Management of patients treated with aspirin or warfarin and evaluation of haemostasis prior to prostatic biopsy: a survey of current practice amongst radiologists and urologists

The Dilemma of Peri-Procedural Warfarin Management: A Narrative Review

Periprocedural vitamin K antagonist management is a complex process and inherently entails multiple clinical issues. Marked variations have been reported in different aspects of this process. These differences were noted at the clinician and institutional levels owing to the lack of evidence-based data leading to many discrepancies in decision-making. This review aims to address the gap of vitamin K antagonist periprocedural management acknowledged by previously published prescribers’ questionnaires. One of the components of this process is “bridging,” which aims to provide minimal interruption of the anticoagulation period through the use of heparin products. Recent studies showed that bridging is increasing bleeding risk. Secondly, interruption decision relies on the classification of thromboembolism risk which depends on trials that did not include patients with atrial fibrillation. Thirdly, the interruption duration is different among different International normalization ratio levels, which strengthens the difference in the clinical practice of preoperative vitamin K antagonist management. Lastly, the resumption of a vitamin-K antagonist after surgery has many scenarios according to the procedure and patient risk of bleeding. Vitamin-K antagonist periprocedural management is complicated due to individual practice and the lack of strictly implemented institutional standardized protocols to guide, manage and evaluate the process.

Safety of heparin bridging therapy for transrectal ultrasound-guided prostate biopsy in patients requiring temporary discontinuation of antithrombotic agents

BACKGROUND

Safety of heparin bridging therapy for transrectal ultrasound-guided prostate (TRUS) biopsy in patients requiring temporary discontinuation of antithrombotic therapy is unknown. This study aimed to assess the relationship between heparin bridging therapy and the incidence of complications after TRUS biopsy.

METHODS

From January 2005 to November 2015, we performed 1307 consecutive TRUS biopsies on 1134 patients in our hospital. The patients were assigned to two groups: those without heparin bridging (the control group) and those with temporary discontinuation of antithrombotic agents with heparin bridging therapy (the bridging group). A 10-12-core TRUS biopsy was performed; the patients were evaluated for bleeding-related complications.

RESULTS

Of 1134 patients, 1109 (1281 biopsies) and 25 (26 biopsies) were assigned to the control and bridging group, respectively. Patient background did not significantly differ between the control and bridging groups, except for age, history of diabetes, cardiovascular diseases, and CHADS2 scores. Compared with the control group, the bridging group showed a significantly higher rate of complication for any complication (35 vs. 8.3%, P < 0.001), bleeding-related complications (27 vs. 4.4%), and urinary tract infection (7.7 vs. 1.2%). No thromboembolic event was observed in the present study. Multivariate logistic analysis showed that heparin bridging therapy was a significant risk factor for the incidence of any complication and bleeding-related complications.

CONCLUSIONS

Heparin bridging therapy with temporal discontinuation of antithrombotic agents may increase the risk of complications after TRUS biopsy. Further, large-scale studies are required to clarify the safety of heparin bridging therapy.

Safety of 12 core transrectal ultrasound guided prostate biopsy in patients on aspirin

Objective:

To prospectively assess safety outcome of TRUS guided prostate biopsy in patients taking low dose aspirin.

Materials and methods:

Consecutive patients, who were planned for 12 core TRUS guided prostate biopsy and satisfied eligibility criteria, were included in the study and divided into two Groups: Group A: patients on aspirin during biopsy, Group B: patients not on aspirin during biopsy, including patients in whom aspirin was stopped prior to the biopsy. Parameters included for statistical analysis were: age, serum prostate specific antigen (PSA), prostate volume, hemoglobin (Hb %), number of hematuria episodes, number of patient reporting hematuria, hematuria requiring intervention, number of patient reporting hematospermia and number of patient reporting rectal bleeding.

Results:

Of 681 eligible patients, Group A and B had 191 and 490 patients respectively. The mean age, prostate volume, serum PSA and pre-biopsy hemoglobin were similar in both Groups with no significant differences noted between them. None of the post-biopsy complications, including number of hematuria episodes (p=0.83), number of patients reporting hematuria (p=0.55), number of patients reporting hematospermia (p=0.36) and number of patients reporting rectal bleeding (p=0.65), were significantly different between Groups A and B respectively. None of the hemorrhagic complication in either group required intervention and were self limiting.

Conclusion:

Continuing low dose aspirin during TRUS guided prostate biopsy neither alters the minor bleeding episodes nor causes major bleeding complication. So, discontinuation of low dose aspirin prior to TRUS guided prostate biopsy is not required.

