s web site.


Appendix 3. Thrombotic Risk Score

CHA2DS2-VASc score for stroke risk in atrial fibrillation Feature Score Congestive Heart Failure 1

Hypertension 1

Age >75 years 2

Age between 65 and 74 years 1

Stroke/TIA/TE 2

Vascular disease (previous MI, peripheral artery disease or aortic plaque)

1

Diabetes mellitus 1

Female 1

High-risk patients may also include those with a prior stroke or TIA occurring >3 months before the planned

surgery and a CHADSVASC score <5, those with prior thromboembolism during temporary interruption of

VKAs

THROMBOTIC RISK SCORE

Risk Mechanical Heart Valve

Atrial Fibrillation VTE

High1 5-6

Any mitral valve prosthesis Any caged-ball or tilting disc

aortic valve prosthesis Recent (within 6 months)

stroke or TIA

CHA2DS2-VASc score of 5 or 6

Recent (within 3 months) stroke or TIA

Rheumatic valvular heart disease

Recent (within 3 months) VTE

Severe thrombophilia (eg, deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)

Moderate 2-4

Bileaflet aortic valve prosthesis and one or more of the of following risk factors: atrial fibrillation, prior stroke or TIA, hypertension, diabetes, congestive heart failure, age>75 year

CHA2DS2-VASc score of 2 to 4

VTE within the past 3-12 months

VTE within the past 3- 12 months

Non-severe thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation)

Recurrent VTE

Active cancer (treated within 6 months or palliative care)

Low 0-1

Bileaflet aortic valve prosthesis without AF and no other risk factors for stroke

CHA2DS2-VASc score of 0 or 1 (assuming no prior stroke or TIA)

VTE >12 months previous and no other risk factors


Appendix 4. Summary Guidance for the Management of Anticoagulation in Interventional Cardiology ASPIRIN Antiplatelet

Indication low doses of aspirin administered once daily significantly reduce platelet aggregability and is indicated in: Primary prevention - risk of heart attack, stroke or vascular occlusion but have not had one. This will include patients over age 50 with hypertension, diabetes or other cardiovascular risk factors Secondary prevention - patients with significant cardiovascular disease. This includes patients with previous Unstable angina, Heart attack, Angioplasty or Coronary artery stents, Angina, Stroke, Peripheral vascular disease and renovascular disease.

Intervention Can be continued for angiograms and is a necessity for any procedure where stenting is considered.

Where an allergy is present, discussion with the consultant Cardiologist is required.

Pacing Discontinuation is not required prior to invasive pacing procedures.

EPS & ablation

Discontinuation is not required prior to these procedures.

CLOPIDOGREL, TICAGRELOR, PRASUGREL Antiplatelet

Indication Reduce platelet aggregation. Used in conjunction with aspirin as part of the ACS treatment regimen for the prevention of atherothrombotic events and post stent insertion to reduce stent thrombosis

Intervention Can be continued for angiograms and is a necessity for any procedure

where stenting is considered.

Where an allergy is present, discussion with the consultant Cardiologist is required.

Pacing Discontinuation is not required prior to invasive pacing procedures.

EPS & ablation

Discontinuation is not required prior to these procedures.

WARFARIN Anticoagulant

Indication Vitamin K antagonist (VKA). Used for thromboembolic prophylaxis in patients with mechanical heart valves, atrial fibrillation, recurrent DVT and/or PE and hypercoagulable disorders. Used also as treatment for first time DVT and/or PE.

Intervention Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve

Can be continued for angiograms. Target INR <4 Where any stenting is indicated the patient will require bridging therapy. For guidance on bridging refer to Appendix 2, Page 69 of the RCHT clinical guideline for thrombosis prevention investigation and management of anticoagulation.


Low thrombotic risk ≤4 CHA2DS2-VASc score or no metal valve

Can be continued for angiograms. Target INR <4 Where any stenting is indicated stop 5 days before procedure. Target INR of <1.7.

Restart warfarin evening of procedure with usual daily dose. Check INR one week later to ensure adequate anticoagulation.

DALTEPARIN/FRAGMIN ENOXAPARIN/CLEXANE LMWH Indication Treatment and prevention of thrombosis

Intervention Treatment dose Stop 24hrs before. Recommence day after procedure.

Prophylactic dose Continue.

Pacing Treatment dose Stop 24hrs before. First dose 24hrs after procedure.


EPS & ablation

Treatment dose Stop 24hrs before. Recommence day after procedure.


Pacing Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve

Continue warfarin. Target INR <4


Stop 5 days before. Target INR <1.5.

Restart warfarin day after procedure with usual daily dose. Check INR one week later to ensure adequate anticoagulation.

