Current estimates indicate that 2 to 3 million Americans take warfarin for prevention of thromboembolism from venous thromboembolism, atrial fibrillation, or prosthetic heart valves. Invasive procedures are performed in as many as 250 000 patients taking warfarin on an annual basis in the United States. Antiplatelet agents such as aspirin and clopidogrel are taken by many more patients for prevention of myocardial infarction and stroke. Consequently, management of antithrombotic agents in the perioperative period is a common and vexing challenge for physicians. Because not all patients are at the same risk of thromboembolism and not all procedures are associated with the same risk of bleeding, it is important for hospitalists to know how to weigh these risks in their patients. The purpose of this module is to review risk factors for thromboembolism and bleeding associated with different thromboembolic disorders and invasive procedures.

To provide hospitalists with current evidence on optimal management of antithrombotic agents in the periprocedural period.

This activity is designed for hospitalists. No prerequisites required.

After completing the module, the participant should be able to:

1. Assess the risk of venous thromboembolism (VTE) associated with interruption of anticoagulation in patients with a history of VTE, deep venous thrombosis, or pulmonary embolism.
2. Assess the risk of arterial thromboembolism (ATE) associated with interruption of anticoagulation in patients with atrial fibrillation.
3. Assess the risk of ATE associated with interruption of anticoagulation in patients with mechanical heart valves.
4. Formulate a plan for preoperative management of anticoagulation taking into account bleeding and thrombotic risk.
5. Propose a plan for postoperative management of anticoagulation taking into account bleeding and thrombotic risk.
6. Manage antiplatelet agents in the perioperative period in patients at risk for ATE.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

Accreditation Statement: The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement: The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)^™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Release date: November 15, 2009. Expiration date: November 15, 2011.

Estimated time to complete activity: 2 hours

Full Disclosure Policy Affecting CME Activities: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The Johns Hopkins University School of Medicine to require the disclosure of the existence of any relevant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The presenting faculty reported the following:

^*Medical Director, Johns Hopkins Antithrombotic Management Service and Clinics, Associate Professor, Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

^†Clinical Pharmacy Specialist, Johns Hopkins Antithrombotic Management Service and Clinics, Johns Hopkins Medical Institutions, Baltimore, Maryland.

Conflict of Interest: Dr Thomas reports having no relevant financial or advisory relationships with corporate organizations related to this activity. Dr Streiff reports receiving research grants from Bristol-Myers Squibb; honoraria from GlaxoSmithKline, Medical Communications Media, Inc, and Sanofi-Aventis; and serving on the speakers’ bureau for Sanofi-Aventis until December 31, 2008.

Off-Label Product Discussion: Use of low–molecular-weight heparin for bridging anticoagulation in patients with prosthetic heart valves.

Disclaimer: The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects before administering pharmacologic therapy to patients.

Address correspondence to: Michael B. Streiff, MD, Associate Professor, Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7300, Baltimore, MD 21205. E-mail: mstreif@jhmi.edu.

Click here to download the references for this educational activity.

The following is an interactive educational module designed to help you gauge your basic knowledge of the topic and then direct you to areas you may need to focus on. It consists of 3 sections: an unaccredited pre-test, a study activity, and a CME post-test. All 3 sections must be completed to receive CME credit.

Supported by an educational grant from Merck & Co., Inc.