Heparin drip for afib? confused

[nope80]

What are the indications for heparin drip in afib? I'm totally confused about heparin drip vs therapeutic subq heparin and the indications for either one in the context of afib? Help, anyone. Thanks!

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[littlealex]

It's essentially based off of the CHADS2VASC indications for anticoag. For AFib you want them on Heparin but acutely you start Heparin to bridge until Warfarin is therapeutic.

More frequently you start Heparin acutely to anticoag for new onset AFib w/ hopes of chasing it w/ a TEE -> DCCV if there are no clots. They still need to be on Warfarin but you try to keep clots from forming while you schedule for possible cardioversion.

 

[jdh71]

It's essentially based off of the CHADS2VASC indications for anticoag. For AFib you want them on Heparin but acutely you start Heparin to bridge until Warfarin is therapeutic.

More frequently you start Heparin acutely to anticoag for new onset AFib w/ hopes of chasing it w/ a TEE -> DCCV if there are no clots. They still need to be on Warfarin but you try to keep clots from forming while you schedule for possible cardioversion.

this doesn't answer his question

 

[littlealex]

this doesn't answer his question

this doesn't answer his question either, at least I tried. You're just being an ahole.

-----------------
Go here:
http://en.wikipedia.org/wiki/CHADS2_score

 

[jdh71]

this doesn't answer his question either, at least I tried. You're just being an ahole.

-----------------
Go here:
http://en.wikipedia.org/wiki/CHADS2_score

You didn't just link to wikipedia did you, doctor?

 

[jdh71]

What are the indications for heparin drip in afib? I'm totally confused about heparin drip vs therapeutic subq heparin and the indications for either one in the context of afib? Help, anyone. Thanks!

I don't think I ever saw therapeutic subQ heparin used for the treatment of acute afib, and looking through the cardio literature for the last few guidelines about afib don't seem to take a stand on drip versus subQ, other than to say that afibbers need anticogualtion of some kind, those with multiple risk factors as mentioned before (and by now you should know these if you're in any IM program worth a ****) then you will need oral anticoagulation and you will use the heparin to prevent clot or further clot propagation until the orals are where you want them. The decision about wether to use a drip or not is probably more attending style than anything else, though I sure you could find something comparing the two somewhere if you'd simply do a search. Personally, I prefer a drip because it's more easily titratable, but even more than that I simply prefer the subQ low-molecular weight heparins. YMMV. Someday you'll be an attending and you'll get to decide which way you want to do it - maybe by then someone, somewhere, in some guideline will tell you what to do.

 

[turkeyjerky]

Do afibbers really need anti coagulation during the short term in house? Stroke is a long term risk not a short term one. Is there any data or even recommendations out there on this? I'm asking b/c I don't know the answer, but that it seems like sticking someone on a heparin gtt just cause they're gonna be in the hospital a couple of days is a little excessive.

 

[jdh71]

Do afibbers really need anti coagulation during the short term in house? Stroke is a long term risk not a short term one. Is there any data or even recommendations out there on this? I'm asking b/c I don't know the answer, but that it seems like sticking someone on a heparin gtt just cause they're gonna be in the hospital a couple of days is a little excessive.

No. You can hold the coumadin for a week in patient with afib by consensus statement in 2006. Though most people do continue the anticoagulation while in the hospital. You almost certainly do NOT need to start a heparin gtts for afib that starts in the hospital, especially if you echo them and don't see any evidence for clot, but this has become practice in many places.

 

[brc12]

Atrial fibrillation generally does not require bridging therapy with heparin. The only time I bridge patients with afib are those already on coumadin who've had a prior stroke and need to be off coumadin for some reason. Acute strokes don't need bridging therapy. You would often see patients in afib in the office; you wouldn't send them to the hospital for a heparin drip would you? management of anticoagulation for cardioversion is a separate category.
SQ heparin has no role in afib.

 

[temmie]

I am assuming that what you mean by SQ heparin are the LMWH like lovenox. There is no recommendation for drip heparin vs the LMWH. As mentioned above,drip is preferred if high risk of bleeding, might get a procedure that needs anti-coag interrupted etc

Otherwise, if they have normal/ close to normal renal function, i use lovenox. No need chasing the q 6hrs PTT and it is not inferior. Cardiologists like heparin but i think it is because they are attendings and have no idea how painful it can be to chase nurses around for your q 6 labs, especially if you spend any time at County hospita painful

The better question has already been answered, which is. Do u need to bridge to coumadin in afib. Answer is no, there is no recommendations for that. Unless of course, you know u already have a clot waiting to blow, sittng in you atrium.

