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Anticoagulation in Cardiovascular Diseases

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Anticoagulation and Hemostasis in Neurosurgery

Abstract

With the increasing prevalence of cardiovascular disease amongst the aging population as well as the expanding indications for the use of oral anticoagulants, physicians are more likely to encounter patients on these medications in the inpatient and outpatient settings. To provide appropriate care for these patients, physicians must understand the pharmacology of the available oral anticoagulants, the clinical indication for anticoagulation, and the appropriate preoperative, perioperative, and postoperative management of these patients. While short-term anticoagulation is often times achieved with the use of intravenous or subcutaneous heparin, chronic anticoagulation is achieved with warfarin or other newer novel anticoagulants (NOAC). Due to the different pharmacologic properties, each of the anticoagulants provides varying challenges and limitations in the clinical setting. Patient with cardiovascular disease have numerous indications for requiring chronic anticoagulant therapy including atrial fibrillation/flutter, prosthetic heart valves, significant heart failure including those requiring mechanical assist devices, and thromboembolic disease. Understanding the clinical indication necessitating the use of oral anticoagulation as well as the specific pharmacology of these agents is essential to providing adequate care to these patients. This chapter provides an in-depth review of the numerous anticoagulant strategies available, the indications for prescribing these therapies, as well as the preoperative, perioperative, and postoperative management of patients on these medications.

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References

  1. Bjork I, Lindahl U. Mechanism of the anticoagulant action of heparin. Mol Cell Biochem. 1982;48(3):161–82.

    Article  CAS  PubMed  Google Scholar 

  2. Hirsh J, Bauer KA, Donati MB, et al. Parenteral anticoagulants: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6):141–59.

    Article  Google Scholar 

  3. Hull RD, Raskob GE, Brant RF, et al. Relation between the time to achieve the lower limit of the APTT therapeutic range and recurrent venous thromboembolism during heparin treatment for deep vein thrombosis. Arch Intern Med. 1997;157:2562–8.

    Article  CAS  PubMed  Google Scholar 

  4. Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:188S–203.

    Article  CAS  PubMed  Google Scholar 

  5. Pirmohamed M. Warfarin: almost 60 years old and still causing problems. Br J Clin Pharmacol. 2006;62(5):509–11.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 Suppl):160S–98.

    Article  CAS  PubMed  Google Scholar 

  7. Freedman MD. Oral anticoagulants: pharmacodynamics, clinical indications and adverse effects. J Clin Pharmacol. 1992;32:196–209.

    Article  CAS  PubMed  Google Scholar 

  8. Makris M, van Veen JJ, McLean R. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010;29:171–81.

    Article  CAS  PubMed  Google Scholar 

  9. Hauel NH, Nar H, Priepke H, et al. Structure-based design of novel potent nonpeptide thrombin inhibitors. J Med Chem. 2002;45:1757–66.

    Article  CAS  PubMed  Google Scholar 

  10. van Ryn J, Stangier J, Haertter S, et al. Dabigatran etexilate—a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost. 2010;103(6):1116–27.

    Article  PubMed  Google Scholar 

  11. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–51.

    Article  CAS  PubMed  Google Scholar 

  12. Eikelboom JW, Connolly SJ, Bruekmann M, et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med. 2013;369(13):1206–14.

    Article  CAS  PubMed  Google Scholar 

  13. Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines (9th edition). Chest. 2012;141:e691S–736.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91.

    Article  CAS  PubMed  Google Scholar 

  15. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981–2.

    Article  CAS  PubMed  Google Scholar 

  16. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–292.

    Article  PubMed  Google Scholar 

  17. Wolf PA, Benjamin EJ, Belanger AJ, et al. Secular trends in the prevalence of atrial fibrillation: the Framingham Study. Am Heart J. 1996;131:790–5.

    Article  CAS  PubMed  Google Scholar 

  18. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):2246–80.

