Periprocedural Antithrombotic Therapy: A Practical Guide for Clinical Practice

Abstract

More than 6 million patients are on anticoagulant therapy and more than one third of adults take antiplatelet therapy in the United States, many of whom will require a surgical procedure while on treatment. The answers to questions regarding periprocedural thrombotic therapy are not at all straightforward and there is tremendous variability in practice across the country and across specialties. While there will always be nuances in clinical care that necessitate variation in practice patterns, algorithms for care allow for less ambiguity and they provide guidelines that are consistent with the most recent evidence in the literature. In this review, we provide: 1) a framework for periprocedureal antithrombotic therapy around the time of surgical procedures, 2) an approach for considering the risk of bleeding at the time of surgery as well as the risk of a thrombotic or thromboembolic event should the antithrombotic therapy be stopped, and 3) a strategy for managing periprocedural bridging therapy. KEY WORDSperiprocedural anticoagulation, antithrombotic therapy, thrombosis, bleeding risk, oral anticoagulation. n IS ANTITHROMBOTIC THERAPY REQUIRED?Answering a question regarding antithrombotic therapy should start with the consideration of whether or not the anticoagulation is still indicated in the first place. However, assuming the patient still has an indication for anticoagulation (and assuming a non-emergent surgery), the next question involves answering questions regarding surgical bleeding risk and the risk of thrombosis/thromboembolism if therapy is withheld. n BLEEDING RISKOne of the major risk-stratifications in assessing bleeding risk involves the risk inherent to the surgery or procedure. There is minimal data to guide decisions regarding procedural bleeding risk. The 2 main factors that impact bleeding risk are the type of procedure and the patient factors that interfere with hemostasis. A frequently cited reference with regard to surgical bleeding is from the American College of Chest Physicians, 1 which used expert consensus to generate a list of high-risk procedures. Interestingly, the major reference for surgical bleeding risk dates back to a metaanalysis of perioperative subcutaneous heparin use for the prevention of pulmonary embolism in 1988.2 Table 1 includes a list of high-risk procedures compiled from these consensus guidelines as well as another recent review. 1,3 In general, this list comprises surgeries that involve highly vascular organs or large incisions. An extensive list of surgical procedures and their associated risk has also been compiled as an appendix to a recent review on periprocedural antithrombotic therapy 4 (also based on expert opinion).There are several validated nonprocedural factors that increase bleeding risk and these include abnormal renal function, nonsteroidal anti-inflammatory medications, low platelet count, and liver disease/coagulopathy. These factors have been combined into a variety of bleeding risk scores: (1) and (4) ATRIA (anticoagulation and risk f...