GL

 

[Instatewaiter]

As said previously, A-fib does not need to be anticoagulated. If you were to calculate your perday stroke risk from the Chads score, it is so small it really doesn't require a heparin drip. Despite this, some attendings will want it.

There are 2 reasons to anticoagulate AF. First, when you admit new onset (<48h) AF they should be anticoagulated with heparin to prevent atrial thrombus so that you can give them a chance at cardioversion. You start the heparin immediately b/c it will limit the risk the fibrillating atrium will form a clot. That way, when they go for TEE cardioversion there isn't a clot and they can be shocked out of fib.

The other reason to anticoagulate is if they are going to go for ablation. If you cannot succesfully cardiovert and your EP won't do an ablation, there really isnt a need to bridge to coumadin (unless your attending really wants it).

If they get cardioverted and go back into sinus, they need to be bridged b/c the risk of atrial clot after cardioversion is higher than being in a-fib for ~4 weeks after the procedure.

Now with dabigitran, no need to bridge.

 

[TheLesPaul]

I thought the heparin bridge's purpose was mainly to do with the warfarin --| protein C and preventing skin necrosis, not necessarily anything to do with the actual indication for the anticoagulation itself. Why wouldn't you need to bridge to coumadin for afib? Are they less likely to develop skin necrosis?

 

[Hamhock]

About two years ago I had a long discussion with a medicine resident (I am trained in emergency medicine) regarding the need to start a heparin drip in the ED for a patient with long-standing Afib (was not going to be cardioverted out of it; no one was going to try ablation) and with an INR of 1.7. The patient was being admitted for an unrelated problem.

We sat down and calculated the chance of a stroke for the next few days and we stopped when the number of zeros after the decimal point required the next line on the ruled paper.

Brand new-onset Afib? I will certainly start the drip in the ED, especially if it is a young person...hell, I may even consider cardioverting in the ED if I am certain of time of onset (very rare, sorry Sir Ian).

But what about starting the long-standing Afib'er who is off coumadin for months (frequent non-compliance at county shops) back on coumadin, as is often requested by PCPs. Doesn't this increase the coagulation in the short term (protein C/S balance with 2,7.9,10)? I realize even some increased coagulation take miniscule chance to only small chance, but it seems a bit concerning.

To put it in terms of hospitalists: would you start warfarin in house or upon discharge in a long-standing Afib'er off warfarin for months without any bridge? If you are the PCP, would you expect the ED doc or hospitalist to do so?

HH

 

[jdh71]

But what about starting the long-standing Afib'er who is off coumadin for months (frequent non-compliance at county shops) back on coumadin, as is often requested by PCPs. Doesn't this increase the coagulation in the short term (protein C/S balance with 2,7.9,10)? I realize even some increased coagulation take miniscule chance to only small chance, but it seems a bit concerning.

To put it in terms of hospitalists: would you start warfarin in house or upon discharge in a long-standing Afib'er off warfarin for months without any bridge? If you are the PCP, would you expect the ED doc or hospitalist to do so?

HH

If someone is admitted (for whatever reason), I think just about every internist would start the coumadin, assuming patient was admitted for a non-bleedy reason.

I'd expect a hospitalist to d/c a chronic afib patient on coumadin with appropriate INR f/u (again assuming non-bleedy). I don't know that I'd "expect" the ED doc to do the same, but it would be nice.

EDIT: I should say, though, that I don't deal with many afibbers as a primary issue any longer, but the situation is a bit similar with the VTE's that many docs want us to follow. Sometimes I'll get a page from the ED asking me about a patient who's supposed to be on coumadin because of PE's, but is off. I tell them to start them back up, unless they or I have some other bleedy reason not to. I do expect hospitalists in this situation to d/c these patients home on their coumadin.

 

[LoudBark]

If someone is admitted (for whatever reason), I think just about every internist would start the coumadin, assuming patient was admitted for a non-bleedy reason.

I'd expect a hospitalist to d/c a chronic afib patient on coumadin with appropriate INR f/u (again assuming non-bleedy). I don't know that I'd "expect" the ED doc to do the same, but it would be nice.

