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BALANCING THROMBOSIS AND BLEEDING RISKS
- 1. BALANCING THROMBOTIC AND BLEEDING RISKS Dr Syed Raza MD, MRCP(UK),Dip Card(UK),CCT(UK),FCCP
- 2. OBJECTIVES 1. Burden of thrombosis and anti thrombotic related bleeding complications 2. Assessment of thrombotic and bleeding risks 3. How best to maintain a balance 4. How to manage common anti thrombotic related bleeding complications
- 3. โข Due to increasing number of elderly population, prevalence of thrombosis related complications and bleeding associated with anti thrombotic treatment is constantly rising. โข There are various tools to assess thrombotic risk but assessment of bleeding risk is often ignored.
- 4. Antithrombotic therapy has revolutionized the medical management of patients. Over the past 20 years, the development of new antithrombotic medications and strategies has reduced ischemic events very significantly.
- 5. WARFARIN
- 6. Newer Anticoagulants โ Direct Thrombin Inhibitors: โข hirudin, lepirudin, desirudin, bivalirudin, โข ximelagatran, Dabigatran โ Xa inhibitors: โข fondaparinux, idraparinux โข Rivaroxaban, Apixaban โ Heparinoids: โข Danaparoid (discontinued)
- 7. YING - YANG PRINCIPLE โข With every approach to reduce thrombosis, however, there is an accompanying risk of increasing bleeding complications . โข Conversely, reducing bleeding complications may increase thrombotic (ischemic) events.
- 8. Thrombosis vs Bleeding โข They both increase morbidity and mortality โข Balancing both ends of the spectrum is essential, and an individualized approach to therapy is advocated.
- 9. Case Scenario โข 80 Yrs male โข Hypertensive โข Congestive Cardiac Failure โข Atrial Fibrillation CHADS2 : 3 CHA2DS2-VAS : 4
- 12. Assessment of Bleeding Risk โข Age โข Hypertension โข Renal Failure โข Hepatic impairment โข Significant anemia/ suspected leukemia HAS โ BLED : 4 >3 : Increased bleeding risk
- 14. How about the thrombo prophylaxis for DVT?
- 16. Case Scenario โข 50-year-old woman scheduled to undergo elective laparoscopic cholecystectomy โ PMH : COPD โ No personal or family history of VTE โ Medications: Spirivaยฎ, albuterol โ Stopped smoking 1 year ago โข What should we recommend for perioperative VTE prophylaxis in this patient?
- 17. Baseline Risk of VTE
- 18. Baseline Risk of VTE Bahl et al. Ann Surg. 2010;251:344-350.
- 20. The Antithrombotic Therapy and Prevention of Thrombosis. ACCP Feb.2012 โข significantly impacted the more than 600 recommendations for the prevention, diagnosis, and treatment of thrombosis โข DVT prophylaxis not for everybody โข Risk stratification for VTE is recommended (many may receive unnecessarily) โข Bleeding risk is to be assessed.
- 21. If the patient develops hemorrhagic stroke but high thrombotic risk Will you โฆ.. โข 1.Stop all anticoagulant โข 2.Use only prophylactic dose anticoagulant. โข 3.IVC Filter โข 4.Continue Oral anticoagulant maintaining low level INR
- 22. FACTORS INFLUENCING DECISION ON RE/COMMENCING AFTER ICH โข Size of expanding haematoma โข Time from onset of haemorrhage โข Degree of INR rise โข Radiological finding โ โSpot Signโ
- 23. The โspot signโ (arrow), contrast extravasation after contrast-enhanced computed tomography, is associated with a high risk of hematoma expansion. GOLDSTEIN J N , GREENBERG S M Cleveland Clinic Journal of Medicine 2010;77:791-799 ยฉ2010 by Cleveland Clinic
- 26. What do the guidelines say ? Initiation of anticoagulant after ICH โ only if risk of thrombosis outweighs risk of bleeding. The European Stroke Initiative : 10-14 days American College of Cardiology : 7-10 days American College of Chest Physicians : LMWH next day. No clear guidelines on Oral anticoagulant.
- 27. Bleeding Risk Assessment Tools โข 1.ACS โ CRUSADE โข 2. AF โ HAS โ BLED โข 3.DVT/PE โ Out Patient Bleeding Risk Index โข 4.DVT- PE โ IMPROVE โข 5. DVT/PE โ HEMORR2HAGES
- 28. THROMBOTIC AND BLEEDING RISK ASSESSMENT IN ACUTE CORONARY SYNDROME
- 29. Antiplatelet agents Aspirin โ โNo doctor, I am on no medicationโฆโ โ Commonest cause of post op wound oozing โ Ticlopidine โ Dipyridamole โ Clopidogrel โ Prasugrel โ Ticagrelor
- 30. Evolving Paradigm for Evaluating ACS Management Strategies Composite Adverse Event Endpoints โบ Angina โบ Major Bleeding โบ MI โบ Minor Bleeding โบ Thrombocytopenia Ischemic Hemorrhag Complications e HIT
- 32. Bleeding Risk Score: CRUSADE
- 33. Predictors of Major Bleeding in ACS โข Older Age โข Female Gender Independent โข Renal Failure Predictors of Major Bleeding โข History of Bleeding in Marker Positive โข Right Heart Catheterization Acute Coronary โข GPIIb-IIIa antagonists Syndromes โข Dual anti platelet โข Use of anticoagulant โข NSAIDS and COX2 Inhibitors Moscucci, GRACE Registry, Eur Heart J. 2003 Oct;24(20):1815-23.
