Guideline for Peri-Procedural Anticoagulation and Bridging ...

1 Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin ** Please note that this Guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required ** Figure A Figure A Classify Procedural Risk of Bleeding(See Figure A)Very Low / LowAnticoagulation (warfarin) WILL NOTneed to be interrupted *Moderate / High / Very HighAnticoagulation (warfarin) WILL need to be interruptedClassify Patient Risk of Thromboembolism (TE)(See Figure B)LowBridging NOTindicated*Discontinue warfarin 5 days before procedure **Resume warfarin post-procedure based on procedural risk of bleeding(See Figure D)ModerateBridging MAY be indicated*Discontinue warfarin 5 days before procedure **Clinical judgement should be used to balance the risk of bleeding and clotting to determine if patient should be bridged or not. HighBridging IS indicatedDiscontinue warfarin 5 days before procedure **(See Figure C for Pre-Procedural Bridging )Resume warfarin/ LMWH post-procedure based on procedural risk of bleeding(See Figure D)Special Population (VAD)See VAD Bridging Guideline * For patients NOT requiring warfarin interruption, INR should be checked prior to procedure to ensure not supratherapeutic.

2 For more complex dental procedures, it may be appropriate to hold 1-2 doses if risk of TE is low. ** It may be necessary to hold warfarin longer than 5 days for select patient populations ( elderly, liver dysfunction, low dose requirements, target INR of , supratherapuetic INR) - At the discretion of the MD performing the procedure, it may be appropriate to check an INR the day before procedure to ensure INR is at baseline. If INR is greater than , a small dose of Vitamin K may be considered - Even in the scenario that Bridging is not indicated, post-procedure DVT prophylaxis should still be considered in procedures that require routine prophylaxis Bridge No Bridge Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin ** Please note that this Guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required ** Figure A Procedural Bleeding Risk Classification* Very Low Risk Dental hygiene or single extraction Selected dermatologic procedures (skin biopsy, skin cancer removal) Cataract surgery Low Risk Arthroscopy Central venous catheter removal Electrophysiologic Testing GI endoscopy without biopsy (colonoscopy, cystoscopy, gastroscopy) Joint or soft tissue injections Uncomplicated dental procedures Minor dermatologic procedures other than above Non-cataract ophthalmologic procedures Non-coronary angiography Radial coronary angiography +/- PCI Internal defibrillator / pacemaker insertion Moderate Risk Axillary node dissection Dilation / curettage GI endoscopy with biopsy (colonoscopy / cystoscopy / gastroscopy) Hemorrhoidal surgery Minor intra-abdominal surgery (hernia repair, hysterectomy, appendectomy, bowel resection, cholecystectomy, polypectomy)

3 Dental surgery / Complex dental procedures or multiple tooth extractions Minor intrathoracic surgery Minor orthopedic surgery (hand, foot, shoulder, carpal tunnel repair) Minor vascular surgery (endarterectomy, carotid bypass surgery) Sternotomy wire removal Selective invasive procedures (bone marrow aspirate / biopsy, lymph node biopsy, thoracentesis, paracentesis, arthrocentesis) High Risk Intestinal anastomosis surgery Major vascular surgery (abdominal aortic aneurysm repair, aortofemoral bypass) Major urologic surgery (prostatectomy, bladder tumor resection) Major lower limb orthopedic surgery (hip replacement, knee replacement) Major thoracic surgery (lobectomy, pneumonectomy) Selected invasive procedures (renal biopsy, lung biopsy, hepatic biopsy, prostate biopsy, cervical cone biopsy, pericardiocentesis, colonic polypectomy) Very High Risk Cardiac surgery (coronary artery bypass, heart valve replacement, heart transplantation) Neurosurgery (intracranial or spinal surgery) * To estimate the risk of bleeding for a specific procedure not included above consider the following: procedures that are likely to incur a higher risk of bleeding include those in a closed area/cavity as well as highly complex or invasive procedures, those involving a large surface area and procedures expected to result in a large amount of inflammation.

4 Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin ** Please note that this Guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required ** Figure B Patient Thromboembolic Risk Classification Indication for Anticoagulation Risk Factors Low Risk Criteria Moderate Risk Criteria High Risk Criteria Bioprosthetic Heart Valve > 3 months after placement Within first 3 months of placement Mechanical Heart Valve Atrial Fibrillation CHF HTN DM Age > 75 Prior CVA / TIA Bileaflet aortic valve AND no risk factors Medtronic Hall tilting disc valve Bileaflet aortic valve AND 1 or more risk factors Prior thromboembolism during interruption of warfarin therapy Any mitral valve prosthesis Older caged-ball / tilting disc aortic valve prosthesis CVA / TIA (within 6 months) Atrial Fibrillation CHADS2-VASc Score CHF (1 point) HTN (1 point) DM (1 point) Prior CVA / TIA / TE (2 points) Age > 75 (2 point) Age 65 74 (1 point) Vascular disease (1 point) Female (1 point)

