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The Perioperative Management of Antithrombotic Therapy^*

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

^* From McMaster University (Dr. Douketis), Hamilton, ON, Canada; Geisinger Clinic (Dr. Berger), Danville, PA; Mount Sinai School of Medicine (Dr. Dunn), New York, NY; University of Miami (Dr. Jaffer), Leonard M. Miller, School of Medicine, Miami, FL; Clinical Thrombosis Center (Dr. Spyropoulos), Lovelace Medical Center, Albuquerque, NM; Duke University (Dr. Becker), Durham, NC; and Boston University (Dr. Ansell), Boston, MA.

Correspondence to: Jack E. Ansell, MD, FACP, FCCP, Department of Medicine, Boston University Medical Center, 88 East Newton St, Boston, MA 02118; e-mail: jack.ansell{at}bmc.org

This article discusses the perioperative management of antithrombotic therapy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). The primary objectives of this article are the following: (1) to address the perioperative management of patients who are receiving vitamin K antagonists (VKAs) or antiplatelet drugs, such as aspirin and clopidogrel, and require an elective surgical or other invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery. The recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al, CHEST 2008; 133:123S–131S). Briefly, Grade 1 recommendations are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade 2 recommendations are referred to as suggestions and imply that individual patient values may lead to different management choices.

The key recommendations in this article include the following: in patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE) at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) LMWH or IV UFH over no bridging during temporary interruption of VKA therapy (Grade 1C); in patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade 2C); in patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C).

In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C); in patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C).

In patients who are undergoing minor dental procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure and coadministering an oral prohemostatic agent (Grade 1B); in patients who are undergoing minor dermatologic procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C); in patients who are undergoing cataract removal and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C).

Key Words: arterial thromboembolism • aspirin • bleeding • bridging anticoagulation • clopidogrel • low-molecular-weight heparin • oral anticoagulant • perioperative • stroke • surgery • unfractionated heparin • venous thromboembolism • vitamin K antagonist