Post on 27-Jul-2020
Management of Anticoagulation in Interventional Cardiology
Clinical Guideline
V1.0
November 2019
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 2 of 21
Summary
Although of proven benefit in a range of indications, antithrombotics are associated with adverse effects, principally abnormal bleeding. When patients on anticoagulation require an invasive procedure, the risks and benefits of stopping or continuing anticoagulation must be considered. To maximise benefit over risks, the selection of patients for treatment with antithrombotics and their management should be evidence based.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 3 of 21
1. Aim/Purpose of this Guideline
1.1. This document applies to all doctors (regardless of grade) and nurses who have the responsibility to identify patients (elective and inpatient) on medications that will increase the risk of bleeding during/after a cardiac procedure. 1.2. This guideline applies to patients taking oral anticoagulation or antiplatelet drugs who require an invasive procedure. It is designed to safely manage the discontinuation of the following medications and where appropriate the prescription of reversal agents or substitutes such as bridging therapy. It aims to standardise management across the cardiac wards in line with international guidelines and in so doing, to minimise morbidity and mortality from thrombosis or haemorrhage.
1.3. This guideline is designed to safely manage the discontinuation of the following medications listed in Appendix 5. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications.
1.4. This guideline is designed to safely manage the discontinuation of the following medications. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications. 1.5. This version supersedes any previous versions of this document. 1.6. Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in.
DPA18 is applicable to all staff; this includes those working as contractors and providers of services.
For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team rch-tr.infogov@nhs.net
2. The Guidance
2.1. Thrombotic risk The risk-benefit ratio of interrupting VKA therapy requires individual consideration. Continuation of anticoagulation during invasive procedures is likely to increase the bleeding risk. Whilst discontinuation is associated with a temporary increase in thrombosis risk. There is debate over the optimal approach to management in this situation and whether VKA therapy should be interrupted and, if so, whether there is a need for bridging therapy with the temporary
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 4 of 21
introduction of an alternative antithrombotic, usually heparin. 2.2. The guidance for the Management of Anticoagulation in Interventional Cardiology is included in the tables of Appendix 3 and Appendix 4. 2.3. The guidance for the discontinuation of antiplatelet/anticoagulation is included in the tables of Appendix 5. 2.4. The guidance for the restarting of antiplatelet / anticoagulation medications is included in the tables of Appendix 6
3. Monitoring compliance and effectiveness
Element to be monitored
All elements to be monitored
Lead Cardiology Department
Tool Review of case notes, using the guidelines as the audit standard with Audit and review tool.
Frequency One year after implementation to complete first audit. Thereafter frequency will depend on our compliance
Reporting arrangements
Reporting into Cardiology Governance
Acting on recommendations and Lead(s)
The Cardiology Department Governance and Audit leads will be responsible for this. The report will be disseminated and an expectation to implement any recommendations of change immediately
Change in practice and lessons to be shared
The recommended actions will be cascaded to the nursing and medical staff involved in the clinical management of these patients, at presentations to the relevant departmental meetings.
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 5 of 21
Appendix 1. Governance Information
Document Title Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0
Date Issued/Approved: 20 September 2019
Date Valid From: November 2019
Date Valid To: November 2022
Directorate / Department responsible (author/owner):
Mohammed Abubakr, Consultant Cardiologist
Contact details: 07833 201879 or 01872 252911
Brief summary of contents
Guidance on the management of anticoagulation in interventional cardiology, and to safely manage the discontinuation of anticoagulation medications. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications.
