BACKGROUND: The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.
METHODS: Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.
RESULTS: A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.
CONCLUSIONS: Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
| Discipline Area | Score |
|---|---|
| Hospital Doctor/Hospitalists |  |
| Internal Medicine | |
| Surgery - General |  |
| Hemostasis and Thrombosis | |
A very practical and relevant document on peri-procedural anticoagulant management.
New evidence on perioperative antithrombotic management is continuously accumulating. These latest ACCP guidelines shed light on some of the important questions that arise in day-to-day practice.
Useful recommendations for practicing physicians.
Not an easy document to read if you are in a hurry with a patient. Among the important statements are: 1. Bridging for warfarin is limited to - (i) those with a recent (< 3 months) history of VTE or (ii) severe thrombophilia, or (iii) selected types of active cancer; 2. Aspirin - "In patients receiving ASA who are undergoing elective non-cardiac surgery, we suggest ASA continuation over ASA interruption"
Perioperative management of antithrombotic therapy is a very important field in clinical practice. The American College of Chest Physicians is a recognizable and competent institution to propose the clinical practice guideline in this area. The almost 300 articles in the reference list is evidence of the impact of this topic in surgical practice.
It's good to have a summary of perioperative strategies for thrombophylaxis in different prothrombotic conditions.