    Article  Google Scholar 

  19. Kannel WB, Wolf PA, Benjamin EJ, et al. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. 1998;82:2N–9.

    Article  CAS  PubMed  Google Scholar 

  20. Wang TJ, Larson MG, Levy D, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation. 2003;107:2920–5.

    Article  PubMed  Google Scholar 

  21. Krahn AD, Manfreda J, Tate RB, et al. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba follow-up study. Am J Med. 1995;98:476–84.

    Article  CAS  PubMed  Google Scholar 

  22. Stewart S, Hart CL, Hole DJ, et al. A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study. Am J Med. 2002;113:359–64.

    Article  PubMed  Google Scholar 

  23. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825–33.

    Article  CAS  PubMed  Google Scholar 

  24. Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002;347:1834–40.

    Article  PubMed  Google Scholar 

  25. Iung B, Vahanian A. Epidemiology of acquired valvular heart disease. Can J Cardiol. 2014;30:962–70.

    Article  PubMed  Google Scholar 

  26. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. 2014;148:e1–132.

    Article  PubMed  Google Scholar 

  27. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease: the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg. 2012;42:S1–44.

    Article  PubMed  Google Scholar 

  28. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–322.

    Article  PubMed  Google Scholar 

  29. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012;126:2020–35.

    Article  PubMed  Google Scholar 

  30. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58(24):e44–122.

    Article  PubMed  Google Scholar 

  31. Vandvik PO, Lincoff AM, Gore JM, et al. Primary and secondary prevention of cardiovascular disease: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest physicians evidence-based clinical practice guidelines. Chest. 2012;141:e637S–68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Nihoyannopoulos P, Smith GC, Maseri A, et al. The natural history of left ventricular thrombus in myocardial infarction: a rationale in support of masterly inactivity. J Am Coll Cardiol. 1989;14:903–11.

    Article  CAS  PubMed  Google Scholar 

  33. Weinreich DJ, Burke JF, Pauletto FJ. Left ventricular mural thrombi complicating acute myocardial infarction. Long-term follow-up with serial echocardiography. Ann Intern Med. 1984;100:789–94.

    Article  CAS  PubMed  Google Scholar 

  34. Stratton JR, Resnick AD. Increased embolic risk in patients with left ventricular thrombi. Circulation. 1987;75:1004–11.

    Article  CAS  PubMed  Google Scholar 

  35. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.

    Article  PubMed  Google Scholar 

  36. Yancy WC, Jessup M, Bozkurt B, et al. Guideline for the management of heart failure. Circulation. 2013;128:e240–327.

    Article  PubMed  Google Scholar 

  37. Dunkman WB, Johnson GR, Carson PE, et al. Incidence of thromboembolic events in congestive heart failure: the V-HeFT VA Cooperative Studies Group. Circulation. 1993;87(6 Suppl):VI94–101.

    CAS  PubMed  Google Scholar 

  38. Dunkman WB. Thromboembolism and antithrombotic therapy in congestive heart failure. J Cardiovasc Risk. 1995;2:107–17.

    Article  CAS  PubMed  Google Scholar 

  39. Katz SD. Left ventricular thrombus and the incidence of thromboembolism in patients with congestive heart failure: can clinical factors identify patients at increased risk? J Cardiovasc Risk. 1995;2:97–102.

    Article  CAS  PubMed  Google Scholar 

  40. Stehlik J, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: twenty-seventh official adult heart transplant report—2010. J Heart Lung Transplant. 2010;29:1089–103.

    Article  PubMed  Google Scholar 

  41. Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013;32(2):157–87.

    Article  PubMed  Google Scholar 

  42. Starling RC, Moazami N, Silvestry SC, et al. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med. 2014;370:1466–7.

    Article  Google Scholar 

  43. Eckman PM, John R. Bleeding and thrombosis in patients with continuous-flow ventricular assist devices. Circulation. 2012;125:3038–47.

    Article  PubMed  Google Scholar 

  44. Tsukui H, Abla A, Teuteberg JJ, et al. Cerebrovascular accidents in patients with a ventricular assist device. J Thorac Cardiovasc Surg. 2007;134:114–23.