Suggested Keywords: Anticoagulation, Antiplatelet, Cardiology, Antithrombotic
Target Audience RCHT CFT KCCG
Executive Director responsible for Policy:
Medical Director
Date revised: Initial version
This document replaces (exact title of previous version):
• Clinical Guideline for Management of Anticoagulation in Interventional Cardiology v1.0 • Clinical Guideline for Restarting Of Antiplatelet/Anticoagulation Medications V1.0 • Clinical Guideline for Discontinuation Of Antiplatelet/Anticoagulation Medications in Pacing and Intervention V1.0
Approval route (names of committees)/consultation:
Cardiology Governance Group
Care Group General Manager confirming approval processes
Sidwell Lawler
Name and Post Title of additional signatories
Not Required
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 6 of 21
Name and Signature of Care Group/Directorate Governance Lead confirming approval by specialty and care group management meetings
{Original Copy Signed}
Name: Becky Osborne
Signature of Executive Director giving approval
{Original Copy Signed}
Publication Location (refer to Policy on Policies – Approvals and Ratification):
Internet & Intranet Intranet Only
Document Library Folder/Sub Folder Clinical / Cardiology
Links to key external standards None required
Related Documents: No
Training Need Identified? None
Version Control Table
Date Version
No Summary of Changes
Changes Made by (Name and Job Title)
14.10.2019 V1.0 Initial version Mohammed Abubakr, Consultant Cardiologist
All or part of this document can be released under the Freedom of Information Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 7 of 21
Appendix 2. Initial Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed Management of Anticoagulation in Interventional Cardiology
Clinical Guideline V1.0
Directorate and service area: Cardiology
New or existing document: New
Name of individual completing assessment: Sian Pelton
Telephone: 07833201879
1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?
This guideline is aimed at all medical and nursing staff caring for patients awaiting interventional cardiology who require management of their anticoagulation. This guideline is designed to safely manage the discontinuation of anticoagulation medications. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications.
2. Policy Objectives*
To standardise clinical practice in the management of anticoagulation in patients awaiting cardiac procedures. To inform and educate all medical and nursing staff to ensure the management of anticoagulation for patients awaiting cardiac procedures is evidence based. This guideline is designed to safely manage the discontinuation of anticoagulation medications. The aim is to minimise the risk of bleeding during/after a procedure whilst minimising the risk of thromboembolic complications that may occur from cessation of some of these medications.
3. Policy – intended Outcomes*
To reduce the number of patients cancelled or delayed in having their cardiac procedures due to incorrect/inconsistent management of anticoagulation. All clinical staff working in cardiology are knowledgeable and confident in their understanding of anticoagulation management in interventional cardiology To standardise care, ensure early, appropriate and timely interventions, better education and reduce morbidity and mortality.
4. *How will you measure the outcome?
Regular feedback from the booking team, wards, cardiac catheter labs and consultant body. Audit of the number of patients who are cancelled or delayed in having their cardiac procedure due to incorrect/inappropriate management of their anticoagulation.
5. Who is intended to benefit from the policy?
Both elective and inpatients on anticoagulation awaiting a cardiac procedure.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 8 of 21
Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence
Age X
Sex (male,
female, trans-gender / gender reassignment)
X
Race / Ethnic communities /groups
X
Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.
X
Religion / other beliefs
X
Marriage and Civil partnership
X
Pregnancy and maternity
X
Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian
X
You will need to continue to a full Equality Impact Assessment if the following have been highlighted:
You have ticked “Yes” in any column above and
No consultation or evidence of there being consultation- this excludes any policies which have
6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.
Workforce Patients Local groups
External organisations
Other
X
Please record specific names of groups
Clinical leads for intervention and pacing have reviewed the guidelines and they have been presented at the Cardiology Audit Meeting.
Cardiology Consultants
What was the outcome of the consultation?
