Anticoagulation Duration


When to Start/Stop Blood thinners?
Aspirin 7 days prior to surgery
- BUT Continue in pt with CVA or MI (especially if getting a CABG)
Plavix (Clopidogrel or prasugrel) 5 days prior to ANY surgery
Warfarin 5 days prior to surgery
  - Check INR prior to starting Arixtra/heparin 24-48 hrs after warfarin

Start
therapeutic Arixtra or Heparin at appropriate dose, or when INR is sub-therapeutic

2-3 days
prior to surgery
Give last pre-op Arixtra 24 hr prior to surgery
or
Stop heparin 6 hr prior to surgery. If INR > 1.5, give Vitamin K per physician.
1 day prior to surgery
Stop Arixtra or Heparin 12 hr after surgery if bleeding risk is low.
If bleeding risk is high, consider reduced dose of Arixtra or Heparin until bleeding risk subsides.
1 day after surgery
INR should be rechecked if above goal the day prior.
Resume warfarin at maintenance dose post-op Day 1 if hemodynamically stable.
Surgery day
Stop xarelto (or other DVT prophylaxis) Post Arthroplasty (Othopedic surgery) for Thromboprophylaxis 35 days post surgery.
Source: Antithrombotic & Thrombolytic Therapy, 8th Ed.

DVT/PE

Proximal DVT of leg provoked by surgery
- target 2.0-3.
- duration 3 months
 
Proximal DVT of leg provoked by nonsurgical transient risk factor
- target 2.0-3.0
- duration 3 months if high bleeding risk*|
- duration indefinitely if low-to-moderate bleeding risk*
 
Distal isolated DVT of leg without severe symptoms or risk factors for extension
- serial imaging of deep veins to eval for extension rather than anticoagulation
- if extends, anticoagulate as below
 
Distal isolated DVT of leg with severe symptoms or risk factors for extension
- target 2.0-3.0
- duration 3 months
- then evaluate for risk-benefit balance of indefinitely further anticoagulation with preference for cessation
 
Distal isolated DVT of leg provoked by surgery or nonsurgical transient risk factor in whom anticoagulation is elected
- target 2.0-3.0
- duration 3 months
 
Unprovoked DVT of leg (including all proximal and those distal clots treated with anticoagulation)
- target 2.0-3.0
- duration 3 months
- then consider those at low-to- moderate bleeding risk* for indefinite further anticoagulation and those at high bleeding risk* for cessation
 
Patients with second unprovoked VTE (DVT or PE)
- target 2.0-3.0
- duration 3 months for those with high bleeding risk*
- duration indefinitely for those with low-to-moderate bleeding risk*
 
DVT and active cancer
- target 2.0-3.0
- duration indefinitely
 
PE provoked by surgery
- target 2.0-3.0
- duration 3 months
 
PE provoked by a nonsurgical transient risk factor
- target 2.0-3.0
- duration 3 months
 
PE unprovoked
- target 2.0-3.0
- duration 3 months
- then consider those at low-to-moderate bleeding risk* for indefinite further anticoagulation and those at high bleeding risk* for cessation
 
PE and active cancer
- target 2.0-3.0
- duration indefinitely
 
Patients incidentally found to have asymptomatic DVT or PE
- same mgmt as comparable pts with symptomatic DVT or PE
 
SVT (superficial vein thrombosis) leg 5+ cm long
- prophylactic dose fondaparinux preferred over LMWH
- duration 45 days
 
UEDVT (upper extr DVT) associated with central venous catheter
- catheter need not be removed if functional and valuable for pt care
 
UEDVT assoc with central venous catheter which is not removed
- target 2.0-3.0
- duration as long as catheter remains
 
UEDVT assoc with catheter which is removed
- target 2.0-3.0
- duration 3 months
 
UEDVT not assoc with catheter
- target 2.0-3.0
- duration 3 months
 
Patients with symptomatic hepatic or splanchnic vein thrombosis (portal, mesenteric, and/or splenic)
- anticoagulation recommended, preference for LMWH over Warfarin if active cancer, liver disease, thrombocytopenia
- duration indefinitely if no transient risk factor and low risk of bleeding, 3 months preferred otherwise
 
