A coroner has called for the development of guidelines on the peri-operative management of anticoagulants after an atrial fibrillation (AF) patient had a fatal stroke after suspending his medication for minor surgery.
The 73-year-old male patient had been on rivaroxaban for many years before being booked in for inguinal hernia surgery in July 2018.
With a complex medical history, the Melbourne man was also on medications to treat type 2 diabetes mellitus, hypercholesterolaemia and controlled gastro-oesophageal reflux disease and had received a porcine aortic valve replacement in 2011.
Considering this, he was advised by his regular cardiologist to suspend the rivaroxaban therapy for 3–4 days prior to surgery.
There was no requirement for bridging therapy but the anticoagulant should be recommenced once the surgeon was “happy with haemostasis”, the cardiologist added in a letter sent to the surgeon and forwarded to the patient.
The surgery was completed two weeks later and proved uncomplicated, taking about 40 minutes, although the surgeon later told the patient to delay recommencing his anticoagulant for two days after observing swelling and bruising on his left side.
But while preparing for discharge two days later, the patient suddenly demonstrated signs of acute thromboembolic stroke, with an inability to walk or form cohesive sentences.
Despite rapid stroke treatment in a Mobile Intensive Care Ambulance (MICA) and at the nearby Austin Hospital he could not be revived, and was pronounced dead the same day.
Victorian Deputy State Coroner Jacqui Hawkins launched an investigation after complaints were raised by the late patient’s family that the cardiologist failed to provide a “full cardiological review” prior to the surgery.
As a result, his advice involved an “excessive amount of time” off anticoagulation prior to surgery, lawyers for the family argued.
Criticism was also levelled at the surgeon for their “lack of care and consideration” for the management of the patient’s anticoagulation medication, along with their “poor standard of pre-operative assessment”.
The patient’s partner told the inquiry she had overheard a phone call in the lead-up to the surgery where he had been verbally advised to cease the anticoagulant six days prior, which was two days earlier than recommended by the cardiologist in his letter.
She was not able to say who had made the phone call and both the surgeon and cardiologist, as well as their staff, denied ever doing so.
However, records from a consultation just before the surgery showed the patient advised hospital staff he had not taken the anticoagulant for six days, although this information was apparently not passed on to the surgeon.
In any event, he had been off rivaroxaban for nine days in total, which likely contributed to his death, the coroner found.
In evidence, the cardiologist defended his advice, stressing it was his usual practice to suspend anticoagulation for a period before and after surgical and other invasive procedures. The duration was determined by variable factors including the time required for the anticoagulation effect to wear off, bleeding risk, as well as history of stroke.
He said full pre-operative work up was only required for patients undergoing major orthopaedic and vascular procedures where risk of cardiac complications was increased. Bilateral hernia surgery did not fall into this class, the cardiologist said.
Besides that, he added no pre-operative review had been requested by the patient, his family, GP, the surgeon or any of their medical staff.
The cardiologist added the high-risk phase for thromboembolic surgery events was in the post-operative period, which was why it was up to the surgeon to restart anticoagulation therapy as soon as bleeding was under control.
“In the absence of major bleeding risk or major bleeding, failure to prescribe postoperative anticoagulants is a significant omission and a departure from guideline based practice,” he told the court.
“Failure to re-commence anti-coagulants in [this] case may have contributed to a tragic outcome in which low risk surgery was followed by an unexpected and untimely death”.
The surgeon conceded this was likely true, although he stressed he had made a deliberate clinical decision to continue to withhold the patient’s rivaroxaban due to the appearance of post-operative bruising and swelling.
This had raised concerns relating to post-operative bleeding risk if the medication was recommenced, the surgeon said, adding he had expected the anticoagulation would restart the day of discharge.
Coroner Hawkins said the likely preventable death highlighted the importance of a multidisciplinary approach in management of AF.
She pointed to evidence raised by the cardiologist who said there was currently no streamlined system for managing AF in Victoria, particularly for perioperative anticoagulant management.
Based on the cardiologists’ description, this had led to a culture that “uses patients as go-betweens in arranging their own specialist care”, the coroner added.
“[This] death has highlighted the post-operative risk of stroke and the importance of the timing of recommencement of anticoagulation medication, particularly in patients with AF,” she said.
“Evidence suggested that this heightened risk may not be fully appreciated by clinicians and that there are variations in practice.
“I note there are no formal clinical guidelines for the management of anticoagulation therapy for peri or post-surgery.”
She recommended that Safer Care Victoria establish a multi-disciplinary working group to develop guidelines for the management of anticoagulation therapy for peri and post-surgery for patients with AF.
The agency should also roll out programs to “increase practitioner awareness, knowledge and performance”, the coroner said.