Agreed
7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 9 of 21
been identified as not requiring consultation. or
Major this relates to service redesign or development
8. Please indicate if a full equality analysis is recommended. Yes No X
9. If you are not recommending a Full Impact assessment please explain why.
Not indicated
Date of completion and submission
14.10.2019 Members approving screening assessment
Policy Review Group (PRG) ‘APPROVED’
This EIA will not be uploaded to the Trust website without the approval of the Policy Review Group. A summary of the results will be published on the Trust’s web site.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 10 of 21
Appendix 3. Thrombotic Risk Score
CHA2DS2-VASc score for stroke risk in atrial fibrillation Feature Score Congestive Heart Failure 1
Hypertension 1
Age >75 years 2
Age between 65 and 74 years 1
Stroke/TIA/TE 2
Vascular disease (previous MI, peripheral artery disease or aortic plaque)
1
Diabetes mellitus 1
Female 1
High-risk patients may also include those with a prior stroke or TIA occurring >3 months before the planned
surgery and a CHADSVASC score <5, those with prior thromboembolism during temporary interruption of
VKAs
THROMBOTIC RISK SCORE
Risk Mechanical Heart Valve
Atrial Fibrillation VTE
High1 5-6
Any mitral valve prosthesis Any caged-ball or tilting disc
aortic valve prosthesis Recent (within 6 months)
stroke or TIA
CHA2DS2-VASc score of 5 or 6
Recent (within 3 months) stroke or TIA
Rheumatic valvular heart disease
Recent (within 3 months) VTE
Severe thrombophilia (eg, deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)
Moderate 2-4
Bileaflet aortic valve prosthesis and one or more of the of following risk factors: atrial fibrillation, prior stroke or TIA, hypertension, diabetes, congestive heart failure, age>75 year
CHA2DS2-VASc score of 2 to 4
VTE within the past 3-12 months
VTE within the past 3- 12 months
Non-severe thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation)
Recurrent VTE
Active cancer (treated within 6 months or palliative care)
Low 0-1
Bileaflet aortic valve prosthesis without AF and no other risk factors for stroke
CHA2DS2-VASc score of 0 or 1 (assuming no prior stroke or TIA)
VTE >12 months previous and no other risk factors
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Appendix 4. Summary Guidance for the Management of Anticoagulation in Interventional Cardiology ASPIRIN Antiplatelet
Indication low doses of aspirin administered once daily significantly reduce platelet aggregability and is indicated in: Primary prevention - risk of heart attack, stroke or vascular occlusion but have not had one. This will include patients over age 50 with hypertension, diabetes or other cardiovascular risk factors Secondary prevention - patients with significant cardiovascular disease. This includes patients with previous Unstable angina, Heart attack, Angioplasty or Coronary artery stents, Angina, Stroke, Peripheral vascular disease and renovascular disease.
Intervention Can be continued for angiograms and is a necessity for any procedure where stenting is considered.
Where an allergy is present, discussion with the consultant Cardiologist is required.
Pacing Discontinuation is not required prior to invasive pacing procedures.
EPS & ablation
Discontinuation is not required prior to these procedures.
CLOPIDOGREL, TICAGRELOR, PRASUGREL Antiplatelet
Indication Reduce platelet aggregation. Used in conjunction with aspirin as part of the ACS treatment regimen for the prevention of atherothrombotic events and post stent insertion to reduce stent thrombosis
Intervention Can be continued for angiograms and is a necessity for any procedure
where stenting is considered.
Where an allergy is present, discussion with the consultant Cardiologist is required.
Pacing Discontinuation is not required prior to invasive pacing procedures.
EPS & ablation
Discontinuation is not required prior to these procedures.
WARFARIN Anticoagulant
Indication Vitamin K antagonist (VKA). Used for thromboembolic prophylaxis in patients with mechanical heart valves, atrial fibrillation, recurrent DVT and/or PE and hypercoagulable disorders. Used also as treatment for first time DVT and/or PE.
Intervention Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve
Can be continued for angiograms. Target INR <4 Where any stenting is indicated the patient will require bridging therapy. For guidance on bridging refer to Appendix 2, Page 69 of the RCHT clinical guideline for thrombosis prevention investigation and management of anticoagulation.
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Low thrombotic risk ≤4 CHA2DS2-VASc score or no metal valve
Can be continued for angiograms. Target INR <4 Where any stenting is indicated stop 5 days before procedure. Target INR of <1.7.
Restart warfarin evening of procedure with usual daily dose. Check INR one week later to ensure adequate anticoagulation.
DALTEPARIN/FRAGMIN ENOXAPARIN/CLEXANE LMWH Indication Treatment and prevention of thrombosis
Intervention Treatment dose Stop 24hrs before. Recommence day after procedure.
Prophylactic dose Continue.
Pacing Treatment dose Stop 24hrs before. First dose 24hrs after procedure.
Prophylactic dose Continue.
EPS & ablation
Treatment dose Stop 24hrs before. Recommence day after procedure.
Prophylactic dose Continue.
Pacing Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve
Continue warfarin. Target INR <4
Low thrombotic risk ≤4 CHA2DS2-VASc score or no metal valve
Stop 5 days before. Target INR <1.5.