Continued administration of antithrombotic agents during transperineal prostate biopsy

Purpose

To determine the safety of continued administration of antithrombotic agents during transperineal (TP) prostate biopsy.

Patients and Methods

A total of 811 men who underwent transrectal ultrasound (TRUS)-guided TP biopsy from January 2008 to June 2012 at our two institutions were retrospectively analyzed. Among these 811 men, 672 received no antithrombotic agents (group I), 103 received and continued administration of antithrombotic agents (group II), and 36 interrupted administration of antithrombotic agents (group III). Overall complications were graded and hemorrhagic complications were compared (group I with group II) using propensity score matching (PSM) analysis.

Results

An overall complication rate of 4.6% was recorded. Hemorrhagic complications occurred in 1.8% and they were virtually identical in all the three groups, and no severe hemorrhagic complications occurred. One patient in group III required intensive care unit admission for cerebral infarction. PSM analysis revealed no statistical difference between groups I and II with regard to the incidence of gross hematuria, perineal hematoma, and rectal bleeding. Multiple regression analysis revealed that hemorrhagic complications were associated with lower body mass index (<21 kg/m², P=0.0058), but not with administration of antithrombotic agents.

Conclusions

Continued administration of antithrombotic agents does not increase the risk of hemorrhagic complications; these agents are well tolerated during TP biopsy.

Discontinuation of anticoagulant or antiplatelet therapy for transrectal ultrasound-guided prostate biopsies: a single-center experience

Purpose

Historically, it was thought that hemorrhagic complications were increased with transrectal ultrasound-guided prostate biopsies (TRUS biopsy) of patients receiving anticoagulation/antiplatelet therapy. However, the current literature supports the continuation of anticoagulation/antiplatelet therapy without additional morbidity. We assessed our experience regarding the continuation of anticoagulation/antiplatelet therapy during TRUS biopsy.

Materials and Methods

A total of 91 and 98 patients were included in the anticoagulation/antiplatelet (group I) and control (group II) groups, respectively. Group I subgroups consisted of patients on monotherapy or dual therapy of aspirin, warfarin, clopidogrel, or low molecular weight heparin. The TRUS biopsy technique was standardized to 12 cores from the peripheral zones. Patients completed a questionnaire over the 7 days following TRUS biopsy. The questionnaire was designed to assess the presence of hematuria, rectal bleeding, and hematospermia. Development of rectal pain, fever, and emergency hospital admissions following TRUS biopsy were also recorded.

Results

The patients' mean age was 65 years (range, 52 to 74 years) and 63.5 years (range, 54 to 74 years) in groups I and II, respectively. The overall incidence of hematuria was 46% in group I compared with 63% in group II (p=0.018). The incidence of hematospermia was 6% and 10% in groups I and II, respectively. The incidence of rectal bleeding was similar in group I (40%) and group II (39%). Statistical analysis was conducted by using Fisher exact test.

Conclusions

There were fewer hematuria episodes in anticoagulation/antiplatelet patients. This study suggests that it is not necessary to discontinue anticoagulation/antiplatelet treatment before TRUS biopsy.

Coagulation concepts update

OBJECTIVE

Since the previous comprehensive radiology review on coagulation concepts that was done in 1990, many studies have been published in the medical and surgical literature that can guide the approach of a radiology practice. The purpose of this article is to provide an analysis of these works, updating the radiologist on proper use and interpretation of coagulation assessment tools, medications that modify the hemostatic system, and the use of transfusions prior to interventions.

CONCLUSION

The basic tools for coagulation assessment have not changed; however, results from subspecialty research have suggested ways in which the use of these tools can be modified and streamlined to safely reduce time and expense for the patient and the health care system.

Peri-operative management of anti-platelet agents

BACKGROUND

Increasing numbers of patients treated with anti-platelet agents are presenting for non-cardiac surgery. We examined the peri-operative management of anti-platelet therapy in patients undergoing elective non-cardiac surgery and the process by which patients received instructions.

METHODS

We interviewed and collected outcome data on 213 consecutive patients aged > or = 45 years presenting for elective non-cardiac surgery at our institution over a 6-week period regarding the peri-operative management of anti-platelet and warfarin therapy.

RESULTS

Anti-platelet therapy was prescribed in 22.5% and warfarin in 5.2% of the study subjects. Aspirin was stopped peri-operatively in 55.3%, while clopidogrel was stopped in the sole patient treated with this. The frequency of anti-platelet agent discontinuation was similar for major and minor surgery. Warfarin was discontinued prior to surgery in all cases. Only 54.2% of those treated with anti-platelet therapy recalled being given instruction regarding pre-operative management of their anti-platelet therapy compared with 90.9% of patients treated with warfarin (P= 0.04). In the absence of instructions, a number of patients made their own decision to stop their aspirin pre-operatively. Post-operatively, only 37% recalled receiving instructions regarding restarting anti-platelet therapy. As a result, three patients failed to do so. In contrast, all those treated with warfarin received clear post-operative instructions.

