NEJM Journal Watch
Daniel D. Dressler, MD, MSc, MHM, FACP, reviewing
New recommendations guide management of perioperative and periprocedural antithrombotic agents.
In their previous guideline on perioperative antithrombotic management (published a decade ago; Chest 2012;141:2 Suppl:e326S. opens in new tab), the ACCP addressed 11 questions; now, they discuss 43 questions, using a structured approach. All recommendations are for perioperative patients who are undergoing elective surgery or procedures.
1. In patients who are receiving vitamin K antagonists (VKAs, e.g., warfarin) and who require VKA interruption prior to surgery:
- Stop VKAs ≥5 days prior to surgery, and restart VKAs <24 hours following surgery.
- Do not provide routine heparin bridging for patients who are receiving VKAs for atrial fibrillation, venous thromboembolism, or mechanical heart valves and are at low-to-moderate risk for thromboembolism. In patients at high risk for thromboembolism, consider heparin bridging. opens in new tab.
- For minor procedures — dental, dermatologic, ophthalmologic, pacemaker placement, and colonoscopy with or without polypectomy — VKA continuation is recommended over disruption; topical hemostatic agents (e.g., oral tranexamic acid) should be employed in appropriate settings.
2. In patients who require perioperative heparin bridging of anticoagulation therapy:
- Stop intravenous unfractionated heparin (UFH) ≥4 hours prior to surgery, and resume UFH ≥24 hours after surgery.
- Stop low-molecular-weight heparin (LMWH), with the last dose approximately 24 hours prior to surgery; resume LMWH ≥24 hours following surgery or procedure.
3. In patients receiving direct-acting oral anticoagulant (DOAC) therapy:
- Based on the specific DOAC, patient factors (e.g., chronic kidney disease), individual patient bleeding risk, and expected surgical or procedural bleeding risk, stop DOACs between 1 day and 4 days prior to surgery or procedure, and resume DOACs 24 to 72 hours after surgery or procedure. Clinicians should consult the guideline for specific timing recommendations. opens in new tab.
4. In patients receiving antiplatelet agents:
- In general, continue aspirin perioperatively for elective noncardiac surgery. If clinicians wish to interrupt aspirin in selected patients, it should be stopped ≤7 days prior to surgery.
- Interruption of P2Y12 inhibitors preoperatively is based on the specific medication (i.e., clopidogrel, 5 days; ticagrelor, 3–5 days; prasugrel, 7 days). Restart agents ≤24 hours after surgery.
- For minor procedures (e.g., dental, dermatologic, ophthalmologic), patients receiving single antiplatelet agents should continue them perioperatively, whereas patients receiving dual antiplatelet agents should continue aspirin and interrupt their P2Y12 inhibitor.
Although most of the guidelines are assigned “conditional recommendation” based on low-certainty or very low–certainty evidence, the compilation provides a framework under which clinicians can offer reasonably consistent antithrombosis practices based on recently published evidence and expert opinions. The online supplement to this guideline. opens in new tab contains an expanded introduction and methods section.
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