Restart warfarin day after procedure with usual daily dose. Check INR one week later to ensure adequate anticoagulation.
EPS & ablation
Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve
For radiofrequency ablation the decision is made on an individual basis. Please consult the operator for guidance.
For VT stimulations, atrial flutter ablations, AV node ablation with PPM implant in same sitting and AV node ablations with PPM insitu continue warfarin. Target INR <4
Low thrombotic risk ≤4 CHA2DS2-VASc score or no metal valve
For radiofrequency ablation and AV node ablation with PPM implant in same sitting stop 5 days before. Target INR <1.5.
Restart warfarin evening of procedure with usual daily dose. Check INR one week later to ensure adequate anticoagulation.
For VT stimulations, atrial flutter ablations and AV node ablations with PPM insitu continue warfarin. Target INR <4
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FONDAPARINUX Antithrombotic - Indirect factor Xa inhibitor Indication Treatment and prevention of thrombosis
Intervention Omit day of procedure. Restart at least 6 hours post-operatively provided haemostasis has been achieved.
Pacing Omit day of procedure. Restart at least 6 hours post-operatively provided haemostasis has been achieved.
EPS & ablation
For radiofrequency ablation and AV node ablation with PPM in same sitting omit day of procedure.
Restart at least 6 hours post-operatively provided haemostasis has been achieved.
For VT stimulations, atrial flutter ablations and AV node ablations with PPM insitu continue.
RIVAROXABAN (XARELTO) / APIXABAN (ELIQUIS) Direct oral anticoagulant - Direct factor Xa inhibitor Indication Direct oral anticoagulants (DOACs) are an alternative for vitamin K
antagonists (VKAs) for prevention of VTE after hip and knee replacement surgery, treatment of DVT and prevention of recurrent VTE and the prevention of thromboembolism in AF. They were previously known as NOACs, but as these medications are no longer ‘novel’, DAOC is going to be the future adopted term for practice
Intervention Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve
Can be continued for angiograms. Where any stenting is indicated the patient will require bridging therapy. For guidance on bridging refer to Appendix 2, Page 69 of the RCHT clinical guideline for thrombosis prevention investigation and management of anticoagulation.
Low thrombotic risk ≤4 CHA2DS2-VASc score or no metal valve
Can be continued for angiograms. Where any stenting is indicated stop 48hrs before procedure.
Resume 48 hrs post-procedure.
Pacing Moderate to high Continue. thrombotic risk
≥4 CHA2DS2-VASc
score or any metal
valve
Low thrombotic risk Stop 48hrs before. ≤4 CHA2DS2-VASc
score or no metal valve
Resume 48 hrs post-procedure.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 14 of 21
DABIGATRAN (PRADAXA) Anticoagulant - Direct thrombin inhibitor Indication Direct oral anticoagulants (DOACs) are an alternative for vitamin K
antagonists (VKAs) for prevention of VTE after hip and knee replacement surgery, treatment of DVT and prevention of recurrent VTE and the prevention of thromboembolism in AF. They were previously known as NOACs, but as these medications are no longer ‘novel’, DAOC is going to be the future adopted term for practice
Intervention Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve
Can be continued for angiograms. Where any stenting is indicated the patient will require bridging therapy. For guidance on bridging refer to Appendix 2, Page 69 of the RCHT clinical guideline for thrombosis prevention investigation and management of anticoagulation.
Low thrombotic risk ≤4 CHA2DS2-VASc score or no metal valve
Can be continued for angiograms. Where any stenting is indicated stop: Renal function (eGFR) ≥ 80 24 hours before ≥ 50-< 80 1-2 days before ≥ 30-< 50 2-3 days before (> 48 hours)
Resume 48 hrs post-procedure.
Pacing Moderate to high Continue. thrombotic risk
≥4 CHA2DS2-VASc
score or any metal
valve
Low thrombotic risk Stop: ≤4 CHA2DS2-VASc Renal function (eGFR) score or no metal ≥ 80 24 hours before valve ≥ 50-< 80 1-2 days before
EPS & ablation
Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve
Continue.
