A retrospective analysis of the periprocedural management of oral anticoagulants in patients undergoing interventional radiology procedures

Abstract

Limited evidence is available to guide periprocedural management of oral anticoagulants in the setting of interventional radiology (IR) procedures. For direct oral anticoagulants, therapy interruption (TI) is based on medication half-life and procedural bleeding risk. Periprocedural management of warfarin includes INR monitoring, and possible bridging with parenteral anticoagulants. It is unknown if these recommendations apply to IR procedures. To evaluate bleeding complications and thromboembolic events following periprocedural management of the factor Xa (FXa) inhibitors or warfarin in patients undergoing IR procedures. We performed a retrospective, observational study at NYU Langone Health (NYULH) of all adult patients who underwent an IR procedure from January 2015 to July 2017 and were receiving apixaban, rivaroxaban, or warfarin. Patients who were pregnant or who had a mechanical heart valve were excluded. At NYULH, TI is not required for FXa inhibitors, and an INR < 3 is recommended for patients on warfarin undergoing low risk procedures. For moderate/high risk procedures, TI for 48 h or 72 h with reduced renal function, is recommended for FXa inhibitors, and an INR < 1.5 is recommended for patients on warfarin. We evaluated 350 IR procedures, with a total of 174 low bleeding risk and 176 moderate/high bleeding risk. The 30-day major bleeding rate was 0.9%, clinically relevant non-major bleeding rate was 3%, minor bleeding rate was 1% and thromboembolic event rate was 1%. The periprocedural oral anticoagulation management strategy at NYULH appears safe given the low 30-day incidence of bleeding and thromboembolic events.

Risk of Stroke and other Thromboembolic Complications after Interruption of DOAC Therapy Compared with Warfarin Therapy in Patients with Atrial Fibrillation: A Retrospective Cohort Analysis

“…As could be expected from the study design, patients in our cohort were older and had higher CHA2DS2-VASc scores (median=5.0, IQR=4.0–6.0) compared with other publications 7-11 14 17 22 23. Rates of thromboembolic complications after TI were also higher (30-day rate 2.54% for warfarin and 6.25% for DOACs; 90-day rate 5.0% for warfarin and 6.9% for DOACs) than usually reported 12-14 16-20. The latter finding might reflect the increased background risk (ie, higher CHA2DS2-VASc scores), or point to an increased risk of complications in hospitalized patients.…”

“…Moreover, the body of data on the implications of treatment interruptions (TI) is still limited in several ways. First, most studies on DOAC TI mainly concern intended interruptions for invasive procedures,16-20 even though interruptions for other reasons are very common 21. There are insufficient data about interruptions due to acute changes in the patient's health, such as documented or expected acute kidney injury; or about unintended interruptions of treatment.…”

Measuring the Impact of a Pharmacist-Driven Blood Factor Education Program: A Prospective, Single-Center Observational Study

“…This is likely due to the overall consolidation of management to the hematology specialists. 9,12 This consolidative approach to enhance care is reasonable, and likely a common practice balanced with institutional education not described. Other reports have identified the importance of educational efforts driven by hematology specialists; however, few details on these programs are offered, including their immediate impact on staff.…”

“…Since this initial report several other factor stewardship initiatives have been described. [7][8][9][10][11][12] Several of these programs describe the formation of a specialist team or guideline development with electronic clinical decision support to drive care and factor management optimization; however, little emphasis is given to the education of the larger supporting staff. This is likely due to the overall consolidation of management to the hematology specialists.…”