What is the treatment for conditions requiring anticoagulation?

Anticoagulation Management for Various Conditions Requiring Anticoagulation

For patients requiring anticoagulation therapy, direct oral anticoagulants (DOACs) are the first-line treatment for most conditions including venous thromboembolism and non-valvular atrial fibrillation, while vitamin K antagonists remain the standard for mechanical heart valves and valvular atrial fibrillation. 1

Venous Thromboembolism (VTE) Management

Acute VTE Treatment

• Initial therapy:
  • DOACs (apixaban, rivaroxaban, edoxaban) are preferred first-line agents for most patients 1, 2
  • For patients with active cancer, low-molecular-weight heparin (LMWH) remains first-line, though growing evidence supports DOACs in this population 1
  • For hemodynamically unstable PE patients, systemic thrombolysis is recommended 3, 2

Duration of Therapy

• Standard recommendations based on etiology: 3
  • Surgery-provoked VTE: 3 months
  • Non-surgical transient risk factor: 3 months
  • Unprovoked VTE: Indefinite if low/moderate bleeding risk; 3 months if high bleeding risk
  • Recurrent unprovoked VTE: Indefinite if low/moderate bleeding risk; 3 months if high bleeding risk
  • Active cancer-associated VTE: Indefinite therapy

Atrial Fibrillation Management

Non-valvular Atrial Fibrillation

• DOACs are preferred over vitamin K antagonists 1
• For patients with contraindication to oral anticoagulation, WATCHMAN device may be considered 4
  • Post-WATCHMAN anticoagulation protocol:
    • Warfarin and aspirin for 45 days
    • If TEE shows minimal residual flow and no device thrombus, transition to dual antiplatelet therapy (aspirin + clopidogrel) for 6 months
    • Then aspirin indefinitely

Valvular Atrial Fibrillation

• Vitamin K antagonists (e.g., warfarin) remain the standard of care 1

Acute Coronary Syndrome (ACS) Management

Anticoagulation in ACS

• Parenteral anticoagulation is recommended for all ACS patients regardless of treatment strategy 3
• Options include:
  • Unfractionated heparin (UFH)
  • Bivalirudin (particularly useful in STEMI patients undergoing PCI to reduce mortality and bleeding) 3
  • Enoxaparin (may be considered as alternative to UFH) 3
  • Important: Fondaparinux should NOT be used to support PCI due to risk of catheter thrombosis 3

Dual Antiplatelet Therapy (DAPT) After ACS

• Standard duration: 12 months after ACS 5
• For high bleeding risk patients (PRECISE-DAPT ≥25): Consider stopping DAPT after 6 months 5
• For high ischemic risk and low bleeding risk: Consider extended DAPT beyond 12 months 5

Special Circumstances

Right Atrial Thrombosis

• Anticoagulation alone is recommended over no anticoagulation 3
• Thrombolysis or surgical thrombectomy is generally not recommended unless there are specific hemodynamic concerns 3

Renal Vein Thrombosis in Neonates

• Anticoagulation is suggested over no anticoagulation 3
• Thrombolysis should be avoided unless the condition is life-threatening (e.g., bilateral thrombosis) 3

Extrahepatic Portal Vein Obstruction

• Permanent anticoagulation is indicated for patients with underlying myeloproliferative neoplasms 3
• Consider anticoagulation for patients with strong prothrombotic conditions or history suggesting intestinal ischemia 3

Perioperative Management

Urological Procedures

• Low bleeding risk procedures that can be performed while continuing aspirin: 3

  • Ureteroscopy
  • Transrectal prostate biopsies
  • Laser prostate procedures
  • Percutaneous renal biopsy

• For patients requiring dual antiplatelet therapy:

  • No elective procedures requiring DAPT interruption should be performed with recent stent placement 3

General Perioperative Recommendations

• For ticagrelor: Discontinue 3-5 days before elective surgery 5
• For prasugrel: Discontinue ≥7 days before surgery 5
• Resume antiplatelet therapy with loading dose within 24 hours after surgery if hemostasis is adequate 5

Bleeding Risk Management

• Perform bleeding risk assessment at each visit using validated tools like HAS-BLED 1
• For major bleeding on vitamin K antagonists: Administer vitamin K and 4-factor prothrombin complex concentrate 1
• For major bleeding on DOACs:
  • Dabigatran: Idarucizumab is effective for reversal 1
  • Rivaroxaban/apixaban: Andexanet alfa is effective for reversal 1
• Avoid concomitant medications that increase bleeding risk when possible 6
• Consider proton pump inhibitors to reduce gastrointestinal bleeding risk 5

Common Pitfalls and Caveats

1. Renal function monitoring: Regularly assess renal function in patients on DOACs, as dose adjustments may be necessary with declining function 6

2. Drug interactions: Be aware of potential interactions, particularly with P-gp and CYP3A4 inhibitors which can increase bleeding risk with DOACs 6

3. Premature discontinuation: Stopping anticoagulation or DAPT prematurely significantly increases risk of thrombotic events 5

4. Neuraxial anesthesia: Special timing considerations are needed when performing spinal/epidural procedures in anticoagulated patients to prevent epidural hematoma 6

5. Bridging therapy: For patients at very high thrombotic risk requiring antiplatelet interruption, consider bridging with intravenous agents 5

6. Fondaparinux contraindication: Never use fondaparinux to support PCI due to risk of catheter thrombosis 3