Periprocedural Anticoagulation Protocols Needed Across Specialties, Says ACC Survey

Deborah Brauser

July 08, 2016

COLUMBIA, MO — Stopping and restarting oral anticoagulation therapy and then starting and stopping parenteral "bridging anticoagulation" for patients who need surgery or other invasive procedures are complex processes that need specific institutional protocols and coordination between several specialties, suggests new research[1].

An American College of Cardiology–approved online survey was created to assess current practice patterns for patients needing to interrupt their anticoagulation therapy.

After evaluating responses from more than 900 clinicians instrumental in managing periprocedural anticoagulation at their centers, the investigators, led by Dr Greg C Flaker (University of Missouri School of Medicine, Columbia), found that more than three out of four responders said a standardized protocol is very important, yet 70% said one wasn't currently available at their practice.

In addition, the survey showed some confusion about how to manage patients treated with a direct-acting oral anticoagulant (DOAC) and showed that many patients were often identified for parenteral anticoagulation based on their CHA2DS2-VASc score. "Although this makes clinical sense, the approach has never been validated," write Flaker and colleagues. "Bridging [anticoagulation] is a complicated undertaking."

They add that past research has shown that low rates of major bleeding and thromboembolic events (TEs) have been observed after the implementation of anticoagulation protocols. "Coordination among specialties, pharmacists, nursing, and other health professionals has great potential for enhancement of care."

The findings are published in the July 12, 2016 issue of the Journal of the American College of Cardiology.

Anticoagulation Initiative

The ACC's Anticoagulation Initiative Work Group was formed in 2013 to examine and recommend ways to improve anticoagulation care. Work-group members developed the current survey, which was initially sent out between July and August 2015 to 9165 ACC members. Of these, 162 interventional cardiologists, 158 general cardiologists, and 163 electrophysiologists completed the survey.

In addition, the American Medical Association–verified Research Now Medical panel identified and approached 3054 other physicians. Of these, 152 internists, 160 gastroenterologists, and 153 orthopedic surgeons responded.

All of the participating physicians had had anticoagulant-receiving patients who underwent surgery or other invasive procedures.

When asked who manages periprocedural anticoagulation at their center, 56% said cardiologists do during a surgical or invasive procedure and 47% said it falls to cardiologists afterward. These percentages surpassed the 36% and 21% who said that during and after decision-making was handled by the physician performing the procedure.

Interestingly, primary-care physicians (cited by 28% as being responsible during the procedure and 34% for afterward), pharmacists (15% and 14%, respectively), and nurse practitioners (11% for before and after) were also involved.

When asked what factors would warrant parenteral anticoagulation because of a high risk for TE, 82% of all responders said if a patient had a mechanical heart valve. However, this number went up to 95% of the electrophysiologists, 94% of the general cardiologists, and 91% of the interventional cardiologists surveyed vs 82%, 65%, and 64% of the gastroenterologists, internists, and orthopedic surgeons, respectively.

In addition, 74% of the total group said a patient having a prior stroke or transient ischemic attack was of sufficient risk to warrant bridging.

A "Template" for Point-of-Care Tools

Although past research has shown that pacemaker and implantable cardioverter-defibrillator (ICD) implantation, cataract removal, and dental extractions have a low enough risk for bleeding that warfarin use doesn't need to be stopped or can be interrupted briefly, 17% to 37% of the respondents said they typically stop this therapy and use parenteral anticoagulation.

However, only 15%, 9%, and 14% of the interventional cardiologists would interrupt therapy for these procedures, respectively; as would 15%, 9%, and 16% of the general cardiologists and 10%, 15%, and 23% of the electrophysiologists.

When another question asked about those with atrial fibrillation at increased TE risk, "the number of respondents who would bridge was similar, irrespective of whether the patient was taking warfarin or a DOAC," report the investigators.

"It appears that the pharmacokinetics of warfarin may have been extrapolated by the respondents to the DOACs, and DOACs are interrupted too early before a procedure," they add.

Although a majority of the electrophysiologists said they wouldn't stop warfarin treatment during a device implantation or replacement, only 34% said they wouldn't stop use of a DOAC during implantation and only 38% said they wouldn't interrupt DOAC use during a replacement.

Overall, the survey findings "provide a template for educational and research projects geared toward the development of clinical pathways and point-of-care tools to improve this area of healthcare," write the researchers.

"This represents an important opportunity for professional societies and guidelines committees to work together to provide meaningful suggestions on the basis of current data."

The study was funded in part by the American College of Cardiology. Flaker reports being a consultant for Boehringer Ingelheim, Pfizer, Bristol-Myers Squibb, and Daiichi-Sankyo. Disclosures for the coauthors are listed in the article.

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