The Curbsiders (00:00.398)
So, Moni, I don't know if you learned, you know, I love history and so I don't know if you've... Okay. ...remember learning about this, but there used to be the signs to protest the Vietnam War. Oh, God. I don't even... Oh, God. It said, make Lovanox not war -friend.

The Curbsiders (00:24.334)
Can we fire you? Not yet. That one was good.

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The Curbsiders (00:53.486)
Welcome back to Curbsiders. I'm Dr. Moni Mean, joined by my effervescent co -host, Dr. Meredith Trubit. How are you this evening? Doing pretty well. How about yourself, I guess? I should be polite. I'm doing just fine. Thanks for asking. On tonight's show, we discuss perioperative antithrombotic management with our guest, Dr. Purvi Hardman. In just a moment, our new guest producer, Dr. Jamie Patel, will tell you a little bit more about our guest. But first, Meredith.

Will you please remind the good people in the audience what it is we do on the show? Sure, Moni, I'd love to. We are the Internal Medicine Podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. And tonight, as you already mentioned, we have Dr. Jamie Patel here, who's guest producing this episode. So, Jamie, why don't you tell us a little bit about our guests tonight? We have a fantastic conversation planned with our guest, Dr. Purvi Hardman, about perioperative anti -...

thrombotic management. Dr. Hardman is a former hospitalist who has now transitioned into an outpatient role in the Ohio State University Preoperative Assessment Clinic. When not seeing patients, she stays busy as the Assistant Director of the Global Health Curriculum at OSU. She has her hands full at work, but the chaos really begins when she comes home to her husband, two young sons, and her dog. She's a longtime listener of the Curbsiders, which she says,

has kept her company on many runs and long drives. Today, we're excited for her to teach us how to assess perioperative thromboembolic and bleeding risks and how we can use this information to build a perioperative antithrombotic management plan for our patients. So without further ado, let's get to it. Reminder that this and most episodes will be available for free CME credit for all healthcare professionals through VCU Health at curbsiders .vcuhealth .org.

And welcome back to Curbsiders. I'm so pumped. We have Porvi here tonight and we are going to start with a little get to know you stuff. So can you give us like a quick one -liner if you wouldn't mind? Yeah. So I am, I used to be a hospitalist at The Ohio State University. And after a couple of years there, I transitioned over to our outpatient preoperative testing clinic. And that is where I'm currently at as a full -time physician. Outside of.

The Curbsiders (03:16.334)
the preoperative testing clinic. I am also the assistant program director for the global health curriculum for our residents at Ohio State. And I'm not busy doing those things. I am with my husband and three kids. Yes, dog included. Just trying to have a good time. What kind of dog? It's a Boredoodle. So it's a border collie poodle mix. Yes.

Lots of energy. Yes. And what's the dog's name? About three miles a day. So that's... Oh my God. Keeps us busy. And what's the dog's name? Rafa. Okay. That's a cute name. Yeah. Yeah. My husband and I, we love playing tennis. So Rafael Nadal was the inspiration. Hence Rafa. As it should be. I mean, he is, in my opinion, the greatest, but I know he's the is the greatest.

He's left -handed, so it makes me very happy. So we'll switch the question a little bit. So why don't we talk a little bit, tell us a little bit about your favorite hobby outside of medicine. Yeah, that's a really good question. So I guess I would say that if you ask my husband and best friend, they would probably say that finding a really good deal is a hobby of mine.

But I think being an Indian woman, that just comes naturally to me. So I don't know, I can't qualify that as a hobby. Other things being, I enjoy painting and photography. So that's something that I've recently sort of taken up. You know, if I'm in the mood to have my toddler create a big mess, we'll start a little abstract painting and then photography. It's hard not to take pictures of really stinking cute.

kids. So that's where I'm at. Should we have the picks of the week? Yeah, that sounds good. All right. What's she got, Meredith? All right. My pick of the week is going to be... So this episode isn't going to air for a little bit because as I mentioned on the last one we did, I'm pregnant and expecting. And so apparently that takes time out of your life. And...

The Curbsiders (05:31.982)
But summer pregnancy in Atlanta is horrific. I don't think it's what anyone planned on. And so I just really would like my pick of the week to be ice cream because I really feel like that's the only thing that's getting me through it. And specifically as a native Texan, Bluebell still gets out to Atlanta. So I'm still able to get that. And I just keep telling myself that the Listeria outbreak was from many years ago. It's still cookies and cream.

Yeah, but I've been doing the ice cream sandwiches for like more calorie control instead of opening a whole pint.

I like this choice. Yeah. Jamie, do you have a pick of the week? Yeah. So my pick of the week is a book that I just read as I just joined a book club and we read What We Carry by Maya Schanberg, Sean Bog Lang. It's a memoir written by a woman who just became a mother and it's about her experiences with the shifting roles between being a daughter and then becoming.

a mother to her own daughter. And it just kind of hit home in a lot of ways. And she deals with all the emotions that come up, the guilt, the anger, and eventually acceptance when she realizes how she wants to build her own relationship with her daughter, sort of after reflecting on the relationship that she had and how that relationship evolves with her own mother.

