Perioperative Management of Anticoagulants and Antiplatelets

Capsule summary adopted from the American College of Chest PhysiciansEvidence-Based Clinical Practice Guidelines 1 Evaluate the thromboembolic risk and hemorrhagic risk of the individual patients 2 Consider temporary cessation of the drug in procedures that carry a significant risk of bleeding 3 Low thromboembolism and bleeding risk Warfarin may be continued with relatively low INR 1.5-1.8 for minor procedures 4 For high bleeding risk with low-thromboembolism-risk group Warfarin can be withheld for 5 days before surgery without any bridging anticoagulation with unfractionated or low molecular weight heparin 5 High-thromboembolism-risk patients Generally such patients should be considered for a more aggressive perioperative management strategy with bridging therapy 6 As compared with warfarin, patients on NOACs are less likely to require bridging therapy due to their short half-life ANTIPLATELET AGENTS1 Use of DAPT following percutaneous coronary procedures and following acute coronary syndrome are common 2 Current recommendations for DAPT range from 4 weeks in patients undergoing elective stenting with bare metal stents to up to 12 months in patients with drug-eluting stents or patients undergoing coronary stenting for acute coronary syndrome 3 Low-dose aspirin alone does not substantially increase the risk of clinically important bleeding after invasive procedures and can usually be continued during surgery 4 If a patient is to undergo high-bleeding-risk surgery and an antiplatelet effect is not desired, clopidogrel, prasugrel and ticagrelor should be discontinued 5-7 days prior to the procedure 5 Early, effective communication between GPs and specialists is useful in managing high-risk patients on anticoagulant/antiplatelet agents during the perioperative periods DAPT, dual antiplatelet therapy; NOACs, new oral anticoagulants Perioperative Management of Anticoagulants and Antiplatelets