501 - Antithrombotic Tx and Surgery, Emotional Health Screening, Change of Mind

From the American College of Chest Physicians (ACCP) Guidelines

1)  Perioperative Management of Antithrombotic Therapy 

The ACCP antithrombotic therapy guidelines, published about specific clinical circumstances such as perioperative management, have become go-to resources for the many patients we have on antithrombotic therapy. This perioperative management guideline was last published in 2012, so was due for an extensive update. These guidelines use a very rigorous process for guideline development, including a strong conflict of interest disclosure policy, comprehensive search for evidence, use of the GRADE system for evaluating evidence, use of a formal consensus process for agreeing on recommendation statements, and publishing any minority opinions (there were a few). 

The guideline focused on the perioperative use of warfarin (the major representative of the vitamin K antagonist medications), non-vitamin K antagonists (direct oral anticoagulants (DOACs)), antiplatelet medications, and heparin bridging (usually by full-dose low molecular weight heparin). Three major indications for anticoagulation were evaluated: chronic atrial fibrillation, mechanical heart valves, and venous thromboembolism (VTE). Thromboembolism risk is divided into low, medium and high risk based on type of artificial valves, CHA₂DS₂Vasc scores, recency of VTE events and thrombophilia. And, just to complete the groupings, they divided the bleeding risk associated with operations and procedures into: minimal risk (e.g., cataract surgery, most dental and dermatologic procedures, pacemaker implantation), low-to-moderate risk (e.g., endoscopy with biopsy, abdominal hysterectomy, laparoscopic

cholecystectomy, foot/hand surgery, hernias, hemorrhoids, bronchoscopy) and high risk (e.g., all major surgeries, endoscopy with polyp removal, epidural injections). 

Selected highlights of the guideline: 

·         Hold VKAs for 5 days prior to elective surgery and resume them within 24 hours after surgery at the patient’s usual dose. (Very low to low certainty evidence) 

·         Heparin bridging is only recommended for those at highest risk of thromboembolism (mechanical valves, CHA2DS2Vasc score >=7, severe thrombophilia, active cancer, etc.) who are managed on VKAs. (Very low to moderate) 

·         Continue VKA for minor ophthalmologic, dermatologic, and dental procedures as well as pacemaker/implantable defibrillator insertions. For dental procedures, if concern exists for bleeding, using tranexamic acid mouthwash and additional sutures may be employed. (Very low to low) 

·         For bridging with LMWH, the last pre-procedure dose (which should equal half of the total daily dose) should be given 24 hours prior to the procedure and resumed 24 hours after the procedure. (Very low to low) 

·         For patients on DOACs, they should be stopped 1-2 days prior to the procedure except for dabigatran, which should be stopped 1-4 days prior (depending on decreased renal function and/or higher bleeding risk). (Very low) 

·         Bridging is not indicated for DOAC interruptions due to their rapid onset of action. DOACs should be resumed 24 hours after the procedure. (Very low) 

·         For antiplatelet agents, aspirin does not need to be stopped prior to surgery, but in the case of high bleeding risk, it can be stopped <=7 days prior to the procedure. Clopidogrel should be stopped 5 days prior to surgery, ticagrelor 3-5 days prior and prasugrel 7 days prior. All should be resumed within 24 hours after the procedure. (Very low) 

·         For cardiac stents (the vast majority of which are drug-eluting these days), if they were recently placed (6-12 weeks) and patients are on aspirin and another antiplatelet medication, either continue both or stop one. For older stents (3-12 months), holding the antiplatelet agent and resuming within 24 hours after the procedure is recommended. (Very low). 

·         For stents requiring dual antiplatelet therapy (DAPT), it is best to delay the elective procedure if possible until DAPT is no longer required. (Very low) 

·         Antiplatelet agents should be continued for minor dermatologic, dental, and ophthalmologic procedures. (Very low to low). 

Because the evidence behind these recommendations is so low, many of these recommendations can be altered given specific clinical circumstances (bleeding risk, thromboembolism risk), so clinical judgment is important. There are many important details, some useful figures, and other (less frequently applicable) scenarios in the full-text of this guideline. 

John’s Comments:

It is pretty humbling to look at the evidence ratings for most of these recommendations. It is, at the same time, somewhat reassuring that the recommendations are getting overall less aggressive. I will definitely bookmark this guideline for those vexing phone calls from the dentist office and preoperative visits where these questions often arise. 

Reference: 

·         Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. CHEST. 2022;162(5):e207-e243. Link 

From the USPSTF

2)  Screening for Depression, Anxiety, and Suicide Risk in Adults

Both depression and anxiety are common, cause significant morbidity, and are estimated to have substantial economic costs.  In 2019, studies indicate 8% of adults experienced at least 1 major depressive episode and 5% experienced an episode with severe impairment in the previous year.  Initial data also indicates prevalence of both depression and anxiety disorders have increased substantially, particularly in certain populations, during the pandemic.  Additionally, in 2019 in the US, almost 50,000 deaths were attributable to suicide and rates are increasing.   

