Optimization of the periinterventional management of patients under oral anticoagulation & antiplatelet therapy
For oral long-term anticoagulation, Vitamin K Antagonists (Phenprocoumon), Direct Oral Anticoagulants (Dabigatran, Rivaroxaban, Apixaban, Edoxaban) and Antiplatelet Drugs (Acetylsalicylic acid, Clopidogrel, Prasugrel, Ticagrelor) are available either alone or in combination with each other. The current main indication is chronic atrial fibrillation. Further indications are: oral anticoagulation of patients after mechanical heart valve replacements, status post stroke, status post myocardial infarction, peripheral artery disease, stent implantation and treatment and secondary prevention of venous thromboembolism.
Every oral anticoagulant has inhibitory effects on the coagulation cascade. They affect partly different clotting factors and have different pharmacological and pharmacokinetic characteristics (adsorption, biological availability, metabolism, elimination, half-life). In case of tissue injury, the cascade cannot work properly under active anticoagulation, which results in life-threatening bleedings.
Antiplatelet drugs, on the contrary, directly affect platelets and prevent the formation of blood clots. The manifestation of platelet inhibition within this substance group is very diverse, which is why agents must be broken off at a different time. All in all, great caution is demanded.
Each year, more than 10% of all patients under active anticoagulation need an intervention. Periinterventional risks of thromboembolism and bleeding must be matched in order to make an individual decision which implies a great challenge. Questions to be answered are whether to continue the medication, when to break off or begin with the “bridge-therapy” with a short-acting non-oral anticoagulant. Multimorbidity is also an important factor to be considered.
Various (inter-) national guidelines concerning periinterventional management of anticoagulants have been published up to now. However, most of them are focused on certain subgroups of anticoagulants, patient populations or surgical procedures. On paper, these enormous text passages including detailed charts and highly complex algorithms meet the requirements for an individual risk assessment of thromboembolic and bleeding. Nevertheless, a guideline-based management of anticoagulation is rarely implemented in daily clinical practice due to its complexity. This leads to a high rate of undesirable and often evitable side effects. Not to mention the fact that patients are confronted with different statements by different divisions (general practitioner, surgeon, anesthetist, pharmacist) concerning the management of their anticoagulants prior to the intervention. This is not only confusing but also very dangerous for patients.
Aim of the study
PERI-KOAG, a new standard of treatment, representatively optimizes the periinterventional management of anticoagulation. The goal is to minimize the risk of thromboembolism and bleeding on the one hand and to improve drug and patient safety, quality of care and interdisciplinary communication between particular interfaces on the other hand.
The core of the PERI-KOAG project is a digital application which supports every individual therapeutic approach as an electronic clinical-decision-support-system. The tool calculates individual risk scores (CHA₂DS₂-VASc Score for thromboembolics & HAS-BLED Score for bleedings) for each patient on the basis of the given medical patient data. Furthermore, it evaluates the bleeding risk of the planned surgical intervention. Based on the PERI-KOAG standard, a specific treatment plan is proposed.
Prof. Dr. Patrick Meybohm, Lisa-Marie Buchner, Eun Ji Park, Christoph Füllenbach