New Papers & Guidelines

16th National Conference on Anticoagulation TherapyOctober 28-30, 2021

New Papers & Guidelines

Presenters:

Tracy Minichiello, MDUC San Francisco, VA Medical Center

Stephan Moll, MDUniversity of North Carolina



Conflicts of Interest

• Dr Minichiello- no actual or potential conflicts of interest in relation to this program or presentation to disclose

• Dr. Moll-Consultant for Bristol Myers Squibb


AC FORUM Literature Updates & Rapid Resources

https://acforum-excellence.org/


CASE

A 62 year old man with cirrhosis and history of alcohol use presents with abdominal pain. On exam vitals are stable but abdomen is tender in right upper quadrant. Labs are significant for PLT count of 105K, creatinine 0.8, AST/ALT: 60/30 normal bili, INR 1.0. ultrasound of RUQ shows thrombosis in left and right portal veins. What anticoagulation regimen do you recommend?

1) None

2) DOAC

3) LMWH

4) LMWH→warfarin


Anticoagulation for Splanchnic Thrombosis

Di Nisio et al. JTN 2020 https://doi.org/10.1111/jth.14836

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Splanchnic Vein Thrombosis

Valeriani et al. Vascular Health and Risk Management 2019:15 449–461

• 10 % of cirrhotic have PVT• 10% of all splanchnic vein thrombosis cases have myeloproliferative disorder• 10% of cancer associated splanchnic vein thrombosis is due to pancreatic CA

• Up to 15% of those with “unprovoked” PVT are diagnosed withcancer in subsequent 1.5 years

10 %


Splanchnic Vein Thrombosis - management

Valeriani et al. Vascular Health and Risk Management 2019:15 449–461

Consult surgery if shock, peritonitis, bowel ischemia, GIB


Splanchnic Vein Thrombosis

WHO TO TREAT?

• Acute • Goal is to prevent bowel ischemia and portal HTN

• Consider GI eval prior to anticoagulation-particularly in chronic PVT due to varices, portal HTN GIB risk

• Chronic • Goal is to prevent progression

• Risk benefit less clear


Splanchnic Vein Thrombosis Anticoagulation

HOW TO TREAT?

• Non cirrhotic → DOAC

• Cancer associated symptomatic →LMWH or DOAC• Favor LMWH if high bled risk

• Cirrhotic→LMWH and then switch to DOAC or warfarin if able

• Above assumes not high bleed risk. If high bleed risk multidisciplinary discussion. Consider delay, low intensity AC, withholding


CASE

A 62 year old man with cirrhosis and history of alcohol use presents with abdominal pain. On exam vitals are stable but abdomen is tender in right upper quadrant. Labs are significant for PLT count of 105K, creatinine 0.8, AST/ALT: 60/30 normal bili, INR 1.0. ultrasound of RUQ shows thrombosis in left and right portal veins. What anticoagulation regimen do you recommend?

1) None

2) DOAC

3) LMWH

4) LMWH→warfarin


CALF VEIN DVT-Which would you anticoagulate?

• A 29-year-old male presented with a calf trifurcation DVT two weeks after a traumatic partial Achilles tendon rupture. His leg will be in a cast for 3 weeks and he will not undergo surgery

• A 40-year-old woman presents with an unprovoked gastrocnemius vein DVT

• A 79-year-old man presents with a posterior tibial vein DVT. He is started on therapeutic anticoagulation but a week later he returns with an upper gastrointestinal bleed due to gastric ulcer. He requires blood transfusion and intensive care unit admission

• A 19-year-old woman is found to have a peroneal vein DVT 1 month after appendectomy. She is currently ambulatory


CALF VEIN DVT

Makedonov et al CO-Hematology 2021

“What the heck is a trifurcation and where is it?” -SM

Calf trifurcation:the popliteal vein distal to the knee creasewhere it divides into the anterior tibial, posterior tibial and peroneal veins


CALF VEIN DVT

• Rate of progression from calf → proximal DVT if untreated ~5-10%

• Calf trifurcation (the popliteal vein distal to the knee crease, where it divides into the anterior tibial, posterior tibial and peroneal veins) DVTs behave more similarly to proximal DVTs, with an annual recurrence risk of 4.7%

• Muscular DVTs (e.g. in the gastrocnemius and soleus veins) have a similar risk of recurrence to deep calf DVT (1.7% vs. 1.6% annual recurrence)

Makedonov et al CO-Hematology 2021


CALF VEIN DVT

Mazzolai et al Eur Journ Preventive Cardiology et al


CALF VEIN DVT-CHEST 2016

Kearon et al. Chest. 2016;149(2):315-352.

Risk factors for extension: d-dimer +, extensive thrombosisclose to proximal veins; active cancer, prior VTE, inpatient


CALF VEIN DVTDVT TREATMENT DURATION

Cancer-associated calf vein DVT Full dose anticoagulation at least 3 months and continue while cancer active

Unprovoked calf vein DVT Full dose anticoagulation 3 months

Provoked/transient risk factor calf vein DVT Full dose anticoagulation May consider intermediate dose ACMay consider ultrasound surveillance (high bleed risk)

6 weeks but continue if risk factor still present

Trifurcation DVT Full dose anticoagulation DVT

At least 3 months, duration as per proximal

Makedonov et al CO-Hematology 2021, Stevens et all CHEST 2021 Mazzolai et al Eur Journ Preventive Cardiology et al

CHEST VTE GUIDELINES 2021: suggest serial u/s over anticoagulation (weak evidence) if no severe symptoms or risk factors for extension


CALF VEIN DVT

• A 29-year-old male presented with a calf trifurcation DVT two weeks after a traumatic partial Achilles tendon rupture. His leg will be in a cast for 3 weeks and he will not undergo surgery

• A 40-year-old woman presents with an unprovoked gastrocnemius vein DVT

• A 79-year-old man presents with a posterior tibial vein DVT. He is started on therapeutic anticoagulation but a week later he returns with an upper gastrointestinal bleed due to gastric ulcer. He requires blood transfusion and intensive care unit admission

• A 19-year-old woman is found to have a peroneal vein DVT 1 month after appendectomy. She is currently ambulatory


CASE

A 66 year old man, 150 kg is seen in the ED for acute chest pain. He is found to have bilateral segmental PE. He is classified as “low risk PE” (no RV dysfunction, normal troponin, BNP, vital signs) and will discharged to home on anticoagulation. What anticoagulation regimen do you recommend?

