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How to manage DOACS around surgery?
- Holding
- Bridging
- Reversing
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Holding DOACS BEFORE surgery
- Hold x 1 day before for low bleeding risk: colonoscopy or upper endoscopy
- Hold x 2 days before for high bleeding risk: abdominal or vascular surgery
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Holding DOACS AFTER surgery
- Restart DOACS 1 day after low bleeding risk
- Restart DOACS 2 -3 days after high bleeding risk
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Holding DOACS in pts with decreased renal function
- If CrCl < 50, Hold Pradaxa for 2 days before low bleeding risk
- Hold Pradaxa for 4 days before high bleeding risk
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DOACs with minimal bleeding risk...such as tooth extraction or skin biopsy
- Delay DOACs until 4-6 hours post-op. This means skipping the morning dose of twice daily DOACs
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What is bridging?
- Dont routinely recommend bridging with injectable anticoagulant (Loveno) while DOACs is held
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Reversal agent for factor Xa inhibitors
- Andexxa >< Apixaban (Eliquis) or Rivaroxaban (Xarelto)
- 4 factor prothromnin complex concentrate: Kcentra
- Idarucizumab (Praxbind) >< Dabigatran
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OPTIMIZE ANTICOAGULATION FOR PATIENTS WITH A-FIB
OPTIMIZE ANTICOAGULATION FOR PATIENTS WITH A-FIB
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Scores to identify risk factors for A.FIB
- CHADS-VASC scores
- Age, sex, gender, Stroke/ thrombo history, HTN, Vascular disease (prior stroke, MI), diabetes history, CHF history
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Anticoagulation in Afib pts?
- Provide a net benefit for most pt with Afib + non-sex risk factor
- DOACs preferred over Warfarin due to non INR monitoring & less intracranial bleeding
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What kind of DOACS to choose?
- Lean toward Eliquis due to less significant bleeding
- BEER criteria states avoid Pradaxa and Xalrelto in elderly
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Pts to avoid DOACs and rely on warfarin?
- Avoid in pts with mechanical heart valve and
- Moderate to severe midtral stenosis
- Non-adherence pts: DOACS may increase clot risk if miss doses >< warfarin much longer acting and maybe forgiving
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Meds to avoid DOACS
- Rifampin or Carbamazepine...lower DOAC level and increase clot risk
=> Recommend warfarin instead with close monitoring
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Ways to limit bleeding risk?
- Adjust DOACS in pt with kidney function
- Manage high BP
- and reevaluate NSAIDs and aspirin
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Aspirin in A.fib pts?
- Not really recommend it, even in lower-risk patients
- Antiplatelets are not as effective...and may not have lower bleeding risk