How I treat anticoagulated patients undergoing an elective procedure or surgery

Abstract

The periprocedural management of patients receiving long-term oral anticoagulant therapy remains a common but difficult clinical problem, with a lack of highquality evidence to inform best practices. It is a patient's thromboembolic risk that drives the need for an aggressive periprocedural strategy, including the use of heparin bridging therapy, to minimize time off anticoagulant therapy, while the procedural bleed risk determines how and when postprocedural anticoagulant therapy should be resumed. Warfarin should be continued in patients undergoing selected minor procedures, whereas in major procedures that necessitate warfarin interruption, heparin bridging therapy should be considered in patients at high thromboembolic risk and in a minority of patients at moderate risk.Periprocedural data with the novel oral anticoagulants, such as dabigatran, rivaroxaban, and apixaban, are emerging, but their relatively short half-life, rapid onset of action, and predictable pharmacokinetics should simplify periprocedural use. This review aims to provide a practical, clinician-focused approach to periprocedural anticoagulant management. (Blood. 2012;120(15):2954-2962)

Perioperative interruption of direct oral anticoagulants in patients with atrial fibrillation: A systematic review and meta‐analysis

“…The increasing prevalence of AF, as well as the need to interrupt anticoagulation for invasive procedures poses a growing problem for a wide variety of clinicians 13. Previous expert narrative reviews have provided guidance to clinicians on the management of DOACs in the perioperative period 14, 15. In order to update these expert reviews with clinical data, we conducted a systematic review and meta‐analysis of the literature on the perioperative management of DOACs in patients with AF.…”

Reversal of warfarin anticoagulation for urgent surgical procedures

“…5,6 Although a mildly elevated INR (\ 1.8) is not predictive of an increased risk of bleeding with surgical procedures, a lower target INR is recommended for certain procedures where bleeding into a confined space could lead to complications. 7 For example, the American Society of Regional Anesthesia and Pain Medicine recommends that the INR must be normalized before initiation of a neuraxial block and \ 1.5 for removal of an epidural catheter.…”

“…Une anticoagulation de transition à l'aide d'héparine de bas poids moléculaire sous-cutanée ou d'héparine non fractionnée intraveineuse, en concomitance avec l'interruption du traitement à la warfarine, pourrait s'avérer nécessaire chez les patients courant un risque élevé de complications thromboemboliques. 5,6 Bien qu'un RIN légèrement élevé (\ 1,8) ne prédise pas un risque accru de saignement lors des interventions chirurgicales, un RIN cible plus bas est recommandé pour certaines interventions au cours desquelles des saignements localisés dans un espace restreint pourraient entraîner des complications. 7 Par exemple, l'American Society of Regional Anesthesia and Pain Medicine recommande que le RIN soit normalisé avant l'installation d'un bloc neuraxial et \ 1,5 pour le retrait d'un cathéter péridural.…”

How to manage new oral anticoagulants in case of surgery

“…If bleeding risk is increased it is recommended to assess the presence and entity of anticoagulant activity by the abovementioned laboratory tests. If residual anticoagulant activity is detected, the use of non-activated prothrombin complex concentrates (PCCs) or activated PCCs (FEIBA) should be considered for the urgent reversal of patients treated with dabigatran and PCCs for rivaroxaban 4 when the procedure cannot be postponed and the risk of bleeding is very high. When surgery cannot be delayed, or in patients requiring surgical approach to stop bleeding, the urgent reversal of NOACs should be performed.…”

“…Anticoagulants should be stopped in high bleeding risk procedures; this means 2-4% of major bleeds rate within 48 h of surgery, while low bleeding risk procedures (0-2% within 48 h) also represent a cause for concern (Table 1). 4 When interruption of therapy is indicated, the practical recommendations for vitamin K antagonists in the peri-operative setting suggest their discontinuation five days before surgery and their resumption 24-48 h after surgery if adequate hemostasis has been achieved. 3 Together with the bleeding risk secondary to procedures, the individual bleeding risk should also be assessed (Table 2).…”