So it's one of those books that every chapter seems to have one of those wow moments that just resonates. And I don't know how this author just continues to do it chapter after chapter. But yeah, it was really good. That's a good one. I know what Monies is going to be too. And so this is going to be a very heavily like, women in medicine pick of the week grouping.

The Curbsiders (07:34.51)
Yeah, and by women in medicine, I actually mean Beyonce. So I saw Beyonce on Saturday at the stadium tour, the Renaissance World Tour. And specifically what brought me the most joy was in the row in front of me was a seven -year -old girl who did not stop dancing for the entire two hours. And the pure joy on her face, I just wish I could bottle that up and take it with me, because it was just so...

wonderful. And even more wonderful is that her mom did not want to be there. She was like on her phone for most of it, except when Crazy in Love came on. I think that was the only time that mom got out of her chair. But other than that, it was just the seven year old going nuts. And it was just, I mean, as you might expect to Beyonce concerts, very empowering. And then you just have this like joyful little seven year old in front of you. And man, I could just I could just do that indefinitely. So.

I imagine that was like seven -year -old Mony, if you went to a Beyonce concert. You know, I was thinking about this. There weren't a lot of women that were selling out stadiums when we were kids. So this was actually a really cool thing to see, like for the girls in the audience and the women too, because like people that were selling out stadiums when we were kids were like, you know, the boy bands. Brittany, Christina. But they weren't selling out stadiums necessarily. Okay. Details. Well, anyway.

I think though, this is probably a good non -sugway into our first case from Cashelek. Jamie, would you mind taking us there? Sure. So we're going to start off with a case of Cathy, who's a 70 year old woman with lupus, antiphosolipid syndrome with prior VTEs, who is currently on warfarin, also has osteoporosis and she presents to the ED after falling while bowling.

She was found to have a displaced left distal radius fracture and the orthopedic surgery team splinted her wrist, but recommended that she return for outpatient operative treatment within one week. They asked for guidance with the perioperative management of her anticoagulation. Thanks, Jamie. So I think before we jump in, I think it's important that we kind of like lay out what we're trying to do on this episode a little bit, cause it's going to be a little bit non -traditional at times. So.

The Curbsiders (10:00.886)
You know, we had the 2022 chest guidelines kind of did the overhaul of the 2012 guidelines. And so lots and lots of things were added in those and specifically like the DOAC's P2Y12 inhibitors and guidance on perialkalab testing were new to the 2022 guidelines. So hence why we're really doing this episode.

And with that in mind, I think we can start by maybe just like really building up from the basics through like how we wanna think about this patient going in for their procedure. So Purvi, can you kind of walk us through how you think about this broadly for a patient, like what framework you may use, and then if you want like kind of going through that for Kathy as well. Yeah, thanks Meredith. So as you mentioned,

There have been a lot of consensus guidelines that are recently being published in this area. And in addition to the 2022 CHESS guidelines, the 2023 Annals of Internal Medicine article titled, Peri -Procedural Anticoagulation is also really quick and comprehensive summary for our listeners. But I always struggle because even with a preponderance of all this recent literature, there's just so much variability and so many nuances to think about.

So we'll sort of start with an overall approach and then fill in some of the details as we go. So first, I generally like to look at the procedure and the relative urgency of the procedure. So in our case from Kaczlak Memorial, Kathy would benefit from an urgent surgical fixation of her radius, really to minimize loss of function from her arm.

Luckily, in this case, we have some time so we can mess with her anticoagulation as necessary. Now, if Kathy were having an emergent procedure, I think we would give her reversal agents in preparation for her surgery, but we'll talk about that a little bit later in the show. Secondly, I like to look at the bleeding risk of the procedure. So table two from the 2022...

The Curbsiders (12:12.526)
The HHS guidelines that we mentioned stratify surgery based on the bleeding risk profile of each surgery. It's important to remember that this is just based on the surgery alone and does not take any other patient characteristics into consideration. Any major orthopedic surgery is considered a high -risk procedure, which confers a greater than 2 % 30 -day risk of bleeding.

Other major surgeries are things like abdominal surgeries, cardiac surgeries, neurosurgeries, and other thoracic surgeries as well. And then you have on the flip side some of the lower bleeding risk procedures. So things like dental, ICD, and pacemaker placements and minor dermatological procedures. But you can look at the table to access a full list of all the procedures and their bleeding risk. Third.

I move on to look at the patient's thromboembolic risk. And I'll say that this is the area that I struggle with the most because there's a lot of ambiguity and it's not black and white, which is sometimes frustrating because every provider has a different approach here. For Kathy, what really puts her at high, meaning a greater than 10 % risk of any arterial thromboembolic event.

or a greater than 10 % risk of any venous thromboembolic event a month, which I think is pretty significant as her lupus with antiphospholipid syndrome and her VTE history. A lot of these high thromboembolic risk patients should be bridged. And table one from the 2022 guidelines that we've been talking about goes through this, in addition to table four, which is a nice stratification of some of these patient -specific risk factors.