- 34. Balancing Events and Bleeding Risk of events Risk of bleeding Risk Degree of Anticoagulation Hemostasis Thrombosis Two sides of the same coin
- 35. Bleeding in ACS Question to be answered: Does bleeding influence the prognosis of ACS patients ?
- 36. Major Bleeding Predicts Mortality in ACS 24,045 ACS patients in the GRACE registry, in-hospital death 40.0 P<0.001 30.0 22.8 Patients (%) 18.6 No Bleed 20.0 16.1 15.3 Bleed 10.0 7.0 5.1 5.3 3.0 0.0 Overall Unstable NSTEMI STEMI ACS Angina Moscucci M et al. Eur Heart J 2003;24:1815-23.
- 37. Warfarin therapy and Bleeding โข Most serious complication of Warfarin โข Common cause for litigation โข Most common sites of serious bleeding: โ Epistaxis and gum bleed โ Soft tissue including wounds โข Serious but less common sites of bleeding: _ Intracranial GIT
- 38. Incidence of Bleeding in Warfarin therapy Fatal bleeding 0.1-1% (Bleeding is cause of death) Major bleeding 0.5-6.5% (GIT, retroperitoneal, intracranial or intra occular bleeding or any bleeding from an orifice + shock / needing transfusion or invasive procedure) Minor bleeding 6.2 - 21.8%
- 39. Management of Overanticoagulated patient on Warfarin: Serious or life-threatening Bleeding โข Admit to Hospital (ICU) โ urgent referral โข Stop Warfarin temporarily โข Local control of bleeding โข Reversal of INR โข Monitor INR 6 hrly and repeat Rx
- 41. Reversal of Anticoagulation โข 1.Vitamin K (Several hours) โ 5-10 mg I/V โข 2.Fresh Frozen Plasma (few hours) 10-50 U/Kg โข 3.Prothrombin Protein Complex ( minutes) โ 10- 50 U/Kg โข 4.Recombinant factor VII a (minutes) โ 40-80 microgram/Kg
- 42. PERIOPERATIVE MANAGEMENT โข Perioperative management of patients on warfarin or antiplatelet therapy involves assessing and balancing individual risks for thromboembolism and bleeding. โข Discontinuing anticoagulant and antiplatelet therapy is usually necessary for major surgery but increases the risk of thrombotic events.
- 43. Managing Peri-operative anticoagulant therapy : 3 Options โข 1. Continue oral anticoagulant โข 2. Stop therapy before surgery and re-start after surgery (eg. Low risk AF) โข 3. Bridge therapy (eg. MVR, High risk AF, Recent VTE) Bridge therapy, is an effective means of reducing the risk of thromboembolism but may increase the risk of bleeding
- 44. How do I bridge ? โข Bridging is use of heparin for a brief period (period between stopping and recommencing oral anti coagulant) โข 1. Unfractionated Heparin โข 2.Low Molecular Weight Heparin
- 45. Chronic anticoagulation and surgery โ (Bridging) : Recommendations ๏ง Stop Warfarin at least 5 days before Start UF Heparin or LMWH once INR less that 1.2 Stop Heparin 6-24 hrs before surgery Start Warfarin soon after surgery Start Heparin after 24 hrs of surgery if no active bleeding Stop Heparin once therapeutic INR is achieved
- 46. Patient Education โข Why they have been prescribed anti platelet and anticoagulant. โข Duration of treatment. โข Advise on compliance โข Importance of monitoring โข Interaction with drugs and diet โข Side effects /bleeding : when to seek medical attention
- 47. Take Home Message Anticoagulants are being under utilized due to fear of bleeding. โข Assessment of bleeding risk must be objective with the use of bleeding risk tools. โข Physicians must maintain a fine balance between thrombosis and bleeding โข Antithrombotic agents are double edged swored that the physicians must chose carefully
Editor's Notes
- The โspot signโ (arrow), contrast extravasation after contrast-enhanced computed tomography, is associated with a high risk of hematoma expansion.
- As far as bleeding/hemorrhagic outcomes, one must consider major and minor bleeding, as well as thrombocytopenia (and HIT). In modern-day treatment one most consider both sides of the scale, and the fact that as more aggressive antithrombotic therapies are used to reduce ischemic complications, the frequency of adverse bleeding outcomes rises.
- The profile of the patient at high risk for bleeding is characterized by older age, renal failure, often female, with a prior history of bleeding.
- Put a slightly different way, physiologic hemostasis and pathological thrombosis are two sides of the same coin. As the degree of anticoagulation increases, the risk of bleeding increases, but the risk of ischemic clinical events goes down. A balance must be struck between freely flowing blood (that doesnโt clot and cause events) and TOO-freely flowing blood (as at the site of bleeding, where physiologic hemostasis is impaired.
- Does bleeding influence the prognosis of ACS patients or is it a necessary evil of ACS therapy?
- These data form the GRACE registry show that there is an association between bleeding and morality across the spectrum of unstable ischemic syndromes.