Patients with asymptomatic hepatic or splanchnic vein thrombosis
- no anticoagulation recommended
- data to guide this situation sparse
 


* Bleeding risk scheme:
Low risk = 0 risk factors
Moderate risk = 1 risk factor
High risk = 2+ risk factors
Risk factors: age > 65, previous bleed, cancer, renal failure, liver failure, thrombocytopenia, previous stroke, diabetes, anemia, antiplatelet therapy, poor anticoagulant control, comorbidity and reduced functional capacity, recent surgery, frequent falls, alcohol use
 

A-Fiv (& A-Flutter, PAF)

Acute A-Fib/Flutter ≥ 48 hrs or unknown duration and cardioversion planned:
- target 2.0-3.0
- duration 3 wks before cardioversion
- duration pre-cardioversion can be truncated if high-quality TEE reassures against atrial thrombus
- duration 4+ wks after cardioversion
- whether to anticoagulate after 4 wks has no evidence to guide therapy. Many pts 1 year out from seemingly successful cardioversion are back in A-fib. Thus ACCP recommends individual risk assessment based on CHADS2 stroke risk, bleeding risk, and other pt specific factors for this   decision 
Acute A-Fib/Flutter known duration < 48 hrs and cardioversion planned:
- IV Heparin or LMWH recommended at presentation if no contraindications present.
- after successful cardioversion anti-coagulate (Warfarin, LMWH, newer agents) at least 4 weeks
- consider long-term anticoagulation after initial 4 weeks based upon individual pt risks as described above for A-fib ≥ 48 hrs 
Chronic Atrial Fibrillation, Paroxysmal A-Fib, and A-Flutter:
- first do CHADS2 score for long-term risk of ischemic stroke: 
CHADVASc Score
  Condition
C Congestive heart failure (or Left ventricular systolic dysfunction)
H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)
A2 Age ≥75 years
D Diabetes Mellitus
S2 Prior Stroke or TIA or 
thromboembolism
V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)
A Age 65 - 74 years
Sc Sex category (i.e. female gender)
Score Risk

Anticoag Tx

Consideration

0 low No antithrombotic therapy (or Aspirin) No therapy if < 60yr & no structural heart dz  -OR-  Aspirin 81 - 325 mg daily
1 Mod Oral anticoagulant
(or Aspirin)
Oral anticoagulant: Either new oral anticoagulant drug e.g. dabigatran or well controlled warfarin at INR 2.0-3.0
-OR-
Aspirin 81 - 325 mg daily, depending on factors such as patient preference
>2 High Oral anticoagulant Oral anticoagulant, using either a new oral anticoagulant drug (e.g. rivaroxaban or dabigatran) or well controlled warfarin at  INR 2.0-3.0

Valve/Structural Dz

Rheumatic mitral valve dz, normal sinus rhythm, and left atrial diameter < 55 mm
- no anticoagulant or antiplatelet recommended
 
Rheumatic mitral valve dz, normal sinus rhythm, and left atrial diameter > 55 mm
- target 2.0-3.0
- duration indefinitely
 
Rheumatic mitral valve dz complicated singly or in combination by A-Fib, left atrial thrombus, or previous systemic embolism
- target 2.0-3.0
- duration indefinitely
 
When percutaneous mitral balloon valvulotomy (PMBV) considered and TEE shows left atrial thrombus
- target 2.0-3.0
- duration until thrombus resolves
 
Patent Foramen Ovale (PFO) or atrial septal aneurysm asymptomatic
- no anticoagulant recommended
 
PFO or atrial septal aneurysm with cryptogenic stroke
- aspirin therapy recommended
 
PFO or atrial septal aneurysm with recurrent cryptogenic stroke events despite aspirin
- target INR 2.0-3.0
- consider device closure over aspirin
 
PFO, cryptogenic stroke, and evidence of DVT
- target 2.0-3.0
- duration 3 months
- consider device closure over Warfarin or no aspirin therapy
 
Infective endocarditis without another particular indication
- no anticoagulant or antiplatelet recommended
 
Aortic bioprosthetic valve with sinus rhythm and no other Warfarin indication
- aspirin 50-100 mg/day
- duration 3 months
 
Transcatheter aortic bioprosthetic valve
- aspirin 50-100 mg/day & clopidogrel 75 mg/day
- duration 3 months
 