Other risk factors that are typically also considered high thromboembolic risks are things like protein CNS deficiency, antithrombin deficiency, antiphospholipid syndrome as in Cathy's case, homozygous factor 5 -Lyden, any recent stroke or BTE, which has been less than three months, any sort of venous thromboembolism associated with the malignancy, patients with AFib with a CHADS2 VASC score greater than seven.

The Curbsiders (14:33.326)
and then your mechanical heart valves that contain the older generation caged ball or tilted disc valves. I was wondering if maybe there's a framework that you use to kind of think through all this stuff, like just kind of making it a little simpler, because I feel like there's just a lot of pieces I'm trying to put together. So I was just wondering if you have like any helpful like framework to think about it. Yeah, definitely. So the framework that I use is stratifying these patients into buckets. So bucket one consists of

the low bleeding risk procedures, in these patients, you would likely continue anticoagulation without any interruption whatsoever. Now your bucket two are your procedures that are at moderate and high bleeding risk in patients that are at moderate thromboembolic risks. And in these patients, you would definitely hold their anticoagulation, but you probably don't need any form of

bridging strategy. But again, this sort of depends on other patient characteristics as well. And this is sort of, in my opinion, the biggest pain point in this entire framework as far as the decision to bridge or not to bridge. Lastly, bucket three, those are your moderate and high bleeding risk procedures in patients that are at high thromboembolic risks. And in these patients,

you would interrupt their anticoagulation and opt for a bridging strategy. So sort of going back to our case with Kathy, Kathy being at high thromboembolic risk is getting a high bleeding risk procedure. So that fits into our bucket three. And if Kathy had a fib with a CHATs2VAScOre of six and had a previous stroke or thromboembolic event, your approach would be

very similar. However, if Cathy was a little bit low risk in that her chats to VASCOR with AFib was a three, you'd probably stop anti -coagulation for go bridging altogether. So before we go too far into, I think, like specifics into bridging and scores and everything, let me just make sure I got you. So it sounds like there's kind of four major things you want to think about when you're considering like.

The Curbsiders (16:59.502)
what goes into the decision for what needs to happen next. And that's first, like what procedure are they having? And two, what's their bleeding risk profile, which I think we'll get into in a second too. And then their thromboembolic risk. And then kind of your fourth step is like, okay, well, what do I need to do with combining all of that information? Does that sound right? Yeah, that's absolutely it. Okay.

We already referenced the different procedures and I think anyone would just have to look up what procedure they're having and the bleeding risk profile of that procedure. So then let's talk a little bit more about maybe some of the scoring systems and stuff that help with establishing bleeding risk and thromboembolic risk. Yeah, that's a great question. And so...

To my knowledge, up until this point, there's not a specific scoring system in the setting of periprocedural anticoagulation that helps with the bleeding risk or the thromboembolic risk. The best resource that I have found, again, is from the tables that we've mentioned before, as far as table four, from the Annals of Internal Medicine article titled Periprocedural Anticoagulation that came out in 2023. And...

It's important to note that a lot of these tables or risk tools don't really take into account the type and length of surgery that does affect a patient's thromboembolic risk. In terms of AFib specifically, what we have is the well -known ChAT -STU -VAS score. Now, what's interesting about the score is that the ChAT -STU -VAS score also has a high sensitivity for estimating the three -month

stroke outcomes in both patients with and without AFib. And then on the flip side, we have the HAAS blood score. The HAAS blood score is used to balance the thrombotic risks of a patient with the bleeding risks in patients with AFib. And it does have good predictive validity for bleeding risk in patients with VTEs. And studies have shown that a score greater than three does suggest an increased risk of bleeding.

The Curbsiders (19:19.406)
Yeah, I'm always trying to figure out which ones to use. And so it's good to know that like, I don't need to go too far outside of what I'm used to, which is, you know, the Chad's Vask and the Hasblood. Cause I feel like there's like a bunch that always come out, but it seems like the old is gold, if you will. What do you do with the scores? Like, so you get, let's say a high, like someone comes in, let's say it's Kathy. She has like a high Chad's Vask and high Hasblood.

I often just feel like, well, it's not good either way then. I throw up my hands. Yeah. I mean, I guess that's what you're doing for like peri -op management is just kind of deciding what that risk is. But are there anything else that like when it's both high, like that you have to consider? Yeah. I mean, when the scores are both high, that kind of puts you in a pickle. And that's when you have to sort of take a step back and one, it can really be a patient led.

discussion as far as what they would consider a safe strategy in a perioperative setting. Second, you always have the option to reach out to the surgeon, which sometimes I do end up doing because let's say the surgeon considers the bleeding risk of the procedure pretty high and they really, really don't want anti -coagulation or bridging anti -coagulation on board. So that'll really help guide my judgment. But,

Ultimately, when the scores are both high, I sort of think of what's the most conservative and safest approach that I could provide for the patient, in which case if there are high risk of bleeding, let's say because they have thrombocytopenia or they've had prior intracranial hemorrhages, anything that sort of predisposes them to really morbid outcomes in the future.

