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Antithrombotic and Thrombolytic Therapy, 8th Ed : ACCP Guidelines: ANTITHROMBOTIC AND THROMBOLYTIC THERAPY, 8TH ED: ACCP GUIDELINES |

The Perioperative Management of Antithrombotic Therapy*: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) FREE TO VIEW

James D. Douketis, MD, FRCP(C); Peter B. Berger, MD, FACP; Andrew S. Dunn, MD, FACP; Amir K. Jaffer, MD; Alex C. Spyropoulos, MD, FACP, FCCP; Richard C. Becker, MD, FACP, FCCP; Jack Ansell, MD, FACP, FCCP
Author and Funding Information

*From McMaster University (Dr. Douketis), Hamilton, ON, Canada; Geisinger Clinic (Dr. Berger), Danville, PA; Mount Sinai School of Medicine (Dr. Dunn), New York, NY; University of Miami (Dr. Jaffer), Leonard M. Miller, School of Medicine, Miami, FL; Clinical Thrombosis Center (Dr. Spyropoulos), Lovelace Medical Center, Albuquerque, NM; Duke University (Dr. Becker), Durham, NC; and Boston University (Dr. Ansell), Boston, MA.

Correspondence to: Jack E. Ansell, MD, FACP, FCCP, Department of Medicine, Boston University Medical Center, 88 East Newton St, Boston, MA 02118; e-mail: jack.ansell@bmc.org



Chest. 2008;133(6_suppl):299S-339S. doi:10.1378/chest.08-0675
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This article discusses the perioperative management of antithrombotic therapy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). The primary objectives of this article are the following: (1) to address the perioperative management of patients who are receiving vitamin K antagonists (VKAs) or antiplatelet drugs, such as aspirin and clopidogrel, and require an elective surgical or other invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery. The recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al, CHEST 2008; 133:123S–131S). Briefly, Grade 1 recommendations are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade 2 recommendations are referred to as suggestions and imply that individual patient values may lead to different management choices.

The key recommendations in this article include the following: in patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE) at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) LMWH or IV UFH over no bridging during temporary interruption of VKA therapy (Grade 1C); in patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade 2C); in patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C).

In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C); in patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C).

In patients who are undergoing minor dental procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure and coadministering an oral prohemostatic agent (Grade 1B); in patients who are undergoing minor dermatologic procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C); in patients who are undergoing cataract removal and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C).

2.0 Perioperative Management of Patients Who Are Receiving VKAs

2.1. In patients who require temporary interruption of a VKA before surgery or a procedure and require normalization of the INR for the surgery or procedure, we recommend stopping VKAs approximately 5 days before surgery over stopping VKAs within a shorter time interval before surgery to allow adequate time for the INR to normalize (Grade 1B).

2.2. In patients who have had temporary interruption of a VKA before surgery or a procedure, we recommend resuming VKAs approximately 12 to 24 h (the evening of or the next morning) after surgery and when there is adequate hemostasis over resumption of VKAs closer to surgery (Grade 1C).

2.3. In patients who require temporary interruption of a VKA before surgery or a procedure and whose INR is still elevated (ie, ≥ 1.5) 1 to 2 days before surgery, we suggest administering low-dose (ie, 1 to 2 mg) oral vitamin K to normalize the INR instead of not administering vitamin K (Grade 2C).

2.4. In patients with a mechanical heart valve or atrial fibrillation or VTE at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose SC LMWH or IV UFH over no bridging during temporary interruption of VKA therapy (Grade 1C); we suggest therapeutic-dose SC LMWH over IV UFH (Grade 2C). In patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade 2C); we suggest therapeutic-dose SC LMWH over other management options (Grade 2C). In patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C).

Values and preferences: In patients at high or moderate risk for thromboembolism, the recommendations reflect a relatively high value on preventing thromboembolism and a relatively low value is on preventing bleeding; in patients at low risk for thromboembolism, the recommendations reflect a relatively high value on preventing bleeding and a relatively low value on preventing thromboembolism.

3.0 Perioperative Management of Patients Who Are Receiving Bridging Anticoagulation

3.1. In patients who require temporary interruption of VKAs and are to receive bridging anticoagulation, from a cost-containment perspective we recommend the use of SC LMWH administered in an outpatient setting where feasible instead of inpatient administration of IV UFH (Grade 1C).