EPS & ablation

Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve

For radiofrequency ablation the decision is made on an individual basis. Please consult the operator for guidance.

For VT stimulations, atrial flutter ablations, AV node ablation with PPM implant in same sitting and AV node ablations with PPM insitu continue warfarin. Target INR <4


For radiofrequency ablation and AV node ablation with PPM implant in same sitting stop 5 days before. Target INR <1.5.

Restart warfarin evening of procedure with usual daily dose. Check INR one week later to ensure adequate anticoagulation.

For VT stimulations, atrial flutter ablations and AV node ablations with PPM insitu continue warfarin. Target INR <4


FONDAPARINUX Antithrombotic - Indirect factor Xa inhibitor Indication Treatment and prevention of thrombosis

Intervention Omit day of procedure. Restart at least 6 hours post-operatively provided haemostasis has been achieved.

Pacing Omit day of procedure. Restart at least 6 hours post-operatively provided haemostasis has been achieved.

EPS & ablation

For radiofrequency ablation and AV node ablation with PPM in same sitting omit day of procedure.

Restart at least 6 hours post-operatively provided haemostasis has been achieved.

For VT stimulations, atrial flutter ablations and AV node ablations with PPM insitu continue.

RIVAROXABAN (XARELTO) / APIXABAN (ELIQUIS) Direct oral anticoagulant - Direct factor Xa inhibitor Indication Direct oral anticoagulants (DOACs) are an alternative for vitamin K

antagonists (VKAs) for prevention of VTE after hip and knee replacement surgery, treatment of DVT and prevention of recurrent VTE and the prevention of thromboembolism in AF. They were previously known as NOACs, but as these medications are no longer ‘novel’, DAOC is going to be the future adopted term for practice


Can be continued for angiograms. Where any stenting is indicated the patient will require bridging therapy. For guidance on bridging refer to Appendix 2, Page 69 of the RCHT clinical guideline for thrombosis prevention investigation and management of anticoagulation.


Can be continued for angiograms. Where any stenting is indicated stop 48hrs before procedure.

Resume 48 hrs post-procedure.

Pacing Moderate to high Continue. thrombotic risk

≥4 CHA2DS2-VASc

score or any metal

valve

Low thrombotic risk Stop 48hrs before. ≤4 CHA2DS2-VASc

score or no metal valve



DABIGATRAN (PRADAXA) Anticoagulant - Direct thrombin inhibitor Indication Direct oral anticoagulants (DOACs) are an alternative for vitamin K

antagonists (VKAs) for prevention of VTE after hip and knee replacement surgery, treatment of DVT and prevention of recurrent VTE and the prevention of thromboembolism in AF. They were previously known as NOACs, but as these medications are no longer ‘novel’, DAOC is going to be the future adopted term for practice


Can be continued for angiograms. Where any stenting is indicated the patient will require bridging therapy. For guidance on bridging refer to Appendix 2, Page 69 of the RCHT clinical guideline for thrombosis prevention investigation and management of anticoagulation.


Can be continued for angiograms. Where any stenting is indicated stop: Renal function (eGFR) ≥ 80 24 hours before ≥ 50-< 80 1-2 days before ≥ 30-< 50 2-3 days before (> 48 hours)


Pacing Moderate to high Continue. thrombotic risk

≥4 CHA2DS2-VASc

score or any metal

valve

Low thrombotic risk Stop: ≤4 CHA2DS2-VASc Renal function (eGFR) score or no metal ≥ 80 24 hours before valve ≥ 50-< 80 1-2 days before

EPS & ablation


Continue.


For radiofrequency ablation and AV node ablation with PPM implant in same sitting stop 48hrs before procedure.




≥ 30-< 50 2-3 days before (> 48 hours)


EPS & ablation


Continue.


For radiofrequency ablation and AV node ablation with PPM implant in same sitting stop: Renal function (eGFR) ≥ 80 24 hours before ≥ 50-< 80 1-2 days before ≥ 30-< 50 2-3 days before (> 48 hours)



Switching between anticoagulant regimes

VKA to DOAC When switching patients from warfarin to

DOAC for stroke and/or systemic

embolism, discontinue warfarin and start

DOAC as soon as the International

Normalized Ratio (INR) <3.0,

When switching patients from warfarin to

DOAC for DVT/PE and prevention of

recurrence of VTE discontinue warfarin and

start DOAC as soon as the International

Normalized Ratio (INR) <2.5

DOAC to VKA Administer concomitantly for at least two

days until INR in appropriate range.

After 2 days of coadministration measure

INR just before next intake of DOAC.

Re-test 48hr after last dose of DOAC.