I would probably opt a safer strategy. So this again is expert opinion, not necessarily anything that's in the literature, but a conservative strategy would be my general approach to no bridging. You know, you mentioned surgeons and I think we're going to get this later, but I think it kind of fits here. So obviously the person doing the procedure, someone to weigh in, but do you ever decide to call anyone else like, you know,

The Curbsiders (21:39.246)
Do you call heme? Do you call cardiology? Like are there every times that you consider bringing them into the conversation? Because I know in the hospital, I feel like when I call them, sometimes I get, they kind of pass it back and forth. And so I don't know if there's just like, maybe I'm just like calling the wrong one. And if there's something that some like wisdom as you do this more than I do that you might have to pass on. I mean, I guess it depends on the clinical context, right? So patients.

let's say with AFib or patients with mechanical valves, I do lean on the cardiologist a lot to sort of help us. Now, mechanical heart valves, there's a lot of literature done and there's a lot of guidance on what to do with mechanical heart valves. So it's not as confusing or complicated as let's say AFib with a high Chats 2 VASc score. But in an outpatient setting, I do have the...

advantage of having a discussion with the cardiologist and this cardiologist is someone who's known the patient for a long time. And so it makes it a little bit easier as far as management strategies go. I do often reach out to hematology and patients that are, that have any form of hypercoagulable state because again, those are sort of tricky patients that are at extremely high risk of venous thromboembolisms in the future.

No, that's really helpful. And I think that actually leads really nicely into the next question, which is talk to me about bridging. Like, do I worry about it all the time? Meaning, you know, warfarin, DOACs, just DOACs, just warfarin. I can't keep any of the straight. So would you mind kind of working our way through that? Yeah. So again, the high thromboembolic risk patients would need to be bridged. So that's sort of your general framework to begin with.

Now, the BRIDGE trial, just to kind of briefly go into it, was published in 2015 and it was a non -inferiority trial that showed that foregoing bridging anticoagulation did not really alter the rates of thromboembolic events, but it did decrease major adverse bleeding. And the BRIDGE study had its own limitations. For example, it only had a small population of patients who are at high risk, meaning,

The Curbsiders (24:02.03)
patients with a fib with a Chats2VAS score of 4 to 6, and that population was about 13 .8%. And then the very high -risk patients, so Chats2VAS score of 5 and 6, that population was about 3 .1%. So again, the study was a little skewed in its patient selection criteria, but overall, or it tells you that in patients with

Afib with the Chats2VASc or less than 6, you probably don't need to bridge them. Now, there are other considerations to keep in mind and scenarios in which you'd want to avoid bridging altogether. So things like patients that have thrombocytopenia or patients that have a prior intracranial hemorrhage. And then as far as DOACS, Moony, you mentioned what to do with those.

In general, DOACs have a really short half -life compared to warfarin, so bridging is not really considered to be necessary unless the timing of surgery is unknown, which happens all the time in an inpatient setting where a patient comes in and then you don't really have a clear surgical date. A couple days later, the patient gets surgery. And if they're at high thromboembolic risk, you might opt to bridge them through that timeframe.

Before we go on, can we also just, when you talk about bridging, I feel like in the hospital where I practice at in my cash lack, we use a lot of heparin drips, but I think that the low molecular weight heparins are also usable. And just kind of the, can you just walk us through pros and cons of like.

which one to use, is there any difference or anything like that for bridging? Yes, so there have been a few studies comparing low molecular weight heparin to IV heparin, so unfractionated heparin products. And overall, IV heparin does have a slightly increased risk of bleeding compared to low molecular weight heparin. However, like you said, on an inpatient setting, a lot of times we just...

The Curbsiders (26:22.574)
put a patient on a heparin drip and stop it six hours prior to surgery. Some of the benefits of a heparin drip compared to low molecular weight heparin products like inoxaparin, which is what we use at my cash lack, or that heparin has a short half -life, so you, in really quick onset and offset, so you can turn the heparin drip on and turn it off if needed. Whereas inoxaparin,

You know, you do need a 24 hour hold if the patient is on therapeutic in OxyParin prior to surgery. So that sort of plays a role as far as your decision making goes. Yeah, no, I think that's helpful to think about. One of the things I think I ran into recently, and I think this might have just been a conversation with an hematologist, but like what I didn't realize about heparin drips while I use them plenty in training is just how finicky they are and how hard they are to monitor with all like the anti -10A's and stuff.

And so obviously the 24 hour stuff right in that next parent, I think is obviously one of the reasons that we don't maybe think about it as often, but just something I hadn't really thought much about. So I don't know if that's helpful. Yeah. I also think about it sometimes because I'm always like, well, it's a planned procedure. Like it's going to happen that day. But I think all of us who work inpatient know or have worked inpatient know that like everyone gets bumped. And so like, it kind of makes sense to that if.

you're more concerned about a higher risk like thromboembolic event that, and there's any doubt in your mind about like length of time that you end up having probably a little bit more control with like a unfractionated heparin versus like a low molecular weight. But if you're pretty confident in it with this and you're more worried maybe about bleeding risk than maybe the low molecular weight heparins, I guess while we're on the topic to...