Values and preferences: This recommendation reflects a consideration not only of the trade-off between the advantages and disadvantages of SC LMWH and IV UFH as reflected in their effects on clinical outcomes (LMWH at least as good, possibly better), but also the implications in terms of resource use (costs) in a representative group of countries (substantially less resource use with LMWH).

3.2. In patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH, we recommend administering the last dose of LMWH 24 h before surgery or a procedure over administering LMWH closer to surgery (Grade 1C); for the last preoperative dose of LMWH, we recommend administering approximately half the total daily dose instead of 100% of the total daily dose (Grade 1C). In patients who are receiving bridging anticoagulation with therapeutic-dose IV UFH, we recommend stopping UFH approximately 4 h before surgery over stopping UFH closer to surgery (Grade 1C).

3.3. In patients undergoing a minor surgical or other invasive procedure and who are receiving bridging anticoagulation with therapeutic-dose LMWH, we recommend resuming this regimen approximately 24 h after (eg, the day after) the procedure when there is adequate hemostasis over a shorter (eg, < 12 h) time interval (Grade 1C). In patients undergoing major surgery or a high bleeding risk surgery/procedure and for whom postoperative therapeutic-dose LMWH/UFH is planned, we recommend either delaying the initiation of therapeutic-dose LMWH/UFH for 48 to 72 h after surgery when hemostasis is secured, administering low-dose LMWH/UFH after surgery when hemostasis is secured, or completely avoiding LMWH or UFH after surgery over the administration of therapeutic-dose LMWH/UFH in close proximity to surgery (Grade 1C). We recommend considering the anticipated bleeding risk and adequacy of postoperative hemostasis in individual patients to determine the timing of LMWH or UFH resumption after surgery instead of resuming LMWH or UFH at a fixed time after surgery in all patients (Grade 1C).

3.4. In patients who are receiving bridging anticoagulation with LMWH, we suggest against the routine use of anti-factor Xa levels to monitor the anticoagulant effect of LMWHs (Grade 2C).

4.0 Perioperative Management of Patients Who Are Receiving Antiplatelet Therapy

4.2. In patients who require temporary interruption of aspirin- or clopidogrel-containing drugs before surgery or a procedure, we suggest stopping this treatment 7 to 10 days before the procedure over stopping this treatment closer to surgery (Grade 2C).

4.3. In patients who have had temporary interruption of aspirin therapy because of surgery or a procedure, we suggest resuming aspirin approximately 24 h (or the next morning) after surgery when there is adequate hemostasis instead of resuming aspirin closer to surgery (Grade 2C). In patients who have had temporary interruption of clopidogrel because of surgery or a procedure, we suggest resuming clopidogrel approximately 24 h (or the next morning) after surgery when there is adequate hemostasis instead of resuming clopidogrel closer to surgery (Grade 2C).

4.4. In patients who are receiving antiplatelet drugs, we suggest against the routine use of platelet function assays to monitor the antithrombotic effect of aspirin or clopidogrel (Grade 2C).

4.5. For patients who are not at high risk for cardiac events, we recommend interruption of antiplatelet drugs (Grade 1C). For patients at high risk of cardiac events (exclusive of coronary stents) scheduled for noncardiac surgery, we suggest continuing aspirin up to and beyond the time of surgery (Grade 2C); if patients are receiving clopidogrel, we suggest interrupting clopidogrel at least 5 days and, preferably, within 10 days prior to surgery (Grade 2C). In patients scheduled for CABG, we recommend continuing aspirin up to and beyond the time of CABG (Grade 1C); if aspirin is interrupted, we recommend it be reinitiated between 6 h and 48 h after CABG (Grade 1C). In patients scheduled for CABG, we recommend interrupting clopidogrel at least 5 days and, preferably, 10 days prior to surgery (Grade 1C). In patients scheduled for PCI, we suggest continuing aspirin up to and beyond the time of the procedure; if clopidogrel is interrupted prior to PCI, we suggest resuming clopidogrel after PCI with a loading dose of 300 to 600 mg (Grade 2C).

4.6. In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C). In patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C). In patients with a coronary stent who have interruption of antiplatelet therapy before surgery, we suggest against the routine use of bridging therapy with UFH, LMWH, direct thrombin inhibitors, or glycoprotein IIb/IIIa inhibitors (Grade 2C).