CONCLUSION

Peri-operative anti-platelet management and communication with patients appears to be sub-optimal. There is a need for standardized processes whereby informed decisions regarding peri-operative anti-platelet therapy are made and communicated clearly to the patients.

Management of patients taking antiplatelet or anticoagulant medication requiring invasive breast procedures: United Kingdom survey of radiologists' and surgeons' current practice

AIM

To determine the current practice in the UK National Health Service Breast Screening Programme for invasive diagnostic procedures and surgery in patients taking anticoagulant and antiplatelet medication.

MATERIALS AND METHODS

Lead radiologists and surgeons at each breast screening service were surveyed to determine current practice. One hundred and five respondents provided information regarding their services, protocols, and willingness to proceed with combinations of procedures and anti-haemostatic medications.

RESULTS

Between units there was wide variation in practice. Within 21 services providing more than one response, 10 (48%) disagreed on whether protocols existed. Decisions to perform biopsies were unrelated to professional group. The taking of a drug history was variable. Surgeons reported more adverse effects than radiologists [21 (48%) versus 12 (26%)], but no difference in self-assessment of knowledge.

CONCLUSION

Both radiologists and surgeons have expressed uncertainty about their understanding of anticoagulant and antiplatelet treatment. This is reflected in a wide range of practice. Guidance regarding the management of these patients is suggested.

Continuing or Discontinuing Low-Dose Aspirin Before Transrectal Prostate Biopsy: Results of a Prospective Randomized Trial

OBJECTIVES

To determine whether the incidence and duration of bleeding complications after transrectal prostate biopsy (PB) in patients not discontinuing low-dose aspirin (LDA) are greater than in those discontinuing it.

METHODS

A total of 200 consecutive subjects taking chronic LDA were enrolled in a prospective trial and were randomly assigned to undergo transrectal PB while continuing LDA (group 1, n = 67), replacing LDA with low-molecular-weight heparin (group 2, n = 67), or discontinuing LDA (group 3, n = 66). The incidence and duration of hematuria, rectal bleeding, and hematospermia for each group were assessed with a self-administered questionnaire. On days 14 and 30 after PB, all men were evaluated with an outpatient visit and a telephone interview, respectively.

RESULTS

The cohort comprised 196 assessable subjects. The median number of biopsy cores taken was 10 (range 6 to 10). The overall bleeding rate was 78.5%, 69.7%, and 81.5% in groups 1, 2, and 3, respectively (P = 0.26). No significant difference was found for hematuria, rectal bleeding, or hematospermia among the groups. No severe bleeding complications occurred. The median duration of hematuria and rectal bleeding was significantly greater statistically in groups 1 and 2 compared with group 3 (6, 4, and 2 days versus 3, 2, and 1 days, respectively; P <0.0001). The proportion of men still reporting hematospermia at 30 days after PB was 21.4%, 18.5%, and 9.3% in groups 1, 2, and 3, respectively (P = 0.2).

CONCLUSIONS

The continued use of LDA in men undergoing transrectal PB did not increase the incidence of mild bleeding complications, although it prolonged the duration of self-limiting hematuria and rectal bleeding. Its effect, however, on severe bleeding remains to be determined.

Contemporary issues in the diagnosis of prostate cancer for the radiologist

Prostate cancer diagnostic techniques have improved considerably in recent years, but they must yet be optimised to ensure cancer detection at a potentially curable stage. Arrangements for prostate biopsy vary throughout Europe, and prostate biopsy may be undertaken by urologists or radiologists. This review discusses current issues relevant for radiologists involved in the detection of early prostate cancer. Prostate biopsy should be based on a systematic approach involving 8-12 cores obtained with peri-prostatic infiltration of local anaesthetic. Quality issues being considered by the United Kingdom Prostate Cancer Risk Management Programme are discussed.

Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis

OBJECTIVES

Low-dose aspirin given for secondary prevention of cardiovascular disease is frequently withdrawn prior to surgical or diagnostic procedures to reduce bleeding complications. This may expose patients to increased cardiovascular morbidity and mortality. Aim of the study was to review and quantify cardiovascular risks because of periprocedural aspirin withdrawal and bleeding risks with the continuation of aspirin.