Low thrombotic risk ≤4 CHA2DS2-VASc score or no metal valve
For radiofrequency ablation and AV node ablation with PPM implant in same sitting stop 48hrs before procedure.
Resume 48 hrs post-procedure.
For VT stimulations, atrial flutter ablations and AV node ablations with PPM insitu continue.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 15 of 21
≥ 30-< 50 2-3 days before (> 48 hours)
Resume 48 hrs post-procedure.
EPS & ablation
Moderate to high thrombotic risk ≥4 CHA2DS2-VASc score or any metal valve
Continue.
Low thrombotic risk ≤4 CHA2DS2-VASc score or no metal valve
For radiofrequency ablation and AV node ablation with PPM implant in same sitting stop: Renal function (eGFR) ≥ 80 24 hours before ≥ 50-< 80 1-2 days before ≥ 30-< 50 2-3 days before (> 48 hours)
Resume 48 hrs post-procedure.
For VT stimulations, atrial flutter ablations and AV node ablations with PPM insitu continue.
Switching between anticoagulant regimes
VKA to DOAC When switching patients from warfarin to
DOAC for stroke and/or systemic
embolism, discontinue warfarin and start
DOAC as soon as the International
Normalized Ratio (INR) <3.0,
When switching patients from warfarin to
DOAC for DVT/PE and prevention of
recurrence of VTE discontinue warfarin and
start DOAC as soon as the International
Normalized Ratio (INR) <2.5
DOAC to VKA Administer concomitantly for at least two
days until INR in appropriate range.
After 2 days of coadministration measure
INR just before next intake of DOAC.
Re-test 48hr after last dose of DOAC.
Continue coadministration until the INR is ≥
2, Monitor INR in first month until stable
values (2.0-3.0) achieved
Parenteral anticoagulation to DOAC:
Intravenous unfractionated heparin (UFH)
Low molecular weight heparin (LMWH)
Discontinue the parenteral anticoagulant
and start DOAC 0-2 hours prior to the time
that the next dose of the alternate therapy
would be due.
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 16 of 21
For unfractionated heparin being
administered by continuous infusion, stop
the infusion and start DOAC at the same
time
DOAC to parenteral anticoagulant
Intravenous unfractionated heparin (UFH)
Low molecular weight heparin (LMWH)
Initiate when next dose of DOAC was due.
It is recommended to wait 12 hours after
the last dose before switching from DOAC
to a parenteral anticoagulant.
DOAC to DOAC Initiate when next dose is due except
where higher plasma concentrations
expected (e.g. renal impairment)
DOAC to dual antiplatelet therapy (Aspirin +
Clopidogrel/Prasugrel/Ticagrelor)
Switch immediately. Discontinue DOAC
and give the first dose of the other
antiplatelet at the time that the next DOAC
dose would have been taken unless
combination therapy needed
Dual antiplatelet therapy (Aspirin +
Clopidogrel/Prasugrel/Ticagrelor) to DOAC
Unless combination therapy is needed,
start DOAC 0 to 2 hours prior to the next
scheduled evening administration of the
drug and omit administration of the other
antiplatelet.
Triple therapy – DOAC or VKA with aspirin
plus clopidogrel/Prasugrel
Combined oral anticoagulant and
antiplatelet therapy is generally
discouraged in atrial fibrillation (AF) outside
of ACS or stenting because of increased
bleeding, hence the decision to use triple
therapy is made on an individual basis in
consultation with a consultant Cardiologist
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 17 of 21
Appendix 5. Summary Guidance for the Discontinuation of Antiplatelet/ Anticoagulation
Setting: Cardiology For Staff: Nurses, doctors Patients: Adult patients awaiting elective and inpatient pacing/intervention
Roles and responsibilities: Doctors and nurses caring for patients To identify patients (elective and inpatient) on medications that will increase the risk of bleeding during/after a procedure and use this guideline to stop these medications in a timely fashion to minimise the risk of bleeding whilst considering if substitute bridging medication is required to prevent thromboembolic complications.
