Antiplatelets, AnticoagulantsWhat are the consequences

Dr Jeremy Wright CardiologistHearts1st, Greenslopes Private Hospital

Outline

2 clinical cases

Overview of haemostasis

Antiplatelet medications

Anticoagulant medications

Strategy for peri-procedural management

Case 1

86yo female RCA stent 6 months ago Hb 55, large colorectal cancer Transfusion, staged anterior resection

Pre-op phone assessment advised stop Aspirin and Clopidogrel 1 week prior to surgery

Anterior resection performed

In recovery - chest pain and intermittent bradycardia

Case 1

Multiple VF arrests Aspirated Intubated

Angio showed stent thrombosis IV heparin, eptifibatide

Prolonged stay in ICU

Discharged home 1 month later

Case 2

83 yo female 2 days post stent to LAD Aspirin and Clopidogrel Pleural effusion Pleural tap requested to exclude empyema

Large haemothorax

Deceased despite resuscitation

Haemostasis

Haemostasis

Antiplatelets

Anticoagulants

Antiplatelet medications

Aspirin- Cartia, Astrix, etc

Clopidogrel- Plavix, Iscover

Prasugrel- Effient

Ticagrelor- Brilinta

Fish Oil, Chinese Herbs

GP IIb/IIIa inhibitors – Reopro, Aggrastat

Coronary Artery Stents

Three ‘Generations’1.) Bare Metal (BMS)2.) Drug Eluting (DES) (first generation)3.) Drug Eluting (DES) (second generation)

BMS require dual antiplatelet therapy for at least 1 month

DES require dual antiplatelet therapy for at least 6 months

Aspirin must continue

Anticoagulants

Older agents- Oral: Warfarin- Injection: Heparin, Clexane, Danaparoid, Fondaparinux

New oral agents- Dabigatran (Pradaxa)- Rivaroxaban (Xarelto)- Apixaban (Eliquis)

New injection agents- Lepirudin (Refludan)- Bivalirudin (Angiomax)- Desirudin (Revasc)

Time required for medications to wear off

Antiplatelets: 7 days

Warfarin: 5 days

Injections: 6-24 hours

New oral agents- Dabigatran (Pradaxa) 2 days if eGFR>50, otherwise 5 days- Rivaroxaban (Xarelto) 1-2 days- Apixaban (Eliquis) 1-2 days

General Principles

Assess thromboembolic risk of stopping medication- Why taking the medication- How long ?- Previous bleeding problems

Assess bleeding risk associated with the procedure

Ultimate responsibility lies with the Dr performing the procedure, assisted by the referring Dr

Bridging medications may be required in some circumstances

Confused?

CSANZ 2009

Warfarin for prosthetic valves ?

Confused?

Society of Interventional Radiology Consensus Guidelines

J Vasc Interv Radiol 2009; 20:S240-S249

Take home messages

Critical to find out what the patient is taking – oral, SC, IV

There are many new medications- If not sure, look it up or ask

These decisions can be complex

Communication is the key