This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure.
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.
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).
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.From the Department of Medicine (Drs Douketis and Spencer), McMaster University, Hamilton, ON, Canada; Department of Medicine (Dr Spyropoulos), University of Rochester, Rochester, NY; Medical Outpatient Department (Dr Mayr), University Hospital Basel, Basel, Switzerland; Division of Hospital Medicine (Dr Jaffer), Department of Medicine, University of Miami Miller School of Medicine, Miami, FL; Division of General Internal Medicine and Center for Clinical Effectiveness (Dr Eckman), University of Cincinnati Medical Center, Cincinnati, OH; Department of Medicine (Dr Dunn), Mount Sinai School of Medicine, New York, NY; and Academy of Swiss Insurance Medicine (Dr Kunz), Department of Medicine, University Hospital Basel, Basel, Switzerland.
Correspondence to: Regina Kunz, MD, MSc (Epi), Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland; e-mail: RKunz@uhbs.ch
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: contributed as Topic Editor for this section.
Financial/nonfinancial disclosures: The authors of this guideline provided detailed conflict of interest information related to each individual recommendation made in this article. A grid of these disclosures is available online at http://chestjournal.chestpubs.org/content/141/2_suppl/e326S/suppl/DC1. In summary, the authors have reported to CHEST the following conflicts of interest: Dr Douketis was a consultant for Boerhinger-Ingelheim and served as a consultant during four advisory board meetings meetings (by Sanofi-Aventis, Astra-Zeneca, Boehringer-Ingelheim, Pfizer) relating to the development and clinical use of novel, but not approved for clinical use, antiplatelet drugs (ticagrelor) and anticoagulant drugs (apixaban, semuloparin, dabigatran). Dr Eckman has received the following university grants: “Using Decision Analytic Modeling to Guide the ACCP Guideline Development Process for Antithrombotic Therapy in Atrial Fibrillation” (Foundation for Informed Medical Decision Making; October 2011-September 2013; $185,000); “Cost-Effectiveness of Screening for Chronic Hepatitis C Infection” (Merck/Schering-Plough; October 2011-September 2012; $58,000); “Greater Cincinnati BEACON Collaborative” (Office of the National Coordinator for Health Information Technology [90BC0016/01]; September 2010-March 2012; ∼ 15% effort); “Cincinnati Center for Clinical and Translational Science and Training (CTSA) ARRA Supplement for Development of Distance Learning Program in Medical Informatics” (National Institutes of Health [NIH]/National Center for Research Resources [NCRR] [UL1 RR026314-01S1]; August 2009-August 2011; ∼ 20% effort); “Cincinnati Center for Clinical and Translational Science and Training (CTSA)” (NIH/NCRR [1U54 RR 025216]; January 2009-February 2014; ∼ 15% effort); “A Patient Specific Decision Support Tool for Bariatric Surgery” (National Institute of Diabetes and Digestive and Kidney Diseases [K23 DK075599]; August 2007-June 2012; no financial support); National Heart, Lung, and Blood Institute (K23 HL085387; June 2008-March 2013; no financial support); and “Cost-Effectiveness of Screening for Chronic Hepatitis B Infection” (Gilead Sciences Inc; March 2008-August 2010; ∼ $56,000). He has also served as consultant for Savient Pharmaceuticals (“Cost Effectiveness Analysis of Gout Medication”; 2010; ∼ $300) and as editorial consultant for the ACP (“Physicians’ Information and Education Resource [PIER]: Module on Pre-Operative Assessment for Bleeding Disorders”; 2006-present; ∼ $250/year). Dr Spyropoulos has served as a consultant to Pfizer, Sanofi-Aventis, and EISAI. Dr Jaffer served as a consultant to sanofi-aventis, Janssen, Canyon Pharmaceuticals, Boehringer Ingelheim, and Daiichi Sankyo; he has formerly spoken on behalf of sanofi-aventis. Dr Jaffer is also on the steering committee of an NHLBI clinical trial. Dr Kunz is a member of the GRADE Working Group, the methodology of which is used in these guidelines. She has an interest in seeing this methodology applied. Drs Spencer, Mayr, and Dunn have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Role of sponsors: The sponsors played no role in the development of these guidelines. Sponsoring organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Guideline panel members, including the chair, and members of the Health & Science Policy Committee are blinded to the funding sources. Further details on the Conflict of Interest Policy are available online at http://chestnet.org.
Endorsements: This guideline is endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the American Society of Health-System Pharmacists, the American Society of Hematology, and the International Society of Thrombosis and Hematosis.
Other contributions: Deborah Siegal, MD, contributed to the generation of the evidence profiles for the recommendations 2.4 and 4.2-4.4.
Additional information: The Appendix S1 and supplement Tables can be found in the Online Data Supplement at http://chestjournal.chestpubs.org/content/141/2_suppl/e326S/suppl/DC1.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).