2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation

Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy

“…However, it is important to note that, for patients undergoing a surgical procedure, initiation of thromboprophylaxis with the new oral anticoagulants is recommended a minimum of 24 hours, and perhaps as long as 72 hours, depending on bleeding risk. 36,187,331 Hence, ASRA regional and pain guidelines are functionally the same.…”

Scientific and Standardization Committee Communication: Guidance document on the periprocedural management of patients on chronic oral anticoagulant therapy: Recommendations for standardized reporting of procedural/surgical bleed risk and patient‐specific thromboembolic risk

“…Last, a recent meta‐analysis of 4519 procedures in patients with AF deemed at bleed risk low enough to warrant uninterrupted VKA or DOAC, including diagnostic gastrointestinal endoscopic procedures, dermatologic procedures, ophthalmological procedures (cataract removal), and dental/maxillofacial surgical procedures revealed pooled incidence rates of major bleed (MB) at 30 days of 3.3% (95% CI: 2.7‐4.0) and 2.0% (95% CI: 1.6‐2.4), respectively, which is higher than the perceived bleeding risk . Surgical and procedural societies have included non‐specific terms that include “not clinically relevant” and “very low bleed risk” to describe bleed risk in procedures associated with a 2‐day MB rate of <1% and, by definition, would not warrant OAC interruption . Other guidance statements on the topic refer to the term “minimal bleed risk” to describe those procedures or surgeries at low enough bleed risk to warrant uninterrupted OAC (or at most a single interruption of DOAC on the day of procedure) …”

“…Patient‐specific TE risk anchors decisions of whether an aggressive periprocedural antithrombotic approach such as bridging therapy with treatment doses of unfractionated heparin (UFH) or low‐molecular‐weight‐heparin (LMWH), typically during VKA interruption, would be used with the intention of preventing perioperative cardioembolic TE in high‐risk patients . Recent systematic reviews, meta‐analyses, and guidance statements on the topic found a lack of uniform definitions of procedural/surgical bleed risk and patient‐specific TE risk, identifying a need to apply a standardized risk stratification approach . Thus, the aim of adopting a standardized periprocedural classification of procedural/surgical bleed risk and patient‐specific TE risk would ensure: (a) harmonized outcome reporting across clinical trials, observational studies and meta‐analyses that would allow comparison and pooling of results; (b) assistance to guideline developers in interpretation of study results as they pertain to patient subgroups undergoing specific procedures; and (c) development of consistent and cost‐efficient institutional protocols whereby the risk classification informs periprocedural anticoagulant management approaches.…”

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition)

“…237 This interval is similar to recent recommendations on resumption of the new oral anticoagulants (NOACs) after a surgical procedure. 238,239 This scenario should rarely be encountered because moderateand high-risk pain procedures should not be done in patients who are on IV heparin.…”