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Medline ® Abstracts for References 1-6

of 'Perioperative management of patients receiving anticoagulants'

1
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Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach.
AU
Douketis JD
SO
Blood. 2011;117(19):5044. Epub 2011 Mar 17.
 
AD
Department of Medicine, McMaster University and St Joseph's Healthcare Hamilton, Hamilton, ON, Canada. jdouket@mcmaster.ca
PMID
2
TI
How I treat anticoagulated patients undergoing an elective procedure or surgery.
AU
Spyropoulos AC, Douketis JD
SO
Blood. 2012 Oct;120(15):2954-62. Epub 2012 Aug 28.
 
The periprocedural management of patients receiving long-term oral anticoagulant therapy remains a common but difficult clinical problem, with a lack of high-quality evidence to inform best practices. It is a patient's thromboembolic risk that drives the need for an aggressive periprocedural strategy, including the use of heparin bridging therapy, to minimize time off anticoagulant therapy, while the procedural bleed risk determines how and when postprocedural anticoagulant therapy should be resumed. Warfarin should be continued in patients undergoing selected minor procedures, whereas in major procedures that necessitate warfarin interruption, heparin bridging therapy should be considered in patients at high thromboembolic risk and in a minority of patients at moderate risk. Periprocedural data with the novel oral anticoagulants, such as dabigatran, rivaroxaban, and apixaban, are emerging, but their relatively short half-life, rapid onset of action, and predictable pharmacokinetics should simplify periprocedural use. This review aims to provide a practical, clinician-focused approach to periprocedural anticoagulant management.
AD
Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, Rochester, NY; and.
PMID
3
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Oral anticoagulation in surgical procedures: risks and recommendations.
AU
Torn M, Rosendaal FR
SO
Br J Haematol. 2003;123(4):676.
 
Surgery in anticoagulated patients is problematic. Coumarin therapy is often discontinued or reversed to reduce the perioperative bleeding risk. Meanwhile, the thromboembolic risk is enhanced. We sought to determine the frequency of bleeding and thromboembolism in anticoagulated patients undergoing routine surgery and to investigate the role of patient characteristics and the level of anticoagulation. We studied patients who attended the Leiden Anticoagulation Clinic for treatment relating to mechanical heart valve prostheses, atrial fibrillation or myocardial infarction and underwent surgery at the Leiden University Medical Centre between 1994 and 1998. Outcome events were bleeding and thromboembolism in the perioperative period. Seventy-two complications occurred in 603 interventions, yielding an overall frequency of 11.9% [95% confidence interval (CI): 9.3-14.9], 9.5% (n = 57) for haemorrhage and 2.5% (n = 15) for thromboembolism. Younger patients tended to have more complications [odds ratio (OR) for>65 years of age: 0.5, 95% CI 0.3-1.0]as did patients with atrial fibrillation (OR for atrial fibrillation versus mechanical heart valve prostheses: 1.8, 95% CI 0.8-4.2). High postoperative levels of anticoagulation were associated with a slightly increased risk of complications [OR international normalized ratio (INR)>3 vs. INR<2: 1.3, 95% CI 0.6-3.0]. We conclude that routine surgery in anticoagulated patients yields a high perioperative bleeding and thromboembolic risk. While neither patient characteristics nor the level of anticoagulation appeared to play a major role in the occurrence of complications, the risk was clearly associated to the type of surgery, with the highest risk in thoracic surgery.
AD
Department of Haematology, Leiden University Medical Centre, Leiden, The Netherlands.
PMID
4
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Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery. The Thromboprophylaxis Collaborative Group.
AU
Kakkar VV, Cohen AT, Edmonson RA, Phillips MJ, Cooper DJ, Das SK, Maher KT, Sanderson RM, Ward VP, Kakkar S
SO
Lancet. 1993;341(8840):259.
 
Low-molecular-weight heparin (LMWH) is effective in the prevention of postoperative venous thromboembolism but does it have the safety advantages over standard heparin (SH) that have been claimed? In a multicentre randomised trial in 3809 patients undergoing major abdominal surgery (1894 LMWH, 1915 SH) heparin was given preoperatively and continued for at least 5 postoperative days. Patients were assessed in the postoperative period and were followed up for at least 4 weeks, the emphasis being on safety. Major bleeding events occurred in 69 (3.6%) patients in the LMWH group and 91 (4.8%) patients in the SH group (relative risk 0.77, 95% confidence interval 0.56-1.04; p = 0.10). 93 indices of major bleeding were observed in the 69 LMWH patients and 141 in the SH patients. (p = 0.058). Severe bleeding was less frequent in the LMWH group (1.0% vs 1.9%; p = 0.02), as was wound haematoma (1.4% vs 2.7%; p = 0.007). Bleeding episodes with LMWH were less likely to lead to further surgery to evacuate a haematoma or to control bleeding, and injection site bruising was also less common in the LMWH group. No significant differences were found in the efficacy of the two agents. Perioperative death rates were 3.3% in the LMWH group and 2.5% in the SH group; pulmonary emboli were detected in 0.7% and 0.7%; and deep-vein thrombosis was diagnosed in0.6% of patients in each group. Follow-up was done on 91% of 3699 evaluable patients. There were 19 further deaths (10 LMWH, 9 SH group) and 25 patients with thromboembolic complications (15 and 10). Of the 3 patients with fatal pulmonary emboli during follow-up 2 had received LMWH and 1 SH. The two drugs were of similar efficacy. The primary end point, the frequency of major bleeding, showed a 23% reduction in the LMWH group, but this difference was not significant. The secondary safety end points revealed that LMWH was significantly better than SH. Fatal pulmonary embolism occurs rarely (0.09%) following discharge from hospital so the cost benefit ratio would not justify prolonged prophylaxis in this setting.
AD
Thrombosis Research Institute, London, UK.
PMID
5
TI
Perioperative management of warfarin and antiplatelet therapy.
AU
Jaffer AK
SO
Cleve Clin J Med. 2009;76 Suppl 4:S37.
 
Perioperative management of patients on warfarin or antiplatelet therapy involves assessing and balancing individual risks for thromboembolism and bleeding. Discontinuing anticoagulant and antiplatelet therapy is usually necessary for major surgery but increases the risk of thrombotic events. Bridge therapy, the temporary perioperative substitution of low-molecular-weight heparin or unfractionated heparin in place of warfarin, is an effective means of reducing the risk of thromboembolism but may increase the risk of bleeding. The timing of warfarin withdrawal and timing of the preoperative and postoperative components of bridge therapy are critical to balancing these risks. Perioperative management of antiplatelet therapy requires special care in patients with coronary stents; the timing of surgery relative to stent placement dictates management in these patients.
AD
Division of Hospital Medicine, University of Miami Miller School of Medicine, PO Box 016760, Miami, FL 33101-6760, USA. ajaffer@miami.edu
PMID
6
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Bridging evidence-based practice and practice-based evidence in periprocedural anticoagulation.
AU
Gallego P, Apostolakis S, Lip GY
SO
Circulation. 2012 Sep;126(13):1573-6.
 
AD
PMID