Perioperative Management of Anticoagulation

Margaret C. Fang, MD, MPH
SUMMARY
Current estimates indicate that 2 to 3 million Americans take anticoagulants for prevention of thromboembolism from venous thromboembolism, atrial fibrillation, or prosthetic heart valves. Invasive procedures are performed in as many as 250 000 patients taking anticoagulants on an annual basis in the United States. Consequently, management of anticoagulants in the perioperative period is a common and vexing challenge for physicians. Because not all patients are at the same risk of thromboembolism and not all procedures are associated with the same risk of bleeding, it is important for hospitalists to know how to weigh these risks in their patients. The purpose of this module is to review risk stratification for thromboembolism and bleeding associated with different thromboembolic disorders and invasive procedures.
 
GOAL
To provide hospitalists with current evidence on recommended management of anticoagulants in the periprocedural period.
 
TARGET AUDIENCE
This activity is designed for hospitalists. 
 
LEARNING OBJECTIVES
After completing the module, the participant should be able to:
 
  1. Assess the risk of venous thromboembolism (VTE) associated with interruption of anticoagulation in patients with a history of VTE, deep venous thrombosis, or pulmonary embolism.
  2. Assess the risk of arterial thromboembolism (ATE) associated with interruption of anticoagulation in patients with atrial fibrillation.
  3. Assess the risk of ATE associated with interruption of anticoagulation in patients with mechanical heart valves.
  4. Formulate a plan for preoperative management of patients taking warfarin that accounts for bleeding and thrombotic risk.
  5. Propose a plan for postoperative management of anticoagulation taking into account bleeding and thrombotic risk.
  6. Develop a perioperative management plan for patients taking a target-specific oral anticoagulant.
CME INFORMATION
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of University of Virginia School of Medicine, ASiM, and the Society of Hospital Medicine. The University of Virginia School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
 
The University of Virginia School of Medicine designates this enduring material, journal-based CME activity, test item writing activity for a maximum of 2.0 AMA PRA Category 1 Credits.TM Physicians should claim only the credit commensurate with the extent of their participation in the activity.   
 
Release date:  November 18, 2015              Expiration date: November 18, 2018
 
Estimated time to complete activity: 2 hours
 
FACULTY & FACULTY DISCLOSURES
Full Disclosure Policy Affecting CME Activities:
The University of Virginia School of Medicine, as an ACCME accredited provider, endorses and strives to comply with the Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, Commonwealth of Virginia statutes, University of Virginia policies and procedures, and associated federal and private regulations and guidelines on the need for disclosure and monitoring of proprietary and financial interests that may affect the scientific integrity and balance of content delivered in continuing medical education activities under our auspices.
 
The University of Virginia School of Medicine requires that all CME activities accredited through this institution be developed independently and be scientifically rigorous, balanced and objective in the presentation/discussion of its content, theories and practices.
 
All faculty presenters participating in an accredited CME activity are expected to disclose relevant financial relationships with commercial entities occurring within the past 12 months (such as grants or research support, employee, consultant, stock holder, member of speakers bureau, etc.). The University of Virginia School of Medicine will employ appropriate mechanisms to resolve potential conflicts of interest to maintain the standards of fair and balanced education to the participant. Questions about specific strategies can be directed to the Office of Continuing Medical Education, University of Virginia School of Medicine, Charlottesville, Virginia.
 
The faculty and staff of the University of Virginia Office of Continuing Medical Education and ASiM have no financial affiliations to disclose.
 
The following relationships have been reported for this activity:
 
Leonard Feldman, MD, FACP, SFHM (Chair)
Associate Professor of Medicine
Johns Hopkins University School of Medicine 
Med-Peds Urban Health Residency Program Director
Associate Program Director, Osler Medical Residency
Director, Comprehensive General Medicine Consult Service
Editor, Consultative, and Perioperative Medicine Essentials for Hospitalists
Baltimore, Maryland
Dr Feldman reports having no significant financial or advisory relationships with corporate organizations related to this activity. 
 
Margaret C. Fang, MD, MPH 
Medical Director, UCSF Anticoagulation Clinic
Associate Professor of Medicine, Division of Hospital Medicine
University of California, San Francisco
San Francisco, CA
Dr Fang reports having no significant financial or advisory relationships with corporate organizations related to this activity.
 
Aditya M. Sharma, MD (Peer Reviewer)
Assistant Professor of Medicine 
Vascular Medicine/Thrombosis
Department of Medicine, Cardiovascular Medicine
University of Virginia
Charlottesville, Virginia
Dr. Sharma reports receving grants/research support from Portola Pharmaceuticals, Inc.
 
Disclosure of Discussion of Non-FDA–Approved Uses for Pharmaceutical Products and/or Medical Devices
The University of Virginia School of Medicine, as an ACCME provider, requires that all faculty presenters identify and disclose any off-label uses for pharmaceutical and medical device products. The University of Virginia School of Medicine recommends that each physician fully review all the available data on new products or procedures prior to clinical use.
 
DISCLAIMER
The opinions and recommendations expressed by faculty and other experts are based on current scientific evidence and standards of care and their professional expertise. This enduring material is produced for educational purposes only.  The University of Virginia School of Medicine implements specific educational planning processes to ensure that content is patient-centric and independent. The University of Virginia School of Medicine recommends that each physician fully review all the available data on new products or procedures prior to clinical use.
 
Click here to download the references for this educational activity.
 
INSTRUCTIONS
The following is an interactive educational module designed to help you gauge your basic knowledge of the topic and then direct you to areas you may need to focus on. It consists of 3 sections: a nondesginated pre-test, a study program, and a CME post-test. All 3 sections must be completed to receive CME credit.
 
Supported by independent educational grants from Boehringer Ingelheim Pharmaceuticals and from Bristol-Myers Squibb Company and Pfizer, Inc.
Course summary
Available credit: 
  • 2.00 AMA PRA Category 1 Credit™
  • 2.00 Equivalent Credit
Course opens: 
11/15/2015
Course expires: 
11/15/2018
Cost:
$0.00
Parent activity set: 
Rating: 
0

Available Credit

  • 2.00 AMA PRA Category 1 Credit™
  • 2.00 Equivalent Credit

Accreditation Period

Course opens: 
11/15/2015
Course expires: 
11/15/2018

Price

Cost:
$0.00
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