Solving Major Problems: Major Bleeding and Major Surgery for Patients on Anticoagulants

This interactive session posed real-life scenarios for hospitalists who frequently deal with difficult anticoagulation questions and grounded it all with the evidence.

The first case discussed was an elderly female on a direct oral anticoagulant (DOAC) for atrial fibrillation (AF) and acetylsalicylic acid (ASA) for coronary artery disease (CAD) who is admitted for symptomatic anemia. Despite an esophagogastroduodenoscopy, colonoscopy, and capsule endoscopy, no source of bleeding is found. The question is, when would you restart a DOAC? It was quickly noted that the ASA should be discontinued. Considerations weighed should include the risk of re-bleeding, and the risk of venous thromboembolism (VTE) along with the patient’s own goals of care. Two retrospective studies were reviewed with one meta-analysis. The American and Canadian gastrointestinal societies, along with the European guidelines, all support a “sweet spot” for resumption of seven to 14 days after bleeding has resolved.

The second case discussed the management of a high VTE-risk patient in the perioperative setting. Is bridging needed? And what about post-op VTE prophylaxis? Hospitalists should consider the patient’s thrombotic risk based on their history of VTE. A recent VTE occurring within the last three months, and especially within the last month, is considered high-risk, while a VTE that occurred more than 12 months ago is considered low-risk. This assessment should be balanced with the procedural bleeding risk, with, for example, major orthopedic surgery posing a high bleeding risk and pacemaker implantation posing a low risk. The evidence reviewed here was a summary of many observational studies including the PROSPECT and BRIDGE trials. The American College of Clinical Pharmacy recommendations were discussed, including the recommendation to bridge with heparin over no heparin bridge for high-VTE-risk patients on vitamin K antagonists (VKA). In line with the recommendations, it was suggested to wait at least 48 to 72 hours before resuming low molecular weight heparin bridging in patients having a high-bleed-risk surgery or procedure. During this pause of full bridging anticoagulation, deep vein thrombosis (DVT) prophylaxis doses of resumed low molecular weight heparin can be given.

The third case illustrated the need for more shared decision making regarding anticoagulation when the evidence is weak or lacking. Shared decision making incorporates clinical evidence and the patient’s unique circumstances, along with their values, to arrive at a decision that is best for that individual patient. It’s an ethical imperative and our patients value it. Some barriers noted were time pressure, discomfort around challenging communication, assumptions about the patient’s poor health literacy, and prognostic or clinical uncertainty. We can improve shared decision making by fostering awareness of choices, introducing options, assisting patients in the evaluation of options based on their goals and concerns, discussing potential harm or benefit, and finally offering a recommendation and assisting patients in following through. Several decision aids for AF might be helpful for patients to visualize risk, however, they are not useful when weighing cerebrovascular accident risk versus bleeding risk.

The fourth case was a young person with a mechanical aortic valve replacement on warfarin who suffered a traumatic intraparenchymal bleed requiring urgent surgical intervention. What should be used to reverse the warfarin? Rapid reversal is required, and thus four-factor prothrombin complex concentrate should be used rather than fresh frozen plasma, with the suggested additional use of intravenous vitamin K in a dose of 5 to10 mg. An open-label, noninferiority, randomized, clinical trial was discussed which showed a much faster reversal of international normalized ratio with prothrombin complex concentrate, versus frozen plasma, for warfarin-related major bleeding. A follow-up question was posed. When should anticoagulants be restarted after intracranial hemorrhage in AF? There have only been three small, randomized, controlled trials so far. Two of these trials showed an increase in intracerebral hemorrhage when anticoagulant (AC) treatment was resumed, and one trial showed an increase in stroke when AC treatment was not resumed. Due to the low quality of data, guidelines on this matter are very non-committal.

The final case discussed perioperative AC in a patient with chronic kidney disease (CKD) or end-stage-renal disease (ESRD) on a DOAC. The patient was going to have a high-bleeding risk procedure. When would you hold and restart the DOAC? CKD and ESRD are both associated with an increased risk of VTE along with an increased bleeding risk. The COMBINE AF database meta-analyses were discussed. They show that there’s no difference in major bleeding between DOAC and warfarin across all degrees of renal function, that DOACs are superior to warfarin for all patients, and that the benefit increases as renal function worsens, along with a mortality benefit with DOACs as compared to warfarin for patients who have a glomerular filtration rate less than 77. The RENAL-AF trial, although small, showed there was no difference between major bleeding events for those on standard 5-mg versus 2.5-mg reduced-dose apixaban. For stage 5 CKD or ESRD patients in the perioperative setting, there is a lack of high-quality evidence. It is suggested to extend the pause duration of holding DOACs three to four days before major surgery and to restart 72 hours after the procedure.

Overall, the cases discussed underscore the importance of individualized decision making, considering both clinical evidence and patient preferences, to optimize anticoagulation therapy in the many complex clinical scenarios we encounter as hospitalists. 

Dr. Dockstader

Dr. Dockstader is a med-peds-trained academic hospitalist practicing adult medicine at the University of New Mexico in Albuquerque, N.M. She is also the director of clinical documentation in the department of medicine, and the secretary for SHM’s New Mexico chapter.