5 CHADS2-VASc score 0 to 4 AND no prior CVA / TIA CHADS2-VASc score 5 to 6 Consider Bridge if CVA / TIA > 3 months Prior thromboembolism during interruption of warfarin therapy CHADS2-VASc score 7 CVA / TIA (within 3 months) Rheumatic valvular heart disease Venous Thromboembolism (VTE) Non-severe Thrombophilia: Heterozygous factor V Leiden Prothrombin gene mutation Severe Thrombophilia: Deficiency of antithrombin Protein C or S deficiency Homozygous factor V Leiden Antiphospholipid antibody syndrome Heterozygous factor V Leiden in addition to Prothrombin gene mutation Single VTE more than 12 months ago AND no other risk factors VTE within past 3 to 12 months Non-severe thrombophilia Recurrent VTE Prior thromboembolism during interruption of warfarin therapy Active cancer Less than 3 months since VTE Severe thrombophilia Special Populations Ventricular Assist Device (VAD) See VAD Bridging Guideline Note: Previous literature and current guidelines historically risk-stratified patients using CHADS2, however CHADS2-VASc has since been validated and adopted into clinical practiceGuideline for Peri-Procedural Anticoagulation and Bridging for Warfarin ** Please note that this Guideline may not be appropriate for all patients and does not replace clinical judgment.

6 Consultation with MD performing procedure may be required ** Figure C Pre-Procedural: Bridging Agent When to Initiate When to Discontinue** Therapeutic LMWH (Dalteparin & Enoxaparin), dosed Q 12 Hours 24 to 48 hours after last dose of warfarin (based on INR) Give last dose 24 hours prior to procedure Therapeutic LMWH (Dalteparin & Enoxaparin), dosed Q 24 Hours Give last dose 24 hours prior to procedure Prophylactic LMWH (Dalteparin & Enoxaparin), dosed Q 24 Hours Give last dose 12-24 hours prior to procedure Fondaparinux* Give last dose 36-48 hours prior to procedure IV Unfractionated Heparin (UFH) Discontinue 4-6 hours prior to procedure Note: For dosing recommendations, please refer to the drug specific DAG * There is limited data to support Bridging with Fondaparinux; however, this is the drug of choice for patients with Heparin-Induced Thrombocytopenia ** Time between last dose of parenteral agent and procedure may need to be extended in patients with renal dysfunction or if regional anesthesia is required.

7 Please see the BWH regional anesthesia in anticoagulated Patients guidelines for more information. Figure D Post Procedural: Resuming Anticoagulation Agent Procedural Bleeding Risk Classification When to Resume Anticoagulation * Warfarin Very Low / Low Restart evening of procedure Moderate** Restart evening of procedure High / Very High Restart evening of procedure * Resumption may be deferred 1-2 days if concerned about bleeding risk LMWH (Dalteparin & Enoxaparin), Fondaparinux, IV UFH Very Low / Low Restart 12-24 hours after Procedure Moderate** Patient risk for TE = Moderate * Restart 24-48 hours after procedure Patient Risk for TE = High * Restart 24 hours after procedure High/ Very High** Patient risk for TE = Moderate * Do not restart LMWH Patient Risk for TE = High * Restart 48-72 hours after procedure * Hemostasis should be established prior to resumption of any Anticoagulation ** Warfarin resumption after procedures thought to have moderate bleeding risk may be deferred for 1-2 days at the discretion of MD if unexpected perioperative bleeding occurs ** For patients at high / very high risk, it may be appropriate to resume LMWH or IV UFH therapy 24 hours after the procedure - Even in the scenario that Bridging is not indicated, post-procedure DVT prophylaxis should still be considered in procedures that require routine prophylaxis - For Moderate risk TE patients with a Moderate procedural bleeding risk.

8 A prophylactic LMWH dose may be used to bridge post-procedure to reduce the risk of bleeding even if therapeutic dose LMWH is used prior to procedure - For High risk TE patients with a High procedural bleeding risk other options include: o Post-procedure Bridging with prophylactic LMWH until bleeding risk minimized then transition back to therapeutic dose LMWH o Post-procedure Bridging with prophylactic LMWH only o Resumption of warfarin alone with no LMWH/IV UFH - Restart warfarin with 15-20% increase of previous maintenance dose & retest INR within 3-4 days Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin ** Please note that this Guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required ** - Due to lack of evidence for preventing arterial TE, some clinicians wouldn t consider Prophylactic LMWH after surgery unless part of routine VTE prophylaxis References: 1.

9 Doherty, , Gluckman, , Hucker, et al, 2017 ACC expert consensus decision pathway for periprocedural management of Anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017;69:871 898. 2. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015; 373:823. 3. Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012. 4. Olesen JB, Lip GYH, Hansen ML, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: Nationwide cohort study BMJ. 2011. 5. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

10 Chest. 2012;141(2 Suppl):e326S-e350S. Approved by Pharmacy and Therapeutics Committee: 11/2017