DRUG INDICATION LHC LHC ? PCI /
PWS PCI /
Rotablation PPM / ICD
(explant/impla nt/
generator change)
CRT-D / CRT- P
(explant/impla nt/
generator change)
Ablation: Narrow
complex tachy / SVT/
AVNRT/ WPW
VT Stimulation Atrial flutter ablation
AV node ablation with PPM in-situ
AV node ablation with PPM implant
Aspirin Antiplatelet continue required required continue continue continue continue continue continue continue
Clopidogrel Ticagrelor Prasugrel
Antiplatelet continue required required continue continue continue continue continue continue continue
Warfarin: Moderate to high risk (≥4 or
any metal valve)
Anticoagulant continue bridging bridging continue continue Patient specific - Liaise
with Dr. Slade
continue continue continue continue
Low risk
continue Stop 5 days before
INR <1.7
Stop 5 days before
INR <1.7
Stop 5 days before
INR <1.5
Stop 5 days before
INR <1.5
Stop 5 days before
INR <1.5
continue Continue Continue Stop 5 days before
INR <1.5
Dalteparin/Fragmin Enoxaparin/Clexane
Treatment dose >10,000IU
LMWH Stop 24hrs before
Stop 24hrs before
Stop 24hrs before
Stop 24hrs before
Stop 24hrs before
Stop 24hrs before
Stop 24hrs before
Stop 24hrs before
Stop 24hrs before
Stop 24hrs before
continue
continue
continue
continue
continue
continue
continue
continue
continue
continue
Prophylactic dose <10,000IU
Rivaroxaban and Apixaban: Moderate to high risk (≥4 or
any metal valve)
Low risk
New oral anticoagulant - Direct factor Xa
inhibitors
continue bridging bridging continue continue continue continue continue continue continue
continue Stop 48hrs before
Stop 48hrs before
Stop 48hrs before
Stop 48hrs before
Stop 48hrs before
continue continue continue Stop 48hrs before
Dabigatran Moderate to high risk (≥4 or
any metal valve)
Anticoagulant - Direct thrombin
inhibitor
continue bridging bridging continue continue continue continue continue continue continue
Low risk continue Stop 48hrs
before Stop 48hrs
before Stop 48hrs
before Stop 48hrs
before Stop 48hrs
before continue continue continue Stop 48hrs
before
Fondaparinux Antithrombotic- Indirect factor Xa
inhibitor
Omit day of procedure
Omit day of procedure
Omit day of procedure
Omit day of procedure
Omit day of procedure
Omit day of procedure
continue continue continue Omit day of procedure
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 18 of 21
Thrombotic risk score
Risk Mechanical Heart Valve Atrial Fibrillation VTE
High1 5-6
Any mitral valve prosthesis Any caged-ball or tilting disc aortic valve
prosthesis Recent (within 6 months) stroke or TIA
CHA2DS2-VASc score of 5 or 6 Recent (within 3 months) stroke or
TIA Rheumatic valvular heart disease
Recent (within 3 months) VTE Severe thrombophilia (eg, deficiency of
protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)
Moderate 2-4
Bileaflet aortic valve prosthesis and one or more of the of following risk factors: atrial fibrillation, prior stroke or TIA, hypertension, diabetes, congestive heart failure, age>75 year
CHA2DS2-VASc score of 2 to 4
VTE within the past 3-12 months
VTE within the past 3-12 months
Non-severe thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation)
Recurrent VTE
Active cancer (treated within 6 months or palliative care)
Low 0-1
Bileaflet aortic valve prosthesis without AF and no other risk factors for stroke
CHA2DS2-VASc score of 0 or 1 (assuming no prior stroke or TIA)
VTE >12 months previous and no other risk factors
CHA2DS2-VASc = congestive heart failure 1, hypertension 1, age >75 years 2, age 65-74 1, diabetes mellitus 1, stroke/TIA/thrombo-
embolism 2, vascular disease 1, sex female 1
1High-risk patients may also include those with a prior stroke or TIA occurring >3 months before the planned surgery and a CHADSVASC score <5, those with prior thromboembolism during temporary interruption of VKAs
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 19 of 21
Appendix 6. Summary of Guidance for the Restarting of Antiplatelet / Anticoagulation Medications DRUG INDICATION LHC LHC ? PCI /
PWS
PCI / Rotablation
PPM / ICD CRT-D CRT-P
Ablation: Narrow complex tachy / SVT/ AVNRT/ WPW
VT Stimulation
Atrial flutter ablation
AV node ablation with PPM in-situ
AV node ablation with PPM implant
Aspirin Antiplatelet continue If stented lifelong lifelong continue continue continue continue continue continue continue
