Overview
This interview explores the updated American College of Chest Physicians clinical practice guideline on the perioperative management of antithrombotic therapy, highlighting definitions, evidence review, risk assessment, and detailed recommendations for managing anticoagulant and antiplatelet drugs in surgical settings.
Guideline Development and Scope
- The guideline updates prior 2008/2012 versions, incorporating new evidence, particularly on direct oral anticoagulants (DOACs).
- It addresses perioperative management for patients with atrial fibrillation, mechanical heart valves, venous thromboembolism, and coronary artery disease.
- The perioperative period is defined as approximately 5 days before to 30 days after planned elective surgery; urgent/emergent surgeries are excluded.
- Recommendations are based on a mix of direct/indirect evidence, study interpretation, and expert consensus.
Key Definitions and Concepts
- Thromboembolic risk stratification depends on patient and procedural factors (e.g., valve type, stroke history, timing of VTE).
- Bleeding risk is mainly procedure-driven rather than patient-driven.
- Pharmacokinetics (half-life, clearance) and pharmacodynamics (duration of drug effect) are critical for timing drug interruption/resumption.
Perioperative Management of Anticoagulants
- Warfarin should be stopped at least 5 days before surgery; extra days may be needed for higher INR targets or slower metabolism.
- Routine preoperative vitamin K administration for elevated INR (>1.5) is not recommended unless INR is unexpectedly high.
- Bridging with heparin is generally discouraged for atrial fibrillation, VTE, and mechanical heart valves, except in selected high-risk cases.
- For DOACs: Interrupt 1–2 days pre-surgery; longer for impaired renal function (notably with dabigatran). Resume 1–2 days post-surgery, depending on bleeding risk.
Management of Minor Procedures
- Continue anticoagulants for most dental, minor skin, pacemaker/ICD, and some colonoscopy procedures.
- Recommendations for minor procedures are conditional; individualized assessment and communication with proceduralists are advised.
Bridging Protocols
- If bridging is used, administer half the total daily dose the morning before surgery.
- Delay post-op bridging for 48–72 hours after high-bleed risk surgeries, integrating VTE prophylaxis as appropriate.
Antiplatelet Therapy Recommendations
- For patients with recent PCI or coronary stents, delay elective surgery when possible.
- If surgery cannot be delayed, continue aspirin and interrupt P2Y12 inhibitors (3–5 days for ticagrelor, 7–10 days for clopidogrel/prasugrel).
- For non-cardiac surgeries, the default is to continue aspirin, with interruption considered for high bleeding risk.
Decisions
- Do not routinely bridge anticoagulation for atrial fibrillation, VTE, or mechanical heart valve patients, except selected high-risk individuals.
- Continue anticoagulants for most minor, low-bleed risk procedures.
- Default to continuing aspirin perioperatively except in high bleeding risk situations.
Action Items
- TBD – Clinicians: Refer to and individualize recommendations from the guideline for perioperative antithrombotic management.
- TBD – Clinicians: Communicate with proceduralists and cardiologists as needed for complex cases involving recent stents, bridging, or unique patient risks.