    Article  PubMed  Google Scholar 

  45. Kato TS, Schulze PC, Yang J, et al. Pre-operative and post-operative risk factors associated with neurologic complications in patients with advanced heart failure supported by a left ventricular assist device. J Heart Lung Transplant. 2012;31:1–8.

    Article  PubMed  Google Scholar 

  46. Korn-Lubetzki I, Oren A, Asher E, et al. Strokes after cardiac surgery: mostly right hemispheric ischemic with mild residual damage. J Neurol. 2007;254:1708–13.

    Article  CAS  PubMed  Google Scholar 

  47. Kato TS, Ota T, Schulze PC, et al. Asymmetric pattern of cerebrovascular lesions in patients after left ventricular assist device implantation. Stroke. 2012;43:872–4.

    Article  PubMed  Google Scholar 

  48. Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009;361:2241–51.

    Article  CAS  PubMed  Google Scholar 

  49. Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation. 2006;113:1807.

    Article  PubMed  Google Scholar 

  50. Petersen SE, Selvanayagam JB, Wiesmann F, et al. Left ventricular non-compaction: insights from cardiovascular magnetic resonance imaging. J Am Coll Cardiol. 2005;46:101–5.

    Article  PubMed  Google Scholar 

  51. Oechslin EN, Attenhofer Jost CH, Rojas JR, et al. Long-term follow-up of 34 adults with isolated left ventricular noncompaction: a distinct cardiomyopathy with poor prognosis. J Am Coll Cardiol. 2000;36:493–500.

    Article  CAS  PubMed  Google Scholar 

  52. Arbustini E, Weidemann F, Hall JL. Left ventricular noncompaction: a distinct cardiomyopathy or a trait share by different cardiac diseases? J Am Coll Cardiol. 2014;64(17):1840–50.

    Article  PubMed  Google Scholar 

  53. Carrier M, Le Gal G, Wells PS, Rodger MA. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med. 2010;152(9):578–89.

    Article  PubMed  Google Scholar 

  54. Heit JA, Silverstein MD, Mohr DN, et al. Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study. Arch Intern Med. 1999;159(5):445–53.

    Article  CAS  PubMed  Google Scholar 

  55. Kearon C, Akl EA, Comerota AJ, et al. American College of Chest Physicians. Antithrombotic therapy for VTE disease: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e419S–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines (9th edition). Chest. 2012;141:e326S–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Spyropoulos AC, Douketis JD. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood. 2012;120:2954–62.

    Article  CAS  PubMed  Google Scholar 

  58. Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011;123:2736–47.

    Article  PubMed  Google Scholar 

  59. Omran H, Bauersachs R, Rübenacker S, et al. The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national multicentre BNK Online bRiDging REgistRy (BORDER). Thromb Haemost. 2012;108:65–73.

    Article  CAS  PubMed  Google Scholar 

  60. Dzik WS. Reversal of drug-induced anticoagulation: old solutions and new problems. Transfusion. 2012;52 Suppl 1:45S–55.

    Article  CAS  PubMed  Google Scholar 

  61. Schulman S, Elbazi R, Zondag M, O’Donnell M. Clinical factors influencing normalization of prothrombin time after stopping warfarin: a retrospective cohort study. Thromb J. 2008;16:15.

    Article  Google Scholar 

  62. Atwell TD, Smith RL, Hesley GK, et al. Incidence of bleeding after 15,181 percutaneous biopsies and the role of aspirin. Am J Roentgenol. 2010;194:784–9.

    Article  Google Scholar 

  63. Schömig A, Sarafoff N, Seyfarth M. Triple antithrombotic management after stent implantation: when and how? Heart. 2009;95:1280.

    Article  PubMed  Google Scholar 

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Correspondence to Mushabbar A. Syed M.D., F.A.C.C. .

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Memon, S.B., Bakhos, L., Syed, M.A. (2016). Anticoagulation in Cardiovascular Diseases. In: Loftus, C. (eds) Anticoagulation and Hemostasis in Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-319-27327-3_15

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