Chest
Volume 141, Issue 2, Supplement, February 2012, Pages e326S-e350S
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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only Articles
Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.11-2298Get rights and content

Background

This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure.

Methods

The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement.

Results

In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C).

Conclusions

Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.

Section snippets

Summary of Recommendations

Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.

2.1. In patients who require temporary interruption of a VKA before surgery, we recommend stopping VKAs

Data Sources

The Medline English-language database was searched from January 1970 to January 2010 using multiple keywords and standardized terminology, where applicable, as outlined in Appendix S1. This search was done in two parts. The first was a systematic review of the literature from 1970 to January 2007, which was used in AT8.6 The second search updated this search strategy to include studies up until January 2010. We supplemented these literature searches by conducting Internet-based searches of //ClinicalTrials.gov

Interruption of VKAs Before Surgery

In patients undergoing major surgery or procedures, interruption of VKAs, in general, is required to minimize perioperative bleeding,64, 65, 66, 67, 68 whereas VKA interruption may not be required in minor procedures as discussed in subsequent sections of this article. Interruption of VKAs before surgery with the intent of achieving normal or near-normal hemostasis at the time of surgery is based on the residual pharmacodynamic effects of VKAs and the associated time required for the

Interruption of Antiplatelet Drugs Before Surgery

Antiplatelet drugs that irreversibly inhibit platelet function—making their short half-lives clinically irrelevant—include ASA, clopidogrel, ticlopidine, and prasugrel.136 For each day after interruption of any of these agents, ∼10% to 14% of normal platelet function is restored; later, it takes 7 to 10 days for an entire platelet pool to be replenished.137, 138

Antiplatelet drugs that reversibly inhibit platelet function, with self-limiting effects depending on their elimination half-lives,

Anticoagulants and Anticoagulant Dose Regimens Considered for Bridging

There is no established single heparin bridging regimen. Variability exists in the type of anticoagulant (LMWH or UFH), intensity of anticoagulation (therapeutic dose, low dose, or intermediate dose), and timing of perioperative administration. In considering which regimen and administration approach to use, there are several points to consider:

  • Anticoagulant intensity to prevent thromboembolism. In the absence of randomized trials assessing the efficacy of different intensities of

Research Recommendations

Additional research is necessary to establish best practices for patients who are receiving antithrombotic therapy and require surgery. Efforts to bridge these gaps in knowledge are ongoing. The randomized placebo-controlled trials PERIOP-2 (A Safety and Effectiveness Study of LMWH Bridging Therapy Versus Placebo Bridging Therapy for Patients on Long Term Warfarin and Require Temporary Interruption of Their Warfarin),215 BRIDGE (Effectiveness of Bridging Anticoagulation for Surgery),216

Acknowledgments

Author contributions: As Topic Editor, Dr Kunz oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.

Dr Douketis: contributed as Deputy Editor for this topic.

Dr Spyropoulos: contributed as a panelist.

Dr Spencer: contributed as a panelist.

Dr Mayr: contributed as a frontline clinician.

Dr Jaffer: contributed as a panelist.

Dr Eckman: contributed as a resource consultant.

Dr Dunn: contributed as a panelist.

Dr Kunz:

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    Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.

    Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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