New Bridging Technique

[allodwick]

Over the last week I have been at meeting of anticoagulation specialists. We had two speakers who debated warfarin bridging. The worst complication for those who are bridged is bleeding. The time of most danger from bleeding is right after the surgery.

#1 said to tailor the bridging to the patient. If you have a low-risk patient (atrial fibrillation) undergoing a procedure with a high risk of bleeding like bowel cancer surgery then it might be best not to bridge. If you have a high-risk of clotting patient (mechanical mitral valve) having a low-risk of bleeding procedure such as arthroscopic surgery then it is probably best to bridge. For all the other classifications like
low risk of clotting person getting low risk of bleeding
high risk of clotting person getting high risk of bleeding
the choice can be made by rolling dice (we were in Las Vegas).

#2 said to bridge everyone but to modify the dosing especially if there is a high risk of bleeding from the procedure.
Procedure - 5 days stop warfarin
Procedure - 4 days start Lovenox 1 mg/kg every 12 hours
Procedure - 3 days same as day 4
Procedure - 2 days same as day 4
Procedure - 1 day give the morning Lovenox but not the evening
Day of Procedure - no anticoagulation
Procedure + 1 day give Lovenox 40 mg X 1 dose & restart warfarin
Procedure + 2 days same as day 1
Procedure + 3 days same as day 1
Procedure + 4 days change Lovenox to 1 mg/kg every 12 hours and continue warfarin. Keep doing this until the INR is in the desired range for two days and then stop Lovenox.

If the person has poor kidney function, the Lovenox would not be raised on procedure + 4 days because of the risk of the Lovenox accumulating in the body and causing bleeding.

They both agreed that Lovenox has not been approved for this use. There have been lots of studies that show that this is opretty safe and effective, but none that were definitive for the FDA to rule that it is a safe and effective procedure. There probably never will be any definitive studies because Lovenox has such a large market share that their only risk is losing that share of the studies turned out poorly. So money will likely not ever be available for the studies.

They also agreed that no study has ever been done with IV heparin drip for people with mechanical heart valves. Therefore, there is no evidence whether it is safe or effective.

[perkicar]

Thanks Al, that is very interesting. I was on a heparin drip for several days after my surgery before my INR was therapeutic. My PTT was pretty darn high, though, seems like it got up to 60 at some point.

[allodwick]

Please everyone remember that I didn't say that heparin drip didn't work. I said that there were no studies showing safety and efficacy.

Heparin drip is also more likely to cause a serious complication called Heparin-Induced Thrombocytopenia (HIT). I have had a patient for a little over a year who went in for a valve replacement and got a heparin drip and developed HIT. She lost her right leg from the knee down and the tip of her tongue to the resulting clots.

[tommy]

Wow, someone actually suggests a 40 mg dose after the procedure! Hallelujah! After my last C-Scope (during my 2 week oozing blood), I tried to get my docs to consider a half-dose (45 mg).

Al, can you possibly get me the name of that speaker and any reference to literature?

Thanks so much.

[allodwick]

There was a lot of discussion so I'm not sure who actually said it. However, here is a link to an article by one of the speakers, Amer Jaffer. He is at Cleveland Clinic and was voted one of the best doctors in America.

[tommy]

Thanks, Al. Was there a link?

[allodwick]

Pub Med doesn't do links. But his e-mail address was there wasn't it?

[tommy]

A google for Amir Jaffer turned up his page at the Cleveland Clinic.
http://http://www.clevelandclinic.org/staff/getstaff.asp?StaffId=2386

Haven't found an email address, but did find a phone number.

[allodwick]

Sorry, I didn't proofread -- I forgot to put the link to the article in. Here it is
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16133889&query_hl=1

Dr. Jaffer's email address is with that article
jaffera@ccf.org

[lance]

Hello Al,

During recent surgery in Ontario my bridging procedure was the same as #2.

Happy to say I did not experience any problems whatsovever.

What a great relief.

By the way, normally I do not follow any sports on TV except equestrian.

On CNN I happened to glance at the TV screen and saw "Lodwick"--to do with golf. By the time I saw it moving across the bottom of the screen most of the info had disappeared to the left.

Because it was Lodwick, and golf, I wondered if it was you son.

[allodwick]

It may have been my son. He is a club head pro and not a tournament player. Fox Sports did a show about the best 18 public holes in Denver. One of the holes at his course was featured and he was interviewed. This is the first that I have heard about it being shown outside the US.

[Sierra Bob]

Al: I guess I'm a dunce!! I don't understand the Lovenox dosage after the procedure: "Procedure + 1 day give Lovenox 40mg X 1 dose...." You can't mean 40 mg of Lovenox and 1 dose of what? Please explain. Sierra Bob

[RCB]

I said that there were no studies showing safety and efficacy.



People would be surprised to know that common medical procedures
exist, although there has never been a study to support it’s efficacy or that
some of the studies that we done have since been proven false. Circumcision
is the best example. The American Pediatric Association had the be embarrassed by The American Cancer Society in to admitting the procedure is not medically necessary.:( All those babies..OUCH!:eek:

[allodwick]

One day after surgery give Lovenox 40 mg only one time is what some are recommending now to cut down on the risk of bleeding but still have some anticoagulation coverage. The warfarin is restarted this day also.

[Sierra Bob]

Regardless of your weight?

[allodwick]

Regardless of your weight!