Anticoagulation Cases Q & A

Combining IVC filter and Coumadin

Q:
75 yo AAF with a PMH of DVT and PE, was treated with Coumadin, and had a GI bleeding due to diverticulosis. After that, Coumadin was stopped and an IVC filter was placed one year ago. Now she is admitted with a new DVT. Should you restart oral anticoagulation?

A:
Yes. After evaluating the bleeding risk for this particular patient, oral anticoagulation is likely to provide additional benefits to the IVC filter al. Two years after placement, IVC filters do not decrease the PE risk, and actually increase the risk for new DVT. Coumadin use is recommended in these patients with IVC filters, although there are no RCTs to support it. The level of evidence is experts' opinion.

Source:
Inferior vena caval filters - UpToDate (paid subscription required)
Venous Thromboembolism Therapy - Cleveland Clinic MedEd.com


Anticoagulation before and after an invasive procedure

Q:
48 yo CF, a smoker with recurrent DVTs is anticoagulated with heparin IV drip during hospital stay. She has a lung nodule on CXR and a bronchoscopy is recommended. How may hours before the procedure you should stop the heparin, and when should you restart it?

A:
For surgeries, heparin should be stopped 6 hours before, and restarted 12 hours after the surgery (if there is no evidence for bleeding).

For procedures, this time can probably be shortened to stopping heparin 2-4 hrs before the procedure, and restarting it 2-6 hrs post procedure. For all patients, Coumadin can be restarted at the normal dose on the night of the procedure.

Source:
Management of anticoagulation before and after elective surgery - UpToDate
Colonoscopy - American Society of Colon and Rectal Surgeons
Oral rivaroxaban is non-inferior to standard therapy for symptomatic pulmonary embolism (PE) and DVT (NEJM, 2012).
Image source: Wikipedia

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