Heme/Onc

80 yo lady presents with a hematoma after a fall

Mary Guan on Jan 22, 2019 - University of Michigan

Cardiology ultimately recommends initiating anticoagulation as soon as possible once hemostasis is achieved and she is safe from a surgical standpoint, as her risk of thrombotic/embolic activity is high with a mechanical mitral valve and atrial fibrillation.

Ms. Brown experienced a trauma-associated bleed while on coumadin. The risk of her rebleeding when on anticoagulation is lower than a patient who spontaneously bled. Even in patients with a GI bleed or a subdural hematoma while on anticoagulation, studies have shown that there is a benefit to re-starting anticoagulation due to a statistically significant lower risk of clot. 

Ms. Brown continues to improve, with her hemoglobin gradually stabilizing in the 10-11 range without requiring addtional blood transfusions. 

How would you reinitiate anticoagulation now?

Expand all answers
Start her on lovenox and bridge to warfarin once she achieves hemostasis for 24-48 hours
This is a reasonable approach. However, since she developed the hematoma while on a Lovenox bridge to warfarin, there is a better choice available that avoids LMWH. Additionally, her weight of 53kg puts her at the lower end of the reliable therapeutic range (patients weighing <45kg were not included in clinical trials for Lovenox).


Start her on a heparin drip, and bridge to warfarin once she achieves hemostasis for 24-48 hours
Yes, this is the best choice.


Start her on a heparin drip and start a low dose of warfarin now
No, please try again


Start her on a heparin drip and bridge to a DOAC once she achieves hemostasis for 24-48 hours
No, DOACs are contraindicated for anticoagulation for patients with mechanical mitral valve.


Ms. Brown is started on a heparin drip, with plans to bridge to warfarin. After 24-48 hours of stable hemoglobin levels, a low dose of warfarin is started (5mg daily) with a goal INR of 2.5-3.5.  

Additionally, in patients with a mechanical mitral or aortic valve at low risk of bleeding, an antiplatelet agent such as low-dose aspirin (50 to 100 mg/day) is suggested in addition to long-term VKA therapy (over not adding such an agent).* 

 

* See https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003464.pub2/full

 

Ms. Brown's hemoglobin eventually stabilizes. She becomes therapeutic on warfarin and is able to become discharged from the hospital under careful watch of her family.

   nejmoa1300615.pdf  Dabigatran, a DOAC is contraindicated in patients with mechanical heart valves.

As a PCP, what can be done to reduce risk of falls in the elderly?

Expand all answers
Calcium supplementation
No, this has not been shown to reduce falls.


Exercise based programs
Yes, exercise interventions have been associated with fewer injurious falls.


Vitamin D supplementation
High dose Vit D has been associated with higher rates of fall-related outcomes.


Decreased activity level
No, this has not been shown to reduce falls.


  1. Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL (2018). Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 319(16):1705–1716.
  2. Gaasch, W., Konkle, B. (2018). Antithrombotic therapy for prosthetic heart valves: Indications. In S. B. Yeon & J. S. Tirnauer, UpToDate. Retrieved January 24, 2019 from https://www.uptodate.com/contents/antithrombotic-therapy-for-prosthetic-heart-valves-indications
  3. Eikelboom JW, Connolly SJ, Brueckmann M, Granger CB, Kappetein AP, Mack MJ, ... Van de Werf F. (2013). Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med, 369(13):1206-14.
  4. Massel DR, Little SH (2013). Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database of Systematic Reviews. Issue 7. Art. No.: CD003464.

Cardiology ultimately recommends initiating anticoagulation as soon as possible once hemostasis is achieved and she is safe from a surgical standpoint, as her risk of thrombotic/embolic activity is high with a mechanical mitral valve and atrial fibrillation.

Ms. Brown experienced a trauma-associated bleed while on coumadin. The risk of her rebleeding when on anticoagulation is lower than a patient who spontaneously bled. Even in patients with a GI bleed or a subdural hematoma while on anticoagulation, studies have shown that there is a benefit to re-starting anticoagulation due to a statistically significant lower risk of clot. 

Ms. Brown continues to improve, with her hemoglobin gradually stabilizing in the 10-11 range without requiring addtional blood transfusions. 

How would you reinitiate anticoagulation now?

Expand all answers
Start her on lovenox and bridge to warfarin once she achieves hemostasis for 24-48 hours
This is a reasonable approach. However, since she developed the hematoma while on a Lovenox bridge to warfarin, there is a better choice available that avoids LMWH. Additionally, her weight of 53kg puts her at the lower end of the reliable therapeutic range (patients weighing <45kg were not included in clinical trials for Lovenox).


Start her on a heparin drip, and bridge to warfarin once she achieves hemostasis for 24-48 hours
Yes, this is the best choice.


Start her on a heparin drip and start a low dose of warfarin now
No, please try again


Start her on a heparin drip and bridge to a DOAC once she achieves hemostasis for 24-48 hours
No, DOACs are contraindicated for anticoagulation for patients with mechanical mitral valve.


Ms. Brown is started on a heparin drip, with plans to bridge to warfarin. After 24-48 hours of stable hemoglobin levels, a low dose of warfarin is started (5mg daily) with a goal INR of 2.5-3.5.  

Additionally, in patients with a mechanical mitral or aortic valve at low risk of bleeding, an antiplatelet agent such as low-dose aspirin (50 to 100 mg/day) is suggested in addition to long-term VKA therapy (over not adding such an agent).* 

 

* See https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003464.pub2/full

 

Ms. Brown's hemoglobin eventually stabilizes. She becomes therapeutic on warfarin and is able to become discharged from the hospital under careful watch of her family.

   nejmoa1300615.pdf  Dabigatran, a DOAC is contraindicated in patients with mechanical heart valves.

As a PCP, what can be done to reduce risk of falls in the elderly?

Expand all answers
Calcium supplementation
No, this has not been shown to reduce falls.


Exercise based programs
Yes, exercise interventions have been associated with fewer injurious falls.


Vitamin D supplementation
High dose Vit D has been associated with higher rates of fall-related outcomes.


Decreased activity level
No, this has not been shown to reduce falls.


  1. Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL (2018). Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 319(16):1705–1716.
  2. Gaasch, W., Konkle, B. (2018). Antithrombotic therapy for prosthetic heart valves: Indications. In S. B. Yeon & J. S. Tirnauer, UpToDate. Retrieved January 24, 2019 from https://www.uptodate.com/contents/antithrombotic-therapy-for-prosthetic-heart-valves-indications
  3. Eikelboom JW, Connolly SJ, Brueckmann M, Granger CB, Kappetein AP, Mack MJ, ... Van de Werf F. (2013). Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med, 369(13):1206-14.
  4. Massel DR, Little SH (2013). Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database of Systematic Reviews. Issue 7. Art. No.: CD003464.

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