Review Key Concepts on Perioperative Management of Anticoagulant and Antiplatelet Therapy
Douketis JD, Spyropoulos, AC. Perioperative Management of Anticoagulant and Antiplatelet Therapy. NEJM Evidence 2023;2(6) [published Online First: 5/23/2023]
Excerpt
This article provided a clear, valuable, and easily readable review of key concepts for safe and effective management of patients who are scheduled to undergo a surgical procedure and are taking medications that alter the blood coagulation process. Surgeons are encouraged to review the entire article. The authors emphasized the importance of preoperative bleeding risk stratification.
A table providing clinical characteristics that facilitate classification of patients into three risk categories (high, low-moderate, and minimal) is provided in the article text. Another table provides guidance for thromboembolic (VTE) risk stratification.
Optimal management of this patient group requires a basic understanding of key pharmacokinetic and pharmacodynamic properties of anticoagulant and antiplatelet drugs. Vitamin K antagonists (VKA) require several days to be eliminated from the patient, while low molecular heparin and direct oral anticoagulant drugs (DOAC) are eliminated within hours (up to 10-12 hours for edoxaban).
Standard perioperative management plans are discussed in the article. Vitamin K antagonists may be continued for low-risk dental and dermatologic procedures. For major surgery, the authors advise against heparin bridging after VKA interruption for patients with atrial fibrillation or patients who have mechanical heart valves because of evidence showing that bridging does not reduce risk for VTE but is associated with increased rates of bleeding. For other patient groups, VKA cessation 5 days before the planned procedure is recommended.
Heparin bridging is recommended for patients at moderate or high risk for thromboembolism. Patients taking DOAC agents can have the drug stopped 10-14 hours prior to the procedure with resumption 2-4 days postoperatively, depending on thromboembolism risk.
In the last section of the article, the authors discuss management of patients taking aspirin; continuation of aspirin is recommended in patients with recent cardiac events or patients undergoing vascular procedures. Interruption of aspirin therapy in other patient groups is chosen based on bleeding and thromboembolism risk assessment.