The USPSTF recently published recommendations for screening for anxiety disorders , depression, and suicide risk in adults.  This was the first time the USPSTF has made a recommendation regarding screening for anxiety disorders.  Recall that a “B” recommendation indicates moderate certainty that screening has a moderate net benefit.  Recommendations Include:

For Anxiety Disorders (includes generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, selective mutism, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, and anxiety not otherwise specified):

·         Screen all adults aged 64 and under for anxiety disorders (B Recommendation)

·         The evidence is insufficient to assess the balance of benefits and harms of screening for anxiety disorders in adults aged >65 (I Recommendation)

This recommendation applies to adults who do not have a diagnosed mental health disorder and are not showing recognized signs or symptoms of anxiety disorders. 

The Task Force notes that selected screening tools widely used in the US include versions of the Generalized Anxiety Disorder (GAD) scale, Edinburgh Postnatal Depression Scale (EPDS) anxiety subscale, Geriatric Anxiety Scale (GAS), and the Geriatric Anxiety Inventory (GAI). 

For Depression:

·         Screen all adults for depression (B Recommendation – same as in 2016)

Commonly used depression screening instruments include the Patient Health Questionnaire (PHQ) in various forms in adults, the Center for Epidemiologic Studies Depression Scale (CES-D), the Geriatric Depression Scale (GDS) in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) for pregnancy and postpartum care.

Since there is little evidence regarding optimal timing for screening or screening interval for either of these disorders, the recommendation notes that a pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in considering risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted.   Potential harms of screening include false-positive screening results that lead to unnecessary referrals, the potential for overdiagnosis and unnecessary treatment, labeling, and stigma. 

For Suicide:

·         The evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adults (I Recommendation – same as in 2014)

Factors resulting in increased risk for suicide attempts include severe psychological distress, major depressive episodes, alcohol use disorder, marital status of being divorced or separated, or being unemployed.  

Mark’s Comments:

For those of us practicing primary care medicine, the morbidity we see resulting from emotional health disorders is overwhelming, and likely many of us feel under resourced to effectively manage those we present care for who are struggling.  Add to that the helplessness many of us feel in the face of the many social drivers of health contributing to mental health disorders that feel out of our control, and the thought of screening to identify even more patients who need treatment might seem paralyzing.  Under such circumstances, the adage “Do what you can, with what you've got, where you are” seems an appropriate place to start.

References:

·         USPSTF.  Screening for Depression and Suicide in Adults:  Recommendation Statement. JAMA June 20, 2023;329(23):2057-2067. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Change of Mind

“What have you rethought recently?”  Adam Grant, PhD (author, podcaster, psychology professor)

There is an old adage taught in many medical schools which says "Half of what we are going to teach you is wrong. Our problem is that we don't know which half."  For me that that number is now greater than 90%, and well more than half of my present medical knowledge wasn’t even known when I was in school!  Statistically, most of us have been in medicine long enough to have had to “re-think” many practices that were at one time held to be “true.”  The scientific method is built upon this premise.  So, on the surface, we clinicians should be very skilled in the process of changing our minds. 

How quickly I forget.  Recently I had a wonderful PRx90 check-in (“Up to 90 minutes every 90 days”) with one of my PeerRxMed buddies.  During the course of our lively conversation, he reminded me that “just because you believe something doesn’t mean you need to keep believing it!” – in this case referencing some administrative burdens (aka: “stupid stuff”) that I had resigned myself to keep soldiering through, sharing my belief that they would “never change.”    

While on the surface his may seem a “duh” statement, in many circles it has become quite trendy to “dig-in” or “double-down” on what we say we believe rather than positioning ourselves to be open to new ideas and the possibility of changing (or perhaps the “safer” alternative, of “evolving”) our beliefs.  Indeed, I was demonstrating this very behavior with my “never change” mindset.  It turns out we’re wired for this.

In his book “Think Again: The Power of Knowing What You Don’t Know,” organizational psychologist Adam Grant writes: “We’re mental misers: we often prefer the ease of hanging on to old views over the difficulty of grappling with new ones.”   He tackles this challenge head-on, encouraging us to embrace intellectual humility when it comes to what we “believe.”  Taking this posture increases the chances we will do the essential work necessary to overcome a natural tendency to resist changing such beliefs,

This week, consider the question “what have I rethought recently” and share what you discover with your PeerRxMed partner or other colleague.  Remember, the willingness  to change one’s mind is not a sign of weakness, but wisdom - and of embracing the scientific method.   And that same science says you’re the only one who can bring about that change of mind.  At least that’s what I believe … for now ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org