What modifications, like if any, do you consider for like end -stage renal disease patients? Generally, low molecular weight heparin products like inoxapurin, if you're using those as your bridging strategy for patients, you can't really use them in patients with end -stage renal disease or creatinine clearance less than 30. And so again, IV heparin is preferred for those patients as far as bridging goes.

The Curbsiders (28:45.998)
Now with some of the delwax, a 48 -hour hold is still pretty sufficient if the bleeding risk of the procedure is moderate to high. However, some guidelines do opt for a 72 -hour hold there. Dapagatrin is an agent that we don't really use here as often, although you might encounter it at some point, and that does require a longer hold, so a four -day hold in patients with the creatinine clearance less than 50. And then...

I just like to add not just modifications for ESRD, but the American Society of Regional Anesthesia Guidelines now calls for a 72 -hour hold for most DOACs. So your pixaban and ribaroxaban would need a 72 -hour hold in patients getting noraxial anesthesia. So things like epidurals for pain purposes during surgery. Yeah, that was actually one of the things that I highlighted in the guidelines because I don't think I've ever thought about that part. But I mean,

Makes sense. Yeah. And I think when I saw that, it made me wonder about lumbar punctures. That's literally what I was thinking. Yeah. Interestingly, LPs, if you look at some tables, LPs are actually considered moderate to high risk for bleeding. It was kind of an aha moment for me because previously as an hospitalist, I can't tell you how many LPs I've done with patients on dual antiplatelet therapy and maybe even anti -coagulation. It's just something you don't think about as LPs being.

somewhat moderate to high risk, but. I guess they just have more devastating ramifications if you do have a bleed. So I think all of that's really helpful. And I feel like we have a much better framework of how you go about thinking about these patients and when you're risk stratifying them and what to consider. Now we're going to get into a little bit more of like.

nitty -gritty details of it. So in what situations might you recommend delaying any planned procedures due to the anticoagulant therapy that they're on? Yeah, that's a great question. So if a patient's being considered for an elective surgery and they have recently just had a stroke or a venous thromboembolism less than three months, or if they have nuance at a fib or an acute intracardiac thrombus, it's probably ideal to

The Curbsiders (31:05.902)
to delay the surgery in these cases. And again, since it's an elective surgery, you have time to wait. A quick word on venous thromboembolisms. So any unprovoked DVT or PE has a higher risk of recurrence with a hazard ratio of 2 .3 compared to a provoked VTE. And within that first month of a diagnosed venous thromboembolism,

the risk of recurrence is as high as 40 % in a lot of studies. And so again, if the surgery is elected waiting greater than three months after, at least one month, but ideally greater than three months after the event is preferred. Now, if the surgery is urgent or emergent, I would likely initiate a discussion with the surgeon about the risk benefit, especially if they're planning to do the surgery within a month of a recent.

thromboembolic event. And again, if there's an option to delay, that would sort of be the route that I push them towards. And then with nuance at AFib, that's another situation that I often sort of want a little bit more of a workup prior to okaying them for surgery. So if the length of AFib has been greater than 48 hours, which is really hard because a lot of our patients aren't really able to tell us how long they've been in AFib for, I generally proceed with an echo.

to make sure that they don't have any sort of acute LV thrombus prior to okaying them for surgery. So when someone has had a recent stroke from their AFib, are they kind of falling into those categories where you're thinking through them like on the AFib spectrum? Are you thinking of them kind of on the VTE where you're trying to delay it for like that like three month period or is it completely separate?

So I think of it more from a VTE spectrum, as far as stroke is concerned, not necessarily VTE, but an arterial thromboembolic event. After six months is technically ideal for a stroke, but you can go as short as three months. And that, as far as recommendations go, the difference between three months to six months, and I don't know the actual numbers, but just three months and six months, the difference in stroke recurrence.

The Curbsiders (33:31.054)
is not as significant as between one month and three months. So you have the option to wait three months. Again, if they can wait longer than six months, it's fine. And that would be for your elective procedures. And then you would do the same if it's like urgent or emergent. You would talk to the surgeon to kind of weigh that risk benefit and make a decision out of that. Let's say you have them.

coming in, there's something that's urgent, emergent, either or, I guess. And the surgeon's like, yeah, we need to, you know, this is important. We need to do the surgery now. And the patient's taking like their anti coagulation. What options are there? Are you considering like reversal agents, letting them ride? You know, and I guess the answer is going to be different too for like vitamin K antagonist versus DOAC, but.

maybe walking us through how you think through that. Yeah, so I mean, I guess if the surgery is absolutely emergent and that there is severe life threatening consequences if they did not undergo surgery, then yes, using reversal agents in patients that are anticoagulated is what we generally do. And so this is also something that you have to address on a case by case basis. So overall in sort of broad,

for our strokes as far as reversal agents go. You know, for patients on Orphan, then IV vitamin K and four factor PCC can be used. Okay, so what I'm hearing is that in general, especially some of these like more nuanced ones, you just kind of have to think through them case by case, like no framework's really gonna fix that. But kind like you did there at the end with talking about like reversal agents and stuff, are there any like...

common pitfalls you see people, traps people fall into when they're thinking through peri -op stuff, like overestimating their clot risk or like, I mean, I'm sure I'm guilty of misusing bridging. So are there like any things that you notice that are like kind of common themes of people that seem to stumble on? Yeah, this is a hard question because, you know, as we sort of talked about in our discussion, the guidelines are all just so new and the guidelines are all so

The Curbsiders (35:53.624)
different too. And so it's hard to sort of put yourself in another clinician's shoes to sort of figure out what they're thinking as far as the bleeding risk and the thromboembolic risk. But overall, you know, I get a few requests from surgeons to bridge DOACs a lot. I'd say that is something that's common and not really understanding, you know, the short half -life of the DOACs.