Continue coadministration until the INR is ≥

2, Monitor INR in first month until stable

values (2.0-3.0) achieved

Parenteral anticoagulation to DOAC:

Intravenous unfractionated heparin (UFH)

Low molecular weight heparin (LMWH)

Discontinue the parenteral anticoagulant

and start DOAC 0-2 hours prior to the time

that the next dose of the alternate therapy

would be due.


For unfractionated heparin being

administered by continuous infusion, stop

the infusion and start DOAC at the same

time

DOAC to parenteral anticoagulant

Intravenous unfractionated heparin (UFH)

Low molecular weight heparin (LMWH)

Initiate when next dose of DOAC was due.

It is recommended to wait 12 hours after

the last dose before switching from DOAC

to a parenteral anticoagulant.

DOAC to DOAC Initiate when next dose is due except

where higher plasma concentrations

expected (e.g. renal impairment)

DOAC to dual antiplatelet therapy (Aspirin +

Clopidogrel/Prasugrel/Ticagrelor)

Switch immediately. Discontinue DOAC

and give the first dose of the other

antiplatelet at the time that the next DOAC

dose would have been taken unless

combination therapy needed

Dual antiplatelet therapy (Aspirin +

Clopidogrel/Prasugrel/Ticagrelor) to DOAC

Unless combination therapy is needed,

start DOAC 0 to 2 hours prior to the next

scheduled evening administration of the

drug and omit administration of the other

antiplatelet.

Triple therapy – DOAC or VKA with aspirin

plus clopidogrel/Prasugrel

Combined oral anticoagulant and

antiplatelet therapy is generally

discouraged in atrial fibrillation (AF) outside

of ACS or stenting because of increased

bleeding, hence the decision to use triple

therapy is made on an individual basis in

consultation with a consultant Cardiologist


Appendix 5. Summary Guidance for the Discontinuation of Antiplatelet/ Anticoagulation

Setting: Cardiology For Staff: Nurses, doctors Patients: Adult patients awaiting elective and inpatient pacing/intervention

Roles and responsibilities: Doctors and nurses caring for patients To identify patients (elective and inpatient) on medications that will increase the risk of bleeding during/after a procedure and use this guideline to stop these medications in a timely fashion to minimise the risk of bleeding whilst considering if substitute bridging medication is required to prevent thromboembolic complications.

DRUG INDICATION LHC LHC ? PCI /

PWS PCI /

Rotablation PPM / ICD

(explant/impla nt/

generator change)

CRT-D / CRT- P

(explant/impla nt/

generator change)

Ablation: Narrow

complex tachy / SVT/

AVNRT/ WPW

VT Stimulation Atrial flutter ablation

AV node ablation with PPM in-situ

AV node ablation with PPM implant

Aspirin Antiplatelet continue required required continue continue continue continue continue continue continue

Clopidogrel Ticagrelor Prasugrel

Antiplatelet continue required required continue continue continue continue continue continue continue

Warfarin: Moderate to high risk (≥4 or

any metal valve)

Anticoagulant continue bridging bridging continue continue Patient specific - Liaise

with Dr. Slade

continue continue continue continue

Low risk

continue Stop 5 days before

INR <1.7

Stop 5 days before

INR <1.7

Stop 5 days before

INR <1.5

Stop 5 days before

INR <1.5

Stop 5 days before

INR <1.5

continue Continue Continue Stop 5 days before

INR <1.5

Dalteparin/Fragmin Enoxaparin/Clexane

Treatment dose >10,000IU

LMWH Stop 24hrs before

Stop 24hrs before

Stop 24hrs before

Stop 24hrs before

Stop 24hrs before

Stop 24hrs before

Stop 24hrs before

Stop 24hrs before

Stop 24hrs before

Stop 24hrs before

continue

continue

continue

continue

continue

continue

continue

continue

continue

continue

Prophylactic dose <10,000IU

Rivaroxaban and Apixaban: Moderate to high risk (≥4 or

any metal valve)

Low risk

New oral anticoagulant - Direct factor Xa

inhibitors

continue bridging bridging continue continue continue continue continue continue continue

continue Stop 48hrs before

Stop 48hrs before

Stop 48hrs before

Stop 48hrs before

Stop 48hrs before

continue continue continue Stop 48hrs before

Dabigatran Moderate to high risk (≥4 or

any metal valve)

Anticoagulant - Direct thrombin

inhibitor

continue bridging bridging continue continue continue continue continue continue continue

