Overview
This webinar discussed the 2022 American College of Chest Physicians (ACCP) guidelines on perioperative management of antithrombotic therapy, focusing on practical approaches and evidence-based recommendations for clinicians managing patients on anticoagulants and antiplatelet agents during elective surgery.
Introduction and Objectives
- Reviewed the significant updates and rationale behind the new ACCP guidelines.
- Panel included key guideline authors and clinical experts in vascular medicine, cardiology, and pharmacy.
- Aimed to clarify practice changes, implementation strategies, and unanswered questions in perioperative antithrombotic management.
Key Areas of the Guidelines
- Guidelines expanded from 11 to 43 clinical questions with 44 statements across four domains: vitamin K antagonists (VKAs, e.g., warfarin), direct oral anticoagulants (DOACs), bridging therapy, and antiplatelet agents.
- Emphasized practical "how-to" advice: risk assessment, interruption/resumption strategies, and bridging decisions.
DOACs (Direct Oral Anticoagulants) Management
- Suggested stopping apixaban/rivaroxaban 1 day before low/moderate-risk and 2 days before high bleeding risk procedures.
- Recommendation against routine bridging with low molecular weight heparin for DOAC patients.
- Routine DOAC level testing before surgery not recommended except for special outlier cases.
- Consider renal function mainly for dabigatran, not for most DOACs unless severe impairment or drug interactions.
Warfarin and Bridging Therapy
- Strong recommendation to continue warfarin for certain cardiac procedures (e.g., pacemaker/ICD placement) over interruption and bridging.
- Suggested continuing warfarin for dental, dermatologic, or ophthalmologic procedures.
- Bridging with heparin generally not needed except for high thromboembolic risk patients (specific definitions provided for high risk).
- Bridging increases major bleeding without clear thromboembolic benefit in most populations.
- Emphasized individual clinical assessment using bleeding and thromboembolic risk stratification tools.
Antiplatelet Therapy Management
- Suggested continuing aspirin during elective non-cardiac surgery, with flexibility for high-bleeding-risk cases.
- Recommended stopping aspirin earlier than 7–10 days before surgery if interrupted.
- For dual antiplatelet therapy (DAPT), continue aspirin but interrupt P2Y12 inhibitors 5–7 days prior, with consideration for high-risk stent scenarios.
- Bridging with intravenous antiplatelet agents (e.g., cangrelor) reserved for select patients with recent high-risk coronary stenting.
Implementation and Institutional Practice
- Successful guideline adoption depends on multidisciplinary collaboration and updated institutional policies and order sets.
- Clinicians encouraged to use guidelines as a starting point, adapting for unique patient factors as needed.
- Emphasized ongoing staff education and communication for safe perioperative management.
Decisions
- Do not routinely bridge DOAC or warfarin patients except in high thromboembolic risk cases.
- Continue aspirin for most elective surgeries, unless high bleeding risk dictates otherwise.
Action Items
- TBD – All Institutions: Update perioperative antithrombotic management protocols in line with 2022 ACCP guidelines.
- TBD – Pharmacy/Anticoagulation Teams: Educate staff on guideline changes and implement revised order sets.
- TBD – Multidisciplinary Teams: Review local practices for bridging and antiplatelet management; ensure alignment with updated evidence.
Questions / Follow-Ups
- Remaining uncertainty over duration of DOAC hold for neuraxial anesthesia due to guideline discrepancies.
- More research needed on perioperative management with dual antiplatelet therapy and novel stent types.
Recommendations / Advice
- Use guideline algorithms for initial decision-making, then individualize for comorbidities, drug interactions, and unique procedural risks.
- Engage all stakeholders (cardiology, surgery, pharmacy, nursing) in protocol updates and patient management planning.