Clopidogrel Ticagrelor Prasugrel
Antiplatelet continue If stented - to be taken for between 1 -12 months
To be taken for between 1 -12 months
continue continue continue continue continue continue continue
Warfarin:
Moderate to high risk (≥4 or any metal valve)
Low risk
Anticoagulant continue Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic dose of LMWH on the day after the procedure. Continue LMWH until a satisfactory INR is achieved
Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic dose of LMWH on the day after the procedure. Continue LMWH until a satisfactory INR is achieved
continue continue Patient specific - Liaise with DDr. Slade
continue continue continue continue
continue Restart warfarin evening of procedure with usual daily dose. Check INR 1
Restart warfarin evening of procedure with usual daily dose. Check INR 1
Restart warfarin day after procedure with usual daily dose. Check INR 1
Restart warfarin day after procedure with usual daily dose. Check INR 1
Restart warfarin evening of procedure with usual daily dose. Check INR 1
continue continue continue Restart warfarin evening of procedure with usual daily dose. Check INR 1
week later to ensure adequate anticoagulation
week later to ensure adequate anticoagulation
week later to ensure adequate anticoagulation
week later to ensure adequate anticoagulation
week later to ensure adequate anticoagulation
week later to ensure adequate anticoagulation
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 20 of 21
Dalteparin / Fragmin Enoxaparin / Clexane
Treatment dose >10,000IU
Prophylactic dose <10,000IU
LMWH Recommence day after procedure
Recommence day after procedure
Recommence day after procedure
First dose 24hrs after procedure
First dose 24hrs after procedure
Recommence day after procedure
Recommence day after procedure
Recommence day after procedure
Recommence day after procedure
First dose 24hrs after procedure
continue
continue
continue
continue
continue
continue
continue
continue
continue
continue
Rivaroxaban Apixaban
Moderate to high risk (≥4 or any metal valve)
Low risk
New oral anticoagulant
- Direct factor Xa inhibitors
continue Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic dose of LMWH on the day after the procedure. Continue LMWH until a satisfactory INR is achieved
Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic dose of LMWH on the day after the procedure. Continue LMWH until a satisfactory INR is achieved
continue
continue continue continue continue continue continue
continue Resume 48 hrs post- procedure
Resume 48 hrs post- procedure
Resume 48 hrs post- procedure
Resume 48 hrs post- procedure
Resume 48 hrs post- procedure
continue continue continue Resume 48 hrs post- procedure
Dabigatran
Moderate to high risk (≥4 or any metal valve)
Anticoagulant
- Direct thrombin inhibitor
continue Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic
Restart warfarin evening of procedure with usual daily dose. Recommence the daily therapeutic
continue continue continue continue continue continue continue
dose of dose of LMWH on the LMWH on the day after the day after the Low risk procedure. procedure. Continue Continue LMWH until a LMWH until a
Management of Anticoagulation in Interventional Cardiology Clinical Guideline V1.0 Page 21 of 21
satisfactory satisfactory INR is INR is achieved achieved continue Resume 48 Resume 48 Resume 48 Resume 48 Resume 48 continue continue continue Resume 48 hrs post- hrs post- hrs post- hrs post- hrs post- hrs post- procedure procedure procedure procedure procedure procedure
Fondaparinux Antithrombotic- Indirect factor Xa inhibitor
restart at least 6 hours post- operatively provided haemostasis has been achieved
restart at least 6 hours post- operatively provided haemostasis has been achieved
restart at least 6 hours post- operatively provided haemostasis has been achieved
restart at least 6 hours post- operatively provided haemostasis has been achieved
restart at least 6 hours post- operatively provided haemostasis has been achieved
restart at least 6 hours post- operatively provided haemostasis has been achieved
continue continue continue restart at least 6 hours post- operatively provided haemostasis has been achieved