1) LMWH→warfarin

2) Rivaroxaban

3) Apixaban

4) IV heparin→DOAC

5) Any of the above would work for me


DOACS in VTE & OBESITY

DOAC levels not recommendedAvoid dabigatran/edoxabanUse LMWH for 1st 4 weeks after bariatric surgery

Martin et al J Thromb Haemst 2021


DOACS in BARIATRIC SURGERY

https://acforum-excellence.org/Resource-Center/resource_files/-2020-05-14-124503.pdf

Martin et al J Thromb Haemst 2021


CASE

A 66 year old man, 150 kg is seen in the ED for acute chest pain. He is found to have bilateral segmental PE. He is classified as “low risk PE (no RV dysfunction, normal troponin, BNP, vital signs) and will discharged to home on anticoagulation. What anticoagulation regimen do you recommend?

1) LMWH→warfarin

2) Rivaroxaban

3) Apixaban

4) IV heparin→DOAC

5) Any of the above would work for me


Case

A 75 year old woman with DM, HTN is referred to your clinic to initiate anticoagulation for new onset AFIB. You are going to start her on a DOAC. She is on ASA for primary CAD prevention. Do you continue this in addition to her full dose DOAC?

1) Yes, she has many risk factors for CAD

2) No, I think the DOAC should cover it


ASA+ ANTICOAGULATION

MANY INDICATIONS FOR ASA

• Primary prevention of CAD

• Secondary prevention of CAD, CVA

• PAD

• Secondary prevention of VTE

Hundreds of thousands of patients in the US are on BOTH ASA plus AC

SHOULD PATIENTS ON ANTICOAGULATION BE ON ASA TOO?

• Commonly agreed upon indications for dual therapy: ACS, recent PCI,


How often are patients anticoagulated with a DOAC for AFIBor VTE, without a recent MI or heart valve replacement,

treated with concomitant aspirin? How does this impact bleeding outcomes?


Case

A 75 year old woman with DM, HTN is referred to your clinic to initiate anticoagulation for new onset AFIB. You are going to start her on a DOAC. She is on ASA for primary CAD prevention. Do you continue this in addition to her full dose DOAC?

1) Yes, she has many risk factors for CAD



Case

A 75 year old man with PAD (iliac bypass 18 months ago),HTN is referred to your clinic to initiate anticoagulation for new onset AFIB. You are going to start him on a DOAC. He is on ASA for his PAD. Do you continue this in addition to his full dose DOAC?

1) Yes, he needs it for his PAD



Eur Heart J, ehab390, https://doi.org/10.1093/eurheartj/ehab390

.

Summary of optimal and alternative antithrombotic strategies in patients with peripheral arterial disease

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PAD

If peripheral stentshort term clopidogrel in addition to AC (~1 month)Add ASA (triple therapy) ONLY in select cases at highest risk ie., prior stent thrombosis, slow flow

Eur Heart J, ehab390, https://doi.org/10.1093/eurheartj/ehab390

.

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Case

A 75 year old man with PAD (iliac bypass 18 months ago),HTN is referred to your clinic to initiate anticoagulation for new onset AFIB. You are going to start him on a DOAC. He is on ASA for his PAD. Do you continue this in addition to his full dose DOAC?

1) Yes, he needs it for his PAD



Case

A 60 year old man with HTN and mechanical aortic valve placed 2017 is on warfarin and ASA. He is admitted to OSH for GIB. INR is 2.0 on admission, warfarin is held and he has EGD which shows gastric ulcer which is treated endoscopically. His Hgb stabilizes and he will resume his warfarin. Should he resume his ASA as well?

1) Yes, he needs it for his mechanical valve

2) No, I think the warfarin should cover it


“prior recommendations to add low-dose ASA to therapeutic VKA ..wasbased on studies performed decades ago

that included older generation prostheses and additional risk factors”

CM Otto et al Circulation 2020


Case

A 60 year old man with HTN and mechanical aortic valve placed 2017 is on warfarin and ASA. He is admitted to OSH for GIB. INR is 2.0 on admission, warfarin is held and he has EGD which shows gastric ulcer which is treated endoscopically. His Hgb stabilizes and he resumes his warfarin. Should he resume his ASA as well?



Should he be bridged when he resumes warfarin?

16th National Conference on Anticoagulation TherapyOctober 28-30, 2021Kovacs MJ et al. BMJ 2021


Case

A 60 year old man with HTN and mechanical aortic valve placed 2017 is on warfarin and ASA. He is admitted to OSH for GIB. INR is 2.0 on admission, warfarin is held and he has EGD which shows gastric ulcer which is treated endoscopically. His Hgb stabilizes and he resumes his warfarin. Should he resume his ASA as well?



Should he be bridged when he resumes warfarin?


Questions?

Documents

New Papers & Guidelines