Another common pitfall is overestimating the thrombotic risk and over bridging, especially in an inpatient setting. You know, we sort of talked about it's just easy if you think that the patient does have a few risk factors, but not necessarily all. And they might not need to be bridged as we talked about previously. And then lastly, just the whole duration of some of the DOAX just.

The variability in different literature with the whole times confuses a lot of people. And honestly, it sort of confuses me. Like I always have to keep referring to a table that is my go -to table. Yeah, which one is that? Just asking for a friend. Yeah. So we have our internal guidelines at our KASHLAK Memorial Hospital that we use. And that's sort of, it's just glued to memory by now.

Again, the chest, they don't really have specific hold times, but actually they do a pretty good job with some of the anti -coagulant, the DOACs, and then also the antiplatelet agents as far as hold time goes. Yeah, so I think just kind of picking one and being consistent probably is helpful since there are so many answers out there, I would think. Yeah. And then just to add to that, the American Society of Regional Anesthesia,

Again, for a lot of folks getting Neuroxial anesthesia, they have a pretty comprehensive guideline too, as far as hold time goes. So I'll refer to that as well for the Neuroxial cases. That's really helpful to think about the DOACs and all that. I know one of my common pitfalls is dealing with warfarin. And mainly, you know, what's the hold time just in general? Like, what is, should I be shooting for? I know like inpatient setting, it gets a little messy sometimes, but.

The Curbsiders (38:13.87)
Like what is the ideal state? And then also half the time they come in, like their INR is subtherapeutic and then sometimes it's like seven. So like, what do I do with that? So starting first with like, what's the ideal state? And then some of these other little wonky ones. Yeah. So in an ideal state, you would want to hold warfarin for about five days prior to surgery. And then really just allow your INR to normalize to one to one, 1 .2. And then as far as.

abridging strategy, you'd want to start a low molecular weight heparin product like inoxaparin or daltaparin. We use inoxaparin at our institution and that would be at a dose of one milligram per kilogram, Q12 hours, 36 hours after the last Coumadin dose. And then you can hold that 24 hours prior to surgery. So that again is an ideal outpatient setting where the surgery is planned. Now, a lot of times, as you guys mentioned, in an inpatient setting,

We have IV heparin that we can use for bridging, realizing that it does sometimes have an increased risk of bleeding compared to anoxaparin. But if you're opting to use IV heparin, then stopping IV heparin four to six hours prior to surgery is generally recommended. Now, as far as super therapeutic and sub -therapeutic INR, so with super therapeutic INR, again, you can hold

were for seven days prior to surgery. As far as subtherapeutic INR, specifically, I don't change my management. I still use a five -day hold because regardless, the patient, if they're going to be bridged, they're going to be anticoagulated in some way, shape, or form. So I oscillate between five and seven days, depending on their INR. And do you still start the, if you're going to use IV heparin, do you still, and let's say their INR is in a normal range for them.

Do you still start that IV heparin 36 hours after the warfarin was stopped? Or if they're on the inpatient setting? Or are you waiting for their INR to actually drop? Because we end up checking it every day, and I feel like that's what we end up doing. I don't know if that's right, though. Yes.

The Curbsiders (40:33.134)
So in an inpatient setting, you have the advantage of checking the INR. And as soon as it drops to less than two, you can start an IV heparin drip. Usually that does take, and again, depending on a patient's metabolism, but a day or two. So no, 36 hours would not be specific to heparin, but you have more data points to help with your decision making in an inpatient setting. And then just hypothetically, because this never happens to me.

Let's say you're checking it every day, the person's inpatient and their INR is still on the higher side, like the day before surgery. Is there any role for like giving them any vitamin K like on that day before surgery to try to like ensure that the surgery can happen? And cause to me there would be downside when you're trying to restart them too on the back end.