Mitral bioprosthetic valve
- target 2.0-3.0
- duration 3 months
 
Bioprosthetic valve in any position after first 3 months post-insertion
- aspirin
- duration indefinite
 
Mechanical aortic valve
- target 2.0-3.0
- consider adding aspirin 50-100 mg/day for pts at low risk of bleeding
- duration indefinite
 
Mechanical mitral valve
- target 2.5-3.5
- consider adding aspirin 50-100 mg/day for pts at low risk of bleeding
- duration indefinite
 
Mechanical valve in aortic and mitral position
- target 2.5-3.5
- consider adding aspirin 50-100 mg/day for pts at low risk of bleeding
- duration indefnite
 
Anterior myocardial infarction (MI) and left ventricular (LV) thrombus or at high risk for LV thrombus (EF <40%, anteroseptal wall motion abnormality) who do not receive stent
- target 2.0-3.0 plus aspirin 75-100 mg/day
- duration first 3 mos
- dual antiplatelet therapy alone for 3-12 months
- single antiplatelet therapy after 12months
 
Anterior MI and LV thrombus or at high risk for LV thrombus (EF <40%, anteroseptal wall motion abnormality) who receive bare metal stent (BMS)
- target 2.0-3.0 plus low-dose aspirin and clopidogrel 75 mg/day
- duration 1st month
- target INR 2.0-3.0 plus single antiplatelet therapy 2nd & 3rd month
- dual antiplatelet therapy alone 4-12 Mo
- standard antiplatelet therapy after 12 months
 
Anterior MI and LV thrombus or at high risk for LV thrombus (EF <40%, anteroseptal wall motion abnormality) who receive drug-eluting stent (DES)
- target 2.0-3.0 plus low-dose aspirin and clopidogrel 75 mg/day
- duration 3-6 months
- dual antiplatelet therapy alone thru 12 months
- standard antiplatelet therapy after 12 months
 
Systolic LV dysfunction with acute LV thrombus but without established CAD
- target 2.0-3.0
- duration at least 3 months
 
 
 

After Major Ortho Surgery

Major orthopedic surgery (total hip, total knee, hip fracture) pts should receive an antithrombotic prophylactic with one of following agents
- LMWH (low molecular wt heparin), fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH (low dose unfractionated heparin), VKA (Warfarin), aspirin (debatable, see article), or intermittant pneumatic compression device (IPCD)
- preference for LMWH over others
- duration minimum 10-14 days post-op
- duration preferred extended up to 35 days
 
Dual prophylaxis with antithrombotic agent and IPCD recommended during hospital stay
- guideline quite specific about features of IPCD necessary to confer benefit
 
Patients with an increased risk of bleeding receive recommendation for IPCD or no prophylaxis over pharmacologic agent
- bleeding risk factors are:
(1) previous major bleeding without change for risk of recurrence,
(2) severe renal failure,
(3) concomitant antiplatelet agent,
(4) surgical factors: history of or difficult-to-control surgical bleeding during the current operative procedure, extensive surgical dissection, revision surgery- absolute risks of bleeding on pharmacologic agents are small- balance of risks, benefits, and preferences should be individualized to the pt
 
Major orthopedic surgery pts who decline or are uncooperative with injections or an IPCD
- apixaban or dabigatran recommended
- rivaroxaban or VKA (Warfarin) if above unavailable
Patients with just knee arthroscopy without history of VTE
- no prophylaxis recommended
 
Patients with isolated lower-leg injuries requiring leg immobilization
- no prophylaxis recommended
 
 

Thrombophilia

ACCP 2012 guideline recommends in patients with asymptomatic thrombophilia (that is, no history of previous VTE) not to use mechanical or pharmacologic thromboprophylaxis.

There is very little evidence to provide guidance on this topic, and even less of quality.
 
For those patients who have had a VTE event in setting of thrombophilia, anticoagulation is recommended
- target 2.0-3.0, even for antiphos-pholipid syndrome pts
- duration indefinitely
 


ITE 2013, Q70
Which one of the following is the recommended duration of thromboprophylaxis following total hip arthroplasty, starting from the day of surgery and including outpatient prophylaxis?

A) 7 days
B) 14 days
C) 35 days
D) 60 days
E) 90 days