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Health See other Health Articles Title: Anticoagulation Interruption and the New ACC/AHA Guidelines on AF Medscape... Cataract Surgery and Colonoscopy Samuel Z. Goldhaber, MD: Hello. This is Dr. Sam Goldhaber for the ClotBlog at theheart.org on Medscape speaking to you from the American College of Cardiology Scientific Symposium in Washington, DC. Today, I have a special guest and a special friend, Dr. Seth Bilazarian. Seth, welcome to the ClotBlog. Today I wanted to discuss with you a problem that you and I get calls and emails about over and over again, and that is how to safely interrupt anticoagulation. There are several different levels that we can quickly talk about, including cataract surgery and colonoscopy, but then we can go into the more nitty gritty area of what do we do with patients who have mechanical heart valves. Let's start with cataract surgery. Do you ever instruct your patients to interrupt their anticoagulation? Seth Bilazarian, MD: It's a great question. I think that I agree with you. It is a real problem. It is a frequent problem. I would say that my practice gets questions about interruption about 3 or 5 times a week, and I would expand it to not just anticoagulation but also antiplatelet therapy. Both are similar in terms of safely balancing the risk of interruption vs collaborating with the proceduralist in terms of making it safe to do the procedure that's planned. The cataract surgery scenario is an interesting one. In my experience, most cataract surgeons don't even ask anymore, but in my community one cataract surgeon was repeatedly asking and I had to make the extra effort to reach out to the surgeon and say, "Is this really necessary? Do you understand that the interruption has a hazard that we can estimate based on the patient's CHADS2 score? Please do not interrupt." This cataract surgeon was very pleasant and said that's not a problem, but it required a little bit of education and my reaching out proactively with my patient to make a change in the behavior of a proceduralist. Dr. Goldhaber: Plus, there are no blood vessels in the cataract. Dr. Bilazarian: Right. On one hand it's easy, but it highlights for our audience that sometimes we have to actually advocate for our patients in terms of this interruption period. Dr. Goldhaber: I guess dental procedures are also a very common issue where we have to work with the oral surgeon. How do you handle those? Dr. Bilazarian: Similarly. In most cases, we're talking about surgeries with a low risk for bleeding, but then of course it would have to be added to what is the level of risk of the patient's interruption. The patient with a higher CHADS2 score might be a case where I really advocate with the oral surgeon that we consider either a very brief interruption or no interruption at all. How about yourself? Dr. Goldhaber: I usually try for no interruption or just getting the international normalized ratio (INR; if it's warfarin) below 2.0 depending on how elaborate the surgery is going to be in the oral cavity. Dr. Bilazarian: How comfortable are the surgeons you deal with in reinitiating warfarin the night before surgery as a strategy to limit the time of interruption on the other end of the surgery? Is that something that you have implemented in your own practice? Dr. Goldhaber: I don't think reinitiation of anticoagulation the night before surgery is something that my surgeons feel at all comfortable with. Generally, I don't try to go down that route. Dr. Bilazarian: Okay. Dr. Goldhaber: I think the most common issue we have to deal with is colonoscopy because our patients over 50 are going to undergo colonoscopy. Dr. Bilazarian: At least they should. Dr. Goldhaber: They should at least once every 10 years. Then if they have even an adenoma, they're going to be screened once every 3 years. If they have a family history, it's once every 5 years or so. Volume-wise, I get a lot of calls about colonoscopy. How do you handle that? Dr. Bilazarian: You and I have covered this in the past, and you helped educate me to persuade colonoscopists to take patients on without stopping anticoagulation in the patient with a higher CHADS2 score. But, in general, we have interrupted. We could try to convince medical subspecialists like our gastroenterology colleagues to start the warfarin the night before to shorten the period of interruption. That is something that I have thought about; but, like you, I have not yet taken it on. I haven't taken that fight to the gastroenterologist, but it seems like it would be a strategy that would be valuable in reducing the interruption period. Dr. Goldhaber: Of course, if we use novel oral anticoagulants (NOACs), we don't have to go down that route either. Dr. Bilazarian: Exactly. Dr. Goldhaber: As we increase our use of the NOACs, that won't be as much of a problem. Generally with NOACs, we wouldn't have to interrupt more than 2 days, but with warfarin it's 4 to at most 5 days of anticoagulation. 1 of 3 Post Comment Private Reply Ignore Thread
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