The American College of Chest Physicians has issued an updated clinical practice guideline for the perioperative management of antithrombotic therapy, which was published in Chest.
More than 10 million people annually worldwide are assessed for perioperative antithrombotic therapy management; such therapy includes vitamin K antagonists (VKA), direct oral anticoagulant (DOAC), heparin bridging, and antiplatelet drugs for those who require a surgery or invasive procedure. The goal of perioperative antithrombotic management is to administer individualized, patient-centric care and minimize perioperative thromboembolism and bleeding.
The new guideline, which addresses 43 patient-intervention-comparator-outcome (PICO) questions, is a significant update of the 2012 guidelines, which addressed 11 PICO questions. The new guideline also provides 44 evidence-based recommendations related to the PICO questions. New topics in the guideline include the perioperative management of patients who are receiving direct oral anticoagulants (DOACs) and P2Y12 inhibitory antiplatelet drugs, as well as guidance on perioperative laboratory testing.
“The target audience for this guideline is the wide array of clinicians involved in perioperative patient care, but it is also relevant for researchers to identify areas of future study, for patients to access a reliable information resource, and for clinical managers to facilitate the development of standardized patient care paths,” stated the authors.
A focus on 4 patient groups
The PICO questions and guideline statements are grouped into 4 categories, reflecting the 4 patient groups clinicians typically encounter: (1) patients receiving a vitamin K antagonist (VKA), focused on warfarin; (2) patients receiving a VKA and using perioperative heparin bridging; (3) patients receiving a DOAC; and (4) patients receiving an antiplatelet drug. The PICO questions are also designed to address numerous practical aspects of perioperative antithrombotic therapy management.
The guideline followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A recommendation for each PICO question was classified as strong (“we recommend”) or conditional (“we suggest”). The certainty of evidence was categorized as high, moderate, low, or very low.
Heparin bridging, VKA therapy, and cardiac procedures
The guideline authors issued 2 strong recommendations, with moderate certainty of evidence. The first strong recommendation is against the use of heparin bridging in patients who receive VKA therapy for atrial fibrillation and require VKA interruption for an elective surgery or procedure. The second strong recommendation is for the continuation of VKA vs VKA interruption and heparin bridging in patients receiving VKA therapy who require a pacemaker or internal cardiac defibrillator implantation. The authors noted that continuation of VKAs around cardiac device procedures is based on the premise that a patient’s international normalized ratio at the time of the procedure is less than 3.0.
Guideline authors consider 18 of their recommendations to be “key recommendations.” Among those, the authors suggest against the use of heparin bridging in patients receiving VKA therapy for a mechanical heart valve who require VKA interruption for an elective surgery or procedure. For patients receiving VKA therapy for venous thromboembolism as the only clinical indication and requiring VKA interruption for an elective surgery or procedure, the authors suggest against the use of heparin bridging.
Therapy interruptions for other procedures
In patients receiving VKA therapy who require VKA interruption for a colonoscopy with anticipated polypectomy, the authors suggest against the use of heparin bridging during VKA interruption.
In patients who are receiving dabigatran and require an elective surgery or procedure, the authors suggest discontinuing dabigatran for 1 to 4 days before the surgery or procedure rather than dabigatran continuation.
In patients who are receiving edoxaban and require an elective surgery or procedure, the authors suggest discontinuing edoxaban for 1 to 2 days before the surgery or procedure compared with edoxaban continuation.
The authors suggest stopping rivaroxaban for 1 to 2 days before the surgery or procedure instead of rivaroxaban continuation in patients who are receiving rivaroxaban and require an elective surgery or procedure.
Direct oral anticoagulants
For patients who require DOAC interruption for an elective surgery or procedure, the authors suggest against the use of perioperative heparin bridging.
The guideline authors also suggest resuming DOACs more than 24 hours after a surgery or procedure vs resuming DOACs within 24 hours among patients who had a DOAC interruption for an elective surgery or procedure. For patients who had DOAC interruption for an elective surgery or procedure, the authors suggest against routine DOAC coagulation function testing to guide perioperative DOAC management.
Acetylsalicylic acid (ASA) continuation is suggested vs ASA interruption in patients who are receiving ASA and are undergoing elective noncardiac surgery. For patients who are receiving ASA and undergoing coronary artery bypass graft surgery, the authors suggest continuation of ASA vs interruption. In patients who are receiving a P2Y12 inhibitor drug, the authors suggest interruption of the P2Y12 inhibitor compared with continuation perioperatively.
Antiplatelet drug therapy, P2Y12 inhibitors
Among patients receiving antiplatelet drug therapy who are undergoing an elective surgery or procedure, the authors suggest against the routine use of platelet function testing before the surgery or procedure to guide perioperative antiplatelet management. In patients who are receiving ASA and a P2Y12 inhibitor who had coronary stents placed within the previous 3 to 12 months and are undergoing an elective surgery or procedure, the authors suggest discontinuing the P2Y12 inhibitor before surgery vs continuation of the P2Y12 inhibitor.
“Although there have been important advances in the perioperative management of anticoagulant and antiplatelet therapy, much work remains to bridge gaps in knowledge,” the authors stated. “A challenging area of research is the perioperative management of antiplatelet drugs, especially those with coronary stents who are receiving ASA and a P2Y12 inhibitor, as there are multiple factors (timing of stent placement, type of surgery, type of antiplatelet therapy) that make it difficult to undertake well-designed randomized trials.”
Guideline development process
The guideline panel comprised a multidisciplinary group of clinicians, including internists, thrombosis specialists, cardiologists, anesthesiologists, surgeons, intensivists, and pharmacists, who worked with methodologists from the Mayo Clinic Evidence Center.
The systematic review was performed in multiple databases through July 2021 and was limited to English-language articles and human studies, as well as by article type (clinical trial, randomized clinical trial, and systematic review).
Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: an American College of Chest Physicians clinical practice guideline. Chest. Published online August 9, 2022. doi:10.1016/j.chest.2022.07.025
Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: an American College of Chest Physicians clinical practice guideline executive summary. Chest. Published online August 10, 2022. doi:10.1016/j.chest.2022.08.004