METHODS

We screened MEDLINE (January 1970-October 2004) with additional manual cross-referencing for clinical studies, surveys on the opinions of doctors and guidelines.

RESULTS

Studies reporting the relative risk of acute cardiovascular events after aspirin withdrawal when compared with its continuation were not found. However, retrospective investigations revealed that aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes. The time interval between discontinuation and acute cerebral events was 14.3 +/- 11.3 days, 8.5 +/- 3.6 days for acute coronary syndromes, and 25.8 +/- 18.1 days for acute peripheral arterial syndromes (P < 0.02 versus acute coronary syndromes). On aspirin-related bleeding risks, we obtained 41 (12 observational retrospective, 19 observational prospective, 10 randomized) studies, reporting on 49 590 patients (14 981 on aspirin). Baseline frequency of bleeding complications varied between 0 (skin lesion excision, cataract surgery) and 75% (transrectal prostate biopsy). Whilst aspirin increased the rate of bleeding complications by factor 1.5 (median, interquartile range: 1.0-2.5), it did not lead to a higher level of the severity of bleeding complications (exception: intracranial surgery, and possibly transurethral prostatectomy). Surveys amongst doctors on the management of this problem demonstrate wide variations. Available guidelines are scarce and in part contradictory.

CONCLUSIONS

Only if low-dose aspirin may cause bleeding risks with increased mortality or sequels comparable with the observed cardiovascular risks after aspirin withdrawal, it should be discontinued prior to an intended operation or procedure. Controlled clinical studies are urgently needed.

Biopsy of the prostate guided by transrectal ultrasound: relation between warfarin use and incidence of bleeding complications

AIM

To determine the relation between warfarin use and the frequency of bleeding complications after biopsy of the prostate guided by transrectal ultrasound (TRUS).

METHODS

Overall, 1022 consecutive patients with suspected prostatic disease were followed after biopsy. Warfarin and aspirin use was determined on the day of the procedure. A TRUS-guided biopsy was performed and patients were offered a questionnaire to complete 10 days after the procedure, to determine any immediate or delayed bleeding complications. Follow-up telephone calls were made to those who had not replied within the stipulated period.

RESULTS

Of the 1000 patients who replied, 49 were receiving warfarin, 220 were receiving aspirin and 731 were not receiving any anticoagulant drugs. Of the 49 subjects reporting current use of warfarin, 18 (36.7%) experienced haematuria, compared with 440 (60.2%) of the patients receiving no anti-coagulant drugs who reported haematuria. This was statistically significant (p = 0.001). Of the group receiving warfarin, 4 (8.2%) experienced haematospermia whereas 153 (21%) of the group receiving no anticoagulant medication reported haematospermia. This difference also was statistically significant (p = 0.030). Rectal bleeding was experienced by 7 (14.3%) of the group receiving warfarin compared with 95 (13%) in the group without anticoagulant medication, but this was not statistically significant (p = 0.80). We also demonstrated that there was no statistically significant association between the severity of the bleeding complications and medication with warfarin.

CONCLUSION

None of the group receiving warfarin experienced clinically important bleeding complications. Our results suggest that the frequency and severity of bleeding complications were no worse in the warfarin group than in the control group and that discontinuing anticoagulation medication before prostate biopsy may be unnecessary.

Morbidity of transrectal ultrasonography-guided prostate biopsies in patients after the continued use of low-dose aspirin

OBJECTIVE

To determine whether low-dose aspirin increases morbidity after transrectal ultrasonography-guided sextant prostate biopsy.

PATIENTS AND METHODS

In a single-centre prospective cohort study of 200 patients who underwent sextant prostate biopsies, those routinely taking low-dose aspirin were encouraged to continue to do so before and after biopsy. The morbidity in each case was assessed using a standardized questionnaire that patients completed in the 7 days after biopsy. The presence of haematuria, rectal bleeding and haematospermia were recorded. The questionnaire also directed the patient to record fevers, use of analgesia and any further treatment received.

RESULTS

In all, 36 patients took aspirin whilst the other 141 did not. There were no major complications in either group. Of the patients on aspirin, 20 (56%) had haematuria, compared with 83 (59%) of those not taking aspirin (difference 3%, 95% confidence interval, CI, -15 to 21). Overall bleeding (haematuria, rectal bleeding and haematospermia) occurred in 22 patients (61%) of the aspirin group and 105 (74%) of the other group (difference 13%, 95% CI -4 to 31). Comparisons of other morbidities between the groups are also discussed.

CONCLUSIONS

There was no statistically significant difference in the incidence of haematuria or overall bleeding after biopsy between the groups. There is no evidence that aspirin needs to be discontinued before sextant prostate biopsy.