Many of the patients diagnosed with atrial fibrillation, particularly those older than 65 years with risk factors, require oral anticoagulation therapy. Patients with other conditions, such as venous thromboembolism, also require regular treatment that includes anticoagulants.
Vitamin K antagonists are usually the first choice of treatment, particularly warfarin, which comes with potential side effects that include hemorrhagic stroke and gastrointestinal bleeding.
However, even the alternatives to warfarin, i.e. target-specific oral anticoagulants (TSOAC) used for the treatment of non-valvular atrial fibrillation (NVAF), also have the bleeding risk.
This is why anticoagulant drugs require strict monitoring and dosage adjustments that usually vary from patient to patient, depending on their health conditions, medications they use, age, etc.
Things become even more complex in the periprocedural period, i.e. before the surgery and other invasive medical interventions.
Surgery and invasive medical interventions increase the risk of bleeding for the patient if anticoagulants are taken too close to the scheduled procedure. However, withholding anticoagulants increases the risk of thrombosis due to the patient's condition for which anticoagulants were originally prescribed.
This often leads to postponement of surgical procedures, which also poses a financial burden to hospitals.
It's important that clinical team weigh all these risks before making informed decisions whether to interrupt oral anticoagulants for a medical procedure or not.
Also, if they decided to interrupt the anticoagulation (warfarin), they also need to decide whether to "bridge" it with intravenous anticoagulants, such as low molecular weight heparin (LMWH).
Mobile apps can help clinicians make informed decisions regarding this complex matter, providing them with evidence-based reference and clinical calculators.
We already reviewed BridgeAnticoag app that helps clinicians manage anticoagulants for patients with non-valvular atrial fibrillation (NVAF) who are scheduled for an invasive procedure, and decide whether they should bridge oral with IV anticoagulants around the procedure.
MAPPP app that we review today is another popular resource for medical providers who care for patients on oral anticoagulation therapy, including vitamin K antagonists (warfarin), TSOAC, and/or antiplatelets.
The goal of the app is to help clinicians determine if and when their patients should stop taking anticoagulants prior to surgery and other medical procedures, when the anticoagulation can be restarted, and should the patient be bridged with heparin.
Unlike BridgeAnticoag app, MAPPP (which stands for Management of Anticoagulation in the Peri-Procedural Period ) app does not just apply to patients with non-valvular atrial fibrillation (NVAF), but any patient on anticoagulant therapy for any reason.
MAPPP app is based on the guide that was created in 2014 by the members of the Peri-Procedural Task Force of the New York State Anticoagulation Coalition and IPRO, the Medicare Quality Improvement Organization for New York State.
Meanwhile, the guide was updated in 2016 and ever since it's been aimed to assist clinicians in the simultaneous evaluation of bleeding risk and underlying risk of thrombosis prior to medical procedures.
MAPPP mobile app uses the guide to support clinical decisions regarding the interruption of anticoagulation and the use of anticoagulant 'bridging', provide detailed guidance for drug dosing and laboratory monitoring prior to the procedure, and encourage communication between clinicians involved in prescribing anticoagulants and performing medical procedures.
There's another difference between MAPPP and BridgeAnticoag app. While the latter provides clinical calculators that users can utilize to determine the risks and benefits of interrupting and bridging anticoagulation, MAPPP app serves more as a clinical reference, as you could see upon opening the app.
There is a list of commonly used antithrombotic drugs, such as warfarin and apixaban, as well as antiplatelet agents.
Upon choosing the anticoagulation drug, users also need to choose bleeding risk from high to minimal, as well as thromboembolic risk. The app doesn't need risk parameters for antiplatelet agents.
Everything is already calculated, and based on the choices made regarding drug and possible risks, the app provides recommended actions, i.e. whether anticoagulant should be interrupted and if the bridging with LMWH is necessary.
MAPPP app provides tables with interruption, bridging and restarting suggestions for each anticoagulant drug from 10 days before the procedure to 10 days after the procedure for warfarin, or based on creatinine clearance for other anticoagulant drugs.
As you may see, users cannot use the app to calculate the values or to adjust them, like in BridgeAnticoag app that allows clinicians to calculate CHA2DS2-VASC score or creatinine clearance.
Also, MAPPP app doesn't provide risk levels based on the type of the procedure, like ACC's app does.
MAPPP is only a reference that clinicians should use only if they know calculated values, or in conjunction with other clinical calculator apps that would help them get the scores.
Keep in mind that MAPPP also generates recommendations that may be different than those from ACC (BridgeAnticoag app). This may be explained because the latter app focuses on patients with non-valvular atrial fibrillation, while MAPPP provides recommendations for other patients on anticoagulation as well.
Nevertheless, MAPPP app is an excellent evidence-based resource for periprocedural management of anticoagulation, whether used alone or along with other apps.
Benefit: Providers who prescribe or manage patients on anticoagulation, perform procedures, and pre-op clearance would benefit from this app