Low risk continue Stop 48hrs

before Stop 48hrs

before Stop 48hrs

before Stop 48hrs

before Stop 48hrs

before continue continue continue Stop 48hrs

before

Fondaparinux Antithrombotic- Indirect factor Xa

inhibitor

Omit day of procedure






continue continue continue Omit day of procedure


Thrombotic risk score

Risk Mechanical Heart Valve Atrial Fibrillation VTE

High1 5-6

Any mitral valve prosthesis Any caged-ball or tilting disc aortic valve

prosthesis Recent (within 6 months) stroke or TIA

CHA2DS2-VASc score of 5 or 6 Recent (within 3 months) stroke or

TIA Rheumatic valvular heart disease

Recent (within 3 months) VTE Severe thrombophilia (eg, deficiency of

protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)

Moderate 2-4

Bileaflet aortic valve prosthesis and one or more of the of following risk factors: atrial fibrillation, prior stroke or TIA, hypertension, diabetes, congestive heart failure, age>75 year

CHA2DS2-VASc score of 2 to 4



Non-severe thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation)

Recurrent VTE

Active cancer (treated within 6 months or palliative care)

Low 0-1

Bileaflet aortic valve prosthesis without AF and no other risk factors for stroke

CHA2DS2-VASc score of 0 or 1 (assuming no prior stroke or TIA)

VTE >12 months previous and no other risk factors

CHA2DS2-VASc = congestive heart failure 1, hypertension 1, age >75 years 2, age 65-74 1, diabetes mellitus 1, stroke/TIA/thrombo-

embolism 2, vascular disease 1, sex female 1

1High-risk patients may also include those with a prior stroke or TIA occurring >3 months before the planned surgery and a CHADSVASC score <5, those with prior thromboembolism during temporary interruption of VKAs


Appendix 6. Summary of Guidance for the Restarting of Antiplatelet / Anticoagulation Medications DRUG INDICATION LHC LHC ? PCI /

PWS

PCI / Rotablation

PPM / ICD CRT-D CRT-P

Ablation: Narrow complex tachy / SVT/ AVNRT/ WPW

VT Stimulation

Atrial flutter ablation

AV node ablation with PPM in-situ

AV node ablation with PPM implant

Aspirin Antiplatelet continue If stented lifelong lifelong continue continue continue continue continue continue continue

Clopidogrel Ticagrelor Prasugrel

Antiplatelet continue If stented - to be taken for between 1 -12 months

To be taken for between 1 -12 months

continue continue continue continue continue continue continue

Warfarin:

Moderate to high risk (≥4 or any metal valve)

Low risk

Anticoagulant continue Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic dose of LMWH on the day after the procedure. Continue LMWH until a satisfactory INR is achieved

Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic dose of LMWH on the day after the procedure. Continue LMWH until a satisfactory INR is achieved

continue continue Patient specific - Liaise with DDr. Slade

continue continue continue continue

continue Restart warfarin evening of procedure with usual daily dose. Check INR 1

Restart warfarin evening of procedure with usual daily dose. Check INR 1

Restart warfarin day after procedure with usual daily dose. Check INR 1

Restart warfarin day after procedure with usual daily dose. Check INR 1

Restart warfarin evening of procedure with usual daily dose. Check INR 1

continue continue continue Restart warfarin evening of procedure with usual daily dose. Check INR 1

week later to ensure adequate anticoagulation







Dalteparin / Fragmin Enoxaparin / Clexane

Treatment dose >10,000IU

Prophylactic dose <10,000IU

LMWH Recommence day after procedure

Recommence day after procedure


First dose 24hrs after procedure







continue

continue

continue

continue

continue

continue

continue

continue

continue

continue

Rivaroxaban Apixaban


Low risk

New oral anticoagulant

- Direct factor Xa inhibitors

continue Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic dose of LMWH on the day after the procedure. Continue LMWH until a satisfactory INR is achieved

Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic dose of LMWH on the day after the procedure. Continue LMWH until a satisfactory INR is achieved

continue

continue continue continue continue continue continue

continue Resume 48 hrs post- procedure

Resume 48 hrs post- procedure




continue continue continue Resume 48 hrs post- procedure

Dabigatran


Anticoagulant

- Direct thrombin inhibitor

continue Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic

Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic

continue continue continue continue continue continue continue

dose of dose of LMWH on the LMWH on the day after the day after the Low risk procedure. procedure. Continue Continue LMWH until a LMWH until a


satisfactory satisfactory INR is INR is achieved achieved continue Resume 48 Resume 48 Resume 48 Resume 48 Resume 48 continue continue continue Resume 48 hrs post- hrs post- hrs post- hrs post- hrs post- hrs post- procedure procedure procedure procedure procedure procedure

Fondaparinux Antithrombotic- Indirect factor Xa inhibitor

restart at least 6 hours post- operatively provided haemostasis has been achieved






continue continue continue restart at least 6 hours post- operatively provided haemostasis has been achieved

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