You bring up a good point as far as downside on the back end. I guess it depends on which lens you're looking at. So from a surgical bleeding risk standpoint, which is sort of something that I focus on a lot, I'd rather the patient have IV vitamin K and that we minimize their bleeding risk going into surgery as opposed to worry about trying to bring the INR back up. So I would say yes, if the day before surgery,

their INR is still not as close to 1 .2, IV vitamin K, or even FFP the morning of surgery are good alternate options. So now let's say we go back to Kathy, who we haven't talked about for a few minutes now. She's getting sad. We've forgotten about her. Yeah. But Kathy, we optimize her. Her numbers look good before surgery.

and she had her surgery and so now we're like back and we're trying to resume her like warfarin. When do you give that first dose post -operatively for the warfarin? Yeah, so generally for warfarin, 24 hours after surgery, you can start the patient on their home dose as long as hemostasis has been achieved. And again, this is a discussion with the surgeon and surgical team as far as whether they think that

The Curbsiders (42:53.134)
they have successfully minimized any other bleeding risks. And do you concomitantly restart them? Because you're going to bridge them on that back end. So are you concomitantly restarting like their heparin drip and or not and or don't start everything? Or what are you doing to Kathy? Yeah, he's going to die on my watch. Heparin or like their low molecular weight heparin to bridge them? Yeah, you can.

Yeah, so since we've already decided that Kathy needs bridging, you would start either, not both, heparin or inoxaparin for this patient. Now you can start the inoxaparin or heparin 24 hours after surgery as well, because realizing that, you know, warfarin will take time for the INR to get to therapeutic levels. And if the surgeon is okay and hemostasis has been achieved,

than 24 hours after you sort of restart both to help with their anticoagulation postoperatively. And one more what if for Ms. Kathy. So what if she's not on WarFriend and she was on a DOAC, but we're talking about restarting her DOAC. Is it the same 24 hours? No. So if Kathy were on a DOAC, the CHESS guidelines actually do mention that...

For DoEx, waiting greater than 24 hours is probably ideal. Again, the rationale behind this is that because DoEx don't have any form of reversal agent that is easily accessible or cheap, waiting a little longer after hemostasis has been achieved is generally an acceptable strategy. Okay. I think those are all my what -ifs for Ms. Kathy. I mean, you're putting Kathy through the ringer.

I know she's on heparin, anoxaparin, a DOAC, warprin. What are you doing? We just want to see what will happen to you. Jamie, I think this is actually probably a good spot to recap since we've covered, I mean, so much ground. Yeah. Thanks for sharing your approach with us, Porvi. Perioperative anticoagulation management is clearly a really complex issue and you've shown us that each patient requires an individualized plan.

The Curbsiders (45:13.294)
It always feels like this delicate balancing act where we're weighing different risks and patient characteristics, but you've addressed a lot of high yield points. And I think your structured approach is a great way to keep clinicians organized. You've also shown us that there are times to recommend delaying a surgery as long as it's safe, such as when we're dealing with a recent stroke, acute DVTs within the first three months, acute intracardiac thrombus.

or new onset AFib. On the other hand, in cases of emergent procedures, it seems like we do have some options for anticoagulant reversal. And although this topic can be incredibly nuanced, I think with your structured stepwise approach, we can all hopefully avoid some of those common pitfalls that you talked about, such as overestimating thromboembolic risk and overusing bridging anticoagulation. Awesome.

So I think that's a good place to kind of maybe segue from anticoagulation a little bit and into antiplatelets. You want to add that to the heparin and the anoxybarin, right? Yeah. I want them on triple therapy. And by triple therapy, I want them on seven agents. So go ahead. Before Meredith's just, I don't even want to go where. Can you please take us to the next case? Sure.

So our next case is Ronald, who's a 67 year old man with coronary artery disease status post percutaneous intervention with drug eluting stent placement in his left circumflex back in 2020. He's also got type two diabetes, hypertension and obesity. And he presented to the hospital with chest pain and was found to have a non -ST elevation MI. Prior to his admission, he was taking aspirin, atorvastatin,

Carvetolol and Lysinopril. He was initially treated with a heparin drip and was loaded with Clopidogrel. His high sensitivity troponin peaked and then subsequently downtrended. And as part of his workup for his NSTEMI, he received a left heart catheterization and was found to have unfortunately severe three vessel coronary artery disease, which is going to require coronary artery bypass grafting. The cardiac surgeon asked that the Clopidogrel be held.

The Curbsiders (47:37.486)
for at least five days prior to performing his CAVAGE. Unfortunately, this seems to be a common scenario that we encounter in inpatient medicine. And it brings up another important piece of periprocedural antithrombotic management, which is what do we do with antiplatelet therapy when a procedure is needed? So Porvi, what's your general approach to creating an antiplatelet management plan? What kind of factors do we need to consider? Thanks, Jamie.

So my approach to antiplatelet therapy is very similar to that of antithrombotics. First, you sort of like to look and see why the patient is needing antiplatelet therapy. As far as aspirin goes, a lot of studies surrounding aspirin in the perioperative period deal with aspirin for secondary prevention, not necessarily primary prevention. And the POIS -2 trial was kind of a two -part study. The first part showed,

that amongst patients that are undergoing non -cardiac surgical procedures, the aspirin was not necessarily beneficial in reducing the incidence of death or MI, but it did increase the risk of bleeding. So in extrapolating this data, I usually tend to hold aspirin if it is used for primary prevention in patients that are getting surgeries that are at high bleeding risk.

