Patients diagnosed with atrial fibrillation frequently require oral anticoagulation therapy, usually vitamin K antagonists such as warfarin, which often comes with potential side effects that include hemorrhagic stroke and gastrointestinal bleeding.
Even the target specific oral anticoagulants (TSOAC), developed as the better alternatives to warfarin for treatment of non-valvular atrial fibrillation (NVAF), have their drawbacks, namely bleeding that may put the patients at risk.
All this require strict monitoring and dosage adjustments that may vary for patient to patient, depending on their other health conditions, medications they use, labs, and so on.
Things may become even more complex for providers if their patients with non-valvular atrial fibrillation on anticoagulation therapy require procedures or surgery.
How should providers handle those patients? Should they interrupt the anticoagulation therapy and if so when should they do that? If they interrupt it, when can it be restarted? Should the patients be bridged with heparin?
It's hard to answer all these questions without proper guidance. Fortunately American College of Cardiology develops some awesome mobile apps that help medical professionals provide better care to patients with atrial fibrillation that require anticoagulation therapy.
Previously on Steadyhealth we reviewed two apps made by American College of Cardiology, first being AntiCoagEvaluator, a stroke risk calculator with guidance on antithrombotic therapy, and the second Statin Intolerance app that helps clinicians address statin side effects.
The recent app they developed is called BridgeAnticoag and it provides a necessary guidance to clinicians across specialties on how to manage anticoagulation therapy in patients with non-valvular atrial fibrillation who are to undergo invasive procedure or surgery.
Basically, it assists providers who need to decide if their NVAF patients who are scheduled for procedure or surgery should have their anticoagulation stopped, bridged and restarted.
You will see the warning right after starting the app, just like in AnticoagEvaluator app, that BridgeAnticoag app is for non-valvular atrial fibrillation patients only, and should not be used to guide therapy in patients with mechanical or bioprosthetic valves.
You'd also notice that BridgeAnticoag app also shares same interface with other apps made by American College of Cardiology, which isn't a bad thing because the interface is clean and easy to use. However, at times it was a slower to response on touch, so it something that should be addressed for future updates.
Explaining how the app works is easier if we use a clinical scenario. For example we have 68 year old male with history of hypertension and non-valvular atrial fibrillation who is scheduled for prostate biopsy. The patient is on warfarin, so we'd like to know if we can interrupt the therapy, and if so, when it should be restarted. Also, since the patient is on warfarin we'd like to know if he needs to be bridged.
The BridgeAnticoag app will require you to first choose current anticoagulant, which is warfarin in our case, and then to answer if the patient has any of the characteristics that may indicate bleeding risk, which in this case was No.
Next step would be assessing the anticoagulant interruption which is mainly based on procedural bleed risk. You can enter it manually if you already know the risk level (i.e. low, intermediate, high, etc.), or you can select from the list of procedures sorted in alphabetical order, and let the app decide.
In our case, prostate biopsy has intermediate bleed risk, as classified by American Urological Association, so we got advice to interrupt anticoagulant. Based on patient's INR measurements, we also got advice to discontinue warfarin 5 days before procedure, with suggested INR recheck 24 hours before procedure.
Guidance on bridging was locked to avoid any conflict entries, so we could go straight to advice on when the anticoagulant can be restarted. The app asks several questions about eventual bleeding complications that may have occurred during the procedure, features that indicate increased bleeding risk, if the complete hemostasis was achieved and if there's a plan to administer parenteral agent after the procedure.
Based on the answers provided, the app offered an advice on restarting warfarin within 24 hours in cooperation with the managing team and surgeon/proceduralist.
To get advice on bridging warfarin, the users will be asked to provide patient's CHA2DS2-VASC score, which can be done by either manual entry or using the built-in calculator, as well as information if there was any trombolitic event recently.
Also, the providers need to indicate if the patient is allergic to heparin, and to provide creatinine clearance information (manually or via built-in calculator) and if they plan to administer unfractionated or low molecular weight heparin. In our case we got advice to perform the procedure without bridging.
You can see all the information, including patient profile, as summary which you can also email to yourself.
To reset the results, simply tap on Start Over with New Patient button at the bottom of the screen. Or if you want to see the guidance for other anticoagulant, you can simply tap on Patient tab, unlock it and enter new coagulant.
For example if the patient used apixaban, we'd get different interruption guidance, which was 48 hours prior to procedure instead of 5 days for warfarin, while the re-initiation is advised within 24 hours of procedure based on post-procedural renal function. Also, you won't get any advice about bridging, because it is not indicated for direct oral anticoagulants.
BridgeAnticoag app mentions several resources, and it's mainly based on 2014 ACC/AHA/HRS Atrial Fibrillation Guideline, as well as 2016 Expert Consensus Pathway on Periprocedural Management of Anticoagulation in NVAF Patients.
I can only conclude that any provider who prescribes anticoagulants to their patients, or performs procedures, surgeries, or pre-op clearance should have BridgeAnticoag app installed on their phones.
It is essential tool that uses current guidelines and trials, as well as evidence based information and built-in calculators to help providers manage anticoagulation therapy in non-valvular atrial fibrillation patients who require procedure or surgery.
Benefit: Providers who prescribe anticoagulants to their patients, perform procedures, surgeries, or pre-op clearance would benefit from this app