Periprocedural antithrombotic management: A review of the literature and practical approach for the hospitalist physician

Many patients who are on long-term antithrombotic therapy (e.g. warfarin and/or antiplatelet agents) must be assessed for temporary discontinuation for a procedure or surgery, making this a salient topic for the hospitalist physician. Discontinuation of antithromhotic therapy can place patients at increased risk of thromboembolic complications while continuing antithrombotic therapy can increase procedure-related bleeding risk. Bridging anticoagulation with heparin or low molecular weight heparins is often used in the periprocedural period, but a great deal of uncertainty exists about how and when to use bridging anticoagulation. Because there is very little Level 1 evidence to define optimal care, both clinical practice and expert consensus guideline opinions vary. For the hospitalist, it is of critical importance to understand the available data, controversies, and management options in order to approach patient care rationally. This review provides a step-wise literature-based discussion addressing the following four questions: (1) What is the optimal management of antiplatelet therapy in the periprocedural period? (2) Are there very low bleeding risk procedures that do not require interruption of oral anticoagulation? (3) Are there low thromboembolic risk populations who do not require periprocedural bridging? (4) How do you manage patients who must discontinue anti-coagulants but are at an increased thrombotic risk?