EDIT: I should say, though, that I don't deal with many afibbers as a primary issue any longer, but the situation is a bit similar with the VTE's that many docs want us to follow. Sometimes I'll get a page from the ED asking me about a patient who's supposed to be on coumadin because of PE's, but is off. I tell them to start them back up, unless they or I have some other bleedy reason not to. I do expect hospitalists in this situation to d/c these patients home on their coumadin.

Patients do NOT need to have a heparin bridge (either IV or SQ) if they are found to be in a-fib (either found as an inpatient or an outpatient). The one and ONLY very RARE exception to this is if an echo is done and a thrombus is seen sitting in the right atrium, then you overlap and bridge the two. This is not common however. The most common scenario is the patient who just happens to be found in a-fib. The risk of a CVA or TIA is extremely low in the time of starting the coumadin and achieving the therapeutic INR. Remember that everything we do in medicine is a risk vs. benefit thing and a heparin drip or even SQ heparin doesn't come with out risks. So......the risk of an embolic even in the 4-5 days it may take to get a therapeutic INR does not outweigh a potentially life threatening bleed from giving heparin (how common is it on a heparin drip for the nurse to overshoot and end up with a PTT of 130? well much more common than someone throwing an embolus for a CVA / TIA).

Even if a patient presents to the hospital with a TIA / CVA and is in a-fib, heparin is not started right away (neither is coumadin), as the risk of hemorrhagic conversion is too high. The coumadin can be started days later if the patient remains stable still without a bridge of heparin.

Patients are commonly started on coumadin in the hospital but do not need to stay in the hospital to achieve a therapeutic INR. If they have reliable follow up they can and are discharged with a subtherapeutic INR and told to follow up with PCP or coumadin clinic in a few days for monitoring. (This is ONLY the rule for a-fib. PE / DVT is a different animal and are always overlapped with heparin and sent home with therapeutic INR).

Of course the risk vs. benefit thing comes up again and if a patient is non-compliant or doesn't have PCP follow up for INR checks......then don't use coumadin because again the risk of a bleed is greater than the risk of a CVA / TIA for a non-compliant patient.

The above of course is only valid if you have first calculated your CHADS2 risk and decided the patient even has enough risks to be put on coumadin in the first place.

 

[jdh71]

Patients do NOT need to have a heparin bridge (either IV or SQ) if they are found to be in a-fib (either found as an inpatient or an outpatient).

Where did I say differently??

 

[TheLesPaul]

You didn't, I did. I still don't think my question has been answered though -- doesn't the initial protein C/S balance vs the clotting factors make starting warfarin initially a procoagulant necessitating the use of a heparin bridge for prevention of skin necrosis, regardless of the actual indication for the anticoagulation?

 

[jdh71]

You didn't, I did. I still don't think my question has been answered though -- doesn't the initial protein C/S balance vs the clotting factors make starting warfarin initially a procoagulant necessitating the use of a heparin bridge for prevention of skin necrosis, regardless of the actual indication for the anticoagulation?

skin necrosis is an unusual complication

recommendations do not recommend a bridge per routine

 

[gutonc]

skin necrosis is an unusual complication

recommendations do not recommend a bridge per routine

This. It's such a rare complication that I imagine the NNH for not bridging approaches the number of people currently hospitalized in the US (NB: I pulled that number out of my butt for rhetorical purposes).

Plenty of good reasons to bridge...fear of warfarin skin necrosis isn't generally one of them. That said, I will guarantee you that every attending who has ever seen a case that they caused will make it their personal practice to bridge from then on and will teach it as gospel to their trainees.

 

[jdh71]

This. It's such a rare complication that I imagine the NNH for not bridging approaches the number of people currently hospitalized in the US (NB: I pulled that number out of my butt for rhetorical purposes).

Plenty of good reasons to bridge...fear of warfarin skin necrosis isn't generally one of them. That said, I will guarantee you that every attending who has ever seen a case that they caused will make it their personal practice to bridge from then on and will teach it as gospel to their trainees.

I rounded with this guy, more than once, on the cardio service in residency. And of course insurance would never pay for the out-patient lovenox, so we always spent days with a couple extra patients on our lists that didn't need to be there watching the INR creep. Ugh.

 

[Trifling Jester]

I agree with most of what has been stated above. No real benefit as far as I know with heparin gtt vs lovenox SQ for atrial fibrillation. No need for it as a bridge to coumadin in the absence of clot, but attendings may do so anyway as a matter of personal preference, or in anticipation of possible cardioversion or ablation. Since we're all at different levels here I also just want to point out that this discussion pertains to non-valvular atrial fibrillation.

-The Trifling Jester