However, the complex assortment of medications is difficult to monitor with standard laboratory tests. Additionally, there is a significant lack of reversal agents. As a result, anti-thrombogenic therapies are often discontinued when patients undergo surgeries and other invasive procedures.
Radiologists performing percutaneous procedures must thus have clear guidelines for anticoagulation management during invasive procedures. This knowledge is crucial so that healthcare providers can improve the outcomes and quality of care.
Let’s explore all there is to anticoagulation management, including how to handle invasive procedures with anticoagulation management requirements.
What Is Anticoagulation Management?
Anticoagulation management is a critical aspect of healthcare. It is centered around preventing and treating blood clots. The task requires maintaining a delicate balance to ensure that the blood remains fluid enough to circulate efficiently. This is crucial for preventing the formation of clots that could cause serious and potentially life-threatening complications such as heart attacks, pulmonary embolisms, and strokes.
Anticoagulants are used in anticoagulation management to inhibit blood clotting factors in veins and arteries.
In the United States, around 3 to 5 million patients suffer from atrial fibrillation, one of the leading reasons for the administration of anticoagulation treatment. This number is predicted to rise to 8 million by 2050.
Other indications for anticoagulation treatment include pulmonary embolism, deep venous thrombosis, and the placement of prosthetic heart valves.
Percutaneous coronary interventions may also require patients to undergo dual antithrombotic therapy. This includes patients with a medical history of coronary artery bypass grafting, stroke, and essential thrombocytosis.
What Are the Complications and Risks Associated With Anticoagulation?
Anticoagulation management is a very common challenge faced by physicians. It requires a precise balance to ensure that the interruption of therapy does not cause a heightened risk of thrombotic events pre and post-operation. However, non-interruption of anticoagulation medications for surgeries can also increase the risk of minor to uncontrolled bleeding.
A balance between thromboembolic and bleeding risks is thus crucial. This can be achieved with case-based considerations to determine whether or not anticoagulation therapy must be interrupted.
In the United States, around 250,000 patients annually require a cessation of anticoagulation therapy to be eligible for surgery.
Patients experiencing certain symptoms may also be indicative of anticoagulant drug-related side effects, including:
- Purple toes
- Bloody stool
- Increase in bruising
- Hematuria
- Unusual bleeding during one’s menstrual period
- Blackish areas, change in temperature, or pain in the area around the toes, fingers, hands, and feet
- Weakness or dizziness
- Excessive bleeding
- Severe headaches and stomach aches
- Bleeding gums
Patients with bleeding disorders like thrombocytopenia, high blood pressure, diabetes, balance issues, liver or kidney problems, or congestive heart failure may also be at a higher risk of side effects from anticoagulation medications.
Pregnant or breastfeeding women may also be exempted from drugs such as warfarin as they can harm the baby or increase the risk of fetal death.
Certain drugs, be they over-the-counter or prescription-based, may also cause an increased risk of bleeding from anticoagulants. This includes medications such as:
- Birth control pills
- Antibiotics
- Anti-seizure drug carbamazepine
- Antithyroid medications
- Immune-suppressing azathioprine
- Pain relievers
- Chemotherapy drugs
- Clofibrate (used to lower cholesterol)
- Antifungal drugs
Herbal supplements, vitamins, and other medications can also interact with anticoagulant drugs, particularly those with a high vitamin K content.
How Anticoagulants and Antiplatelets Work
Common anticoagulants include:
- Warfarin
- Fondaparinux
- Edoxaban
- Dabigatran
- Rivaroxaban
- Heparin
- Apixaban
- Edoxaban
- Enoxaparin
Meanwhile, antiplatelets include:
- Eptifibatide
- Clopidogrel
- Ticlopidine
- Ticagrelor
- Dipyridamole
- Aspirin
- Prasugrel
- Ticagrelor
Anticoagulants are used to prevent or hinder coagulation by interfering with the blood proteins, known as factors, that are involved in the process. Different anticoagulants interact with different factors to reduce clotting.
Meanwhile, antiplatelets work by interfering with the platelets’ binding process which induces the formation of blood clots.
Bedside Evaluation for Anticoagulation Management
In elective surgery, the following approach is recommended for evaluating anticoagulation management:
- Determining the thromboembolic risk based on three major conditions: prosthetic heart valves, atrial fibrillation, and recent arterial or venous thromboembolism
- Evaluating the potential bleeding risk based on patients’ clinical characteristics and the type of surgery they are supposed to undergo
- Using clinical judgment to ascertain risks and benefits as well as indications for whether or not anticoagulation therapy must be interrupted
- Determining whether or not a short-acting, bridging anticoagulation is required to minimize thromboembolic risks and limit the period of subtherapeutic anticoagulation
During the preoperative period, bridging is rarely indicated except in patients with an active venous or arterial thrombosis or with mechanical heart valves. entails:
- Discontinuing warfarin five days before the surgery
- Beginning subcutaneous low molecular weight heparin (LMWH) or unfractionated heparin (UFH) three days before the surgery
- Assessing International Normalized Ratio (INR) two days before the surgery and administering 1 to 2 milligrams of vitamin K if the levels are greater than 1.5
- Discontinuing LMWH 24 hours before the surgery. If the patient is administered IV UFH, it must be discontinued 4 to 6 hours before the surgery.
In the postoperative period, warfarin can be administered 12 to 24 hours post-surgery provided there are no issues that may increase the risk of bleeding.
Among patients who have undergone a minor procedure and received perioperative bridging therapy, LMWH or UFH may be resumed 6 hours later. This time frame should be extended to 24 hours for high-bleed risk procedures.
Final Thoughts
Effective anticoagulation management is extremely crucial when a patient undergoes invasive procedures to enhance outcomes and reduce risks associated with excessive bleeding or blood clotting.
If you’re looking to learn more about anticoagulation management and other treatments, Hospital Procedure Consultant courses can provide you with the knowledge and skills you need.
Resources:
Wigle, P. Hein, B. Bernheisel, C. Anticoagulation: Updated Guidelines for Outpatient Management. Am Fam Physician. 2019 Oct 1;100(7):426-434
Jaffe, T. Raiff, D. Ho, L. Kim, C. Management of Anticoagulant and Antiplatelet Medications in Adults Undergoing Percutaneous Interventions. AJR Am J Roentgenol. 2015 Aug;205(2):421-8