So again, this is an area where there is a lot of variability, but that's my general approach. Now, the caveat to aspirin therapy is that if it is used for secondary prevention, you can almost always continue aspirin therapy except for certain cases, and we'll talk about those cases here in a little bit. So this was sort of based out of the second part of the POIS -2 trial.

that showed that in patients like Ronald who do have a history of a prior stent placement, aspirin was beneficial in reducing their perioperative MIs compared to placebo. And this was regardless of the duration of the stent placement compared to the surgical procedure. Again, if aspirin is used for secondary prevention, you can almost always continue it except for cases that involve

The Curbsiders (50:00.298)
neurosurgical procedures, certain urological cases, and then posterior chamber ophthalmic cases that require a retrobar block. So that's aspirin. And then when we think about treatment with P2Y12 inhibitors, we generally have to stop the P2Y12 inhibitors. There are certain timeframes as far as whole time goes for certain P2Y12 inhibitors, but if a patient is

on, let's say, clopidogrel, you will need to stop that five days prior to surgery. Now, if they're on clopidogrel monotherapy for, let's say, recurrent strokes, we do have the option to transition the patient off of the P2Y12 inhibitors and onto aspirin only that they can take throughout their perioperative period. Okay. So obviously holding on the front end is important. I think the part that I always also struggle with is knowing

When we restart it on the back end, I think that would be helpful. Yeah. So for some of the P2Y12 inhibitors, again, because a lot of them are irreversible agents, waiting a little bit longer is an acceptable strategy. So greater than 48 hours after surgery, again, discussion with a surgeon is necessary here because you can't start a P2Y12 inhibitor and then

reverse them as easily. Yeah, can't take it back kind of saying it. And what about aspirin that is technically reversible? With aspirin, again, for primary prevention, and in certain cases would really be the only time that you hold the aspirin. Since you're sort of continuing aspirin through the perioperative period, honestly, you could probably restart aspirin within 12 hours after surgery. So you don't necessarily need to.

wait as long with aspirin therapy. Yeah. So we talked a little bit about his cabbage situation and like what we do with his management there. I think the thing that always trips me up and I think it's just like me going back to my panic as a med student is what's the difference in sort of holding times for drug eluding stents versus bare metal. It sounds like you mean wait times after bare metal stent and drug eluding stent. So.

The Curbsiders (52:23.854)
In patients that are getting elective surgeries, it's ideal to wait six weeks after a bare metal stent placement and then six months minimum after drug eluting stent placement. The rationale behind this is that major adverse cardiovascular outcomes are the highest in the six week timeframe following a stent placement and then it sort of plateaus after six months. But again, this is really for some of those elective cases.

And even urgent cases with emergent cases, you probably don't have much of an option. It would likely proceed to surgery. Um, and I guess that's a good segue into talking about like which consultants you'll need. Um, so obviously if you're talking about like recent stenting and everything, if there's any question, I imagine you'd have like your cardiologist involved. Um, are you kind of deferring though for like, um,

which like specialists you may need based on the event that you're kind of trying to plan around. So I, kind of to what Moni's question was on the previous case, like neurology, if it was like a recent stroke, cardiology, if it was like recent stenting, hematology, if you're just throwing your hands up in the air, like you just don't care. Yeah, like what rumble are you going to start in the street? Yeah. Yeah. I think the biggest one here is cardiology for,

And especially in Ronald's case, you probably want their input throughout Ronald's hospitalization. But yeah, a patient with a recent MI that is on dual antiplatelet agent, having the backup of your friendly cardiologist is really helpful. All right. Corby, do you have any take -home points for us? I know we covered like so much ground. Yes, that's a lot of information that we covered.

but some key take home points that I would like to highlight are, if for any case, looking at the bleeding risk, the thromboembolic risk, and then sort of using those two pieces of information to determine which one of the three buckets that a patient falls into is a good starting point and a good framework to consider. Now, remember that some of the low risk procedures do not need any form of interruption in anti -c -

The Curbsiders (54:46.062)
coagulation or antiplatelet therapy. And lastly, you can almost always continue aspirin monotherapy except for certain neurosurgical, urological, and ophthalmic cases.

This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Yummy. Okay. Okay. Still hungry for more? Yep. Join our Patreon and get all episodes ad free plus twice monthly bonus episodes at patreon .com slash Curbsiders. You can find show notes at thecurbsiders .com and sign up for our mailing list and get our weekly show notes in your inbox, including our Curbsiders Digest.

recapping the latest practice changing articles, guidelines, and news in internal medicine. And we're committed to high value practice changing knowledge. And to do that, we need your feedback. So please subscribe, rate, and review the show on YouTube, Spotify, or Apple podcasts. Or email us at askcurbsiders at gmail .com. A reminder that this and most episodes are available for free CME credit for all healthcare professionals through BCU Health at curbsiders .bcuhealth .org. Special thanks again to our writer producer, Dr. Jamie Patel, and to our whole Curbsiders team.

Our technical production is done by the team at PodPace, Elizabeth Proto runs our social media, and Stuart Brigham composed our theme music. Until next time, I've been Monia Meen. I'm Jamie Patel. And as always, I'm still Meredith Truvett. So thank you and good night.