Order From Chaos: ACC Presents Guide to Periprocedural Anticoagulation in AF, With an App

Larry Hand

January 19, 2017

PHILADELPHIA, PA — The American College of Cardiology (ACC) has published revised recommendations on managing anticoagulation in patients with nonvalvular atrial fibrillation who undergo procedures ranging from dental extraction to surgery[1].

And soon, said researchers, clinicians will have an app available to use at the bedside to help determine whether anticoagulants should be interrupted prior to procedures, whether to use a bridge parenteral medication, and when to start back anticoagulants after procedures.

The recommendations were published as an expert consensus decision pathway, designed to complement guidelines, January 9, 2017 in the Journal of the American College of Cardiology. The app, to be available in February, will be a free download for iPhone and Android.

"It's a very high-volume scenario. There's a lot of variability in practice," writing committee chair Dr John U Doherty (Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, Pennsylvania) told heartwire from Medscape. "We thought that it would be a situation in which we could offer guidance and make it clear where that guidance is strongly supported by the literature and where things are a little bit more nuanced and a little bit more ambiguous than that guided by expert consensus."

In North America alone, more than 250,000 nonvalvular AF patients undergo surgery annually, he noted in an ACC statement. The high volume and the fact that the perioperative period involves several providers across disciplines create potential risk, according to the researchers.

The new document is aimed primarily at guiding managing elective, planned procedures, but some recommendations may apply to some urgent or emergent care, according to the researchers.

Doherty and colleagues learned from a survey done last year[2], in which 945 clinicians of multiple disciplines responded, that considerable variability exists regarding anticoagulation practices in these patients.

"We saw a lot of what we considered non–evidence-based and not necessarily rational use of bridging in this group of patients that led us to conclude that guidance was necessary," he said.

"One premise is there's a lot more bridging than is warranted based on the patient's risk of a thrombotic event," he continued. "We also felt like there was a misunderstanding of the pharmacokinetics of these newer drugs compared with warfarin. There was bridging going on with the newer agents that is almost never necessary because these drugs act in a way that has a very rapid onset of action."

Doherty and colleagues provided 11 guidance statements in the article, starting with whether to interrupt vitamin K antagonist (VKA) therapy, including warfarin. They continue through whether to use bridge therapy and through restarting direct oral anticoagulants (DOACs) postprocedure. The DOACs covered are dabigatran (Pradaxa, Boehringer Ingelheim), rivaroxaban (Xarelto, Bayer/Janssen Pharmaceuticals), apixaban (Eliquis, Bristol-Myers Squibb/Pfizer), and edoxaban ( Savaysa/Lixiana, Daiichi Sankyo).

They also provided four algorithms in figures for guiding whether to interrupt VKA therapy, whether to interrupt DOAC therapy, whether to bridge, and how to restart anticoagulation.

However, the app being developed will be a single application.

"It's going to be a single app and you will have the ability to enter the app at various points. Once people have a good sense of what their CHA2DS2-VASc score was and what their risk was, they would probably want to jump in at different points of the app," Doherty told heartwire.

The important parts of the app are to be able to enter a specific procedure and to be able to get guidance whether the patient would need to have their anticoagulation interrupted, he continued.

Patients with a CHA2DS2-VASc score of 4 or less don't need to be bridged, he explained, while a patient with a high CHA2DS2-VASc score of 7 to 9 or a patient with a recent thrombotic event should be strongly considered for bridging. Intermediate-risk patients, unless they've had a recent thrombotic event, probably should not get bridged, he added.

"There are probably going to be fewer people that end up getting bridged that are bridged now in clinical practice," he said. "The only instances in which a DOAC would need to be bridged is if the patient is unable to take oral meds for some period of time postprocedure."

Dr Geoffrey D Barnes (University of Michigan, Northville), who wrote a key points article on the decision pathway for the ACC website[3], told heartwire , "I think they did a really good job of updating some of the previous recommendations based on some of the newer evidence. I think their figures are very well laid out and they're easy for clinicians to follow.

"I also think they asked some really important and clinically relevant questions, helping clinicians think about what a patient's risk of stroke is, what the bleeding risk associated with the procedure or certain factors is. How is that going to weight into when to stop an anticoagulant? Should bridging be given? Those sorts of things," he said.

"I think the app will be extremely helpful for clinicians who use apps on a daily basis," he continued. "I think the figures are going to be really useful for clinicians who maybe don't rely on their phones or other apps. Print out the key figures, post them in your office to refer to. I think they did a great job of finding multiple ways to make this accessible for as many clinicians as possible."

Doherty reported no relevant financial relationships; disclosures for the coauthors are listed in the paper. Barnes reported consulting for Janssen, Pfizer/Bristol-Myers Squibb, and Portola and research funds from Pfizer/Bristol-Myers Squibb.

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