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Published by American College of Chest Physicians · GRADE
This guideline updates the 2012 iteration and addresses the perioperative management of patients receiving long-term oral anticoagulant (VKAs, DOACs) or antiplatelet therapy who require elective surgery, focusing on optimal interruption, resumption, and bridging strategies.
Key Takeaways
Updates the 2012 iteration (9th Edition). Addresses 43 PICO questions and introduces new domains such as the perioperative management of DOACs, P2Y12 inhibitor antiplatelet drugs, and guidance on perioperative laboratory testing. A July 2023 Corrigendum updated Table 1 related to thromboembolism risk stratification.
In patients requiring VKA (warfarin) interruption for an elective surgery/procedure, we suggest stopping VKAs (warfarin) >= 5 days over an interruption of < 5 days before an elective surgery/procedure.
In patients requiring VKA (warfarin) interruption for an elective surgery/procedure, we suggest resuming VKA (warfarin) within 24 hours over a delay to > 24 hours after an elective surgery/procedure.
In patients requiring VKA (warfarin) interruption for an elective surgery/procedure, we suggest resuming the first post-operative VKA dose at the patient’s usual dose over resuming VKA with double the usual dose.
In patients requiring VKA interruption for an elective surgery/procedure who have an elevated INR (ie, > 1.5) 1 to 2 days before the surgery/procedure, we suggest against routine use of pre-operative vitamin K.
In patients receiving VKA therapy for a mechanical heart valve who require VKA interruption for an elective surgery/procedure, we suggest against heparin bridging.
In patients receiving VKA therapy for atrial fibrillation who require VKA interruption for an elective surgery/procedure, we recommend against heparin bridging.
In patients receiving VKA therapy for VTE as the sole clinical indication who require VKA interruption for an elective surgery/procedure, we suggest against heparin bridging.
In patients receiving VKA therapy who are classified as high risk for thromboembolism and who require VKA interruption for an elective surgery/procedure, we suggest heparin bridging over no heparin bridging.
In patients receiving VKA therapy who are classified as low-to-moderate-risk for thromboembolism and who require VKA interruption for an elective surgery/procedure, we suggest against heparin bridging.
In patients receiving VKA therapy who need a dental procedure, we suggest continuation of VKA over VKA interruption.
In patients receiving VKA therapy who need a dental procedure, we suggest using a pro-hemostatic agent with continuation of VKA over alternative management options.
In patients receiving VKA therapy who require a minor dermatologic procedure, we suggest continuation of VKA over VKA interruption.
In patients receiving VKA therapy who require a minor ophthalmologic procedure, we suggest continuation of VKA over VKA interruption.
In patients receiving VKA therapy who require a pacemaker or ICD implantation, we recommend continuation of VKA over VKA interruption and heparin bridging.
In patients receiving VKA therapy who require VKA interruption for a colonoscopy with anticipated polypectomy, we suggest against heparin bridging during the period of VKA interruption.
In patients receiving therapeutic-dose IV UFH bridging for an elective surgery/procedure, we suggest stopping UFH >= 4 hours before a surgery/procedure over stopping IV UFH < 4 hours before a surgery/procedure.
In patients receiving therapeutic-dose IV UFH bridging for an elective surgery/procedure, we suggest resuming UFH >= 24 hours after a surgery/procedure over resuming UFH within 24 hours after a surgery/procedure.
In patients receiving LMWH bridging for an elective surgery/procedure, we suggest administering the last pre-operative LMWH bridging dose at approximately 24 hours over administering the last dose 10 to 12 hours before a surgery/procedure.
In patients receiving LMWH bridging for an elective surgery/procedure, we suggest administering the first post-operative LMWH bridging dose at least 24 hours after a surgery/procedure over administering it less than 24 hours after a surgery/procedure.
In patients receiving LMWH bridging for an elective surgery/procedure, we suggest administering half the total daily dose of LMWH the day prior to the surgery/procedure over administering the full dose of LMWH the day prior.
In patients receiving LMWH bridging for an elective surgery/procedure, we suggest against routine measurement of anti-factor Xa levels to guide perioperative LMWH management.
In patients receiving apixaban who require an elective surgery/procedure, we suggest stopping apixaban for 1 to 2 days before the surgery/procedure over apixaban continuation.
In patients receiving dabigatran who require an elective surgery/procedure, we suggest stopping dabigatran for 1 to 4 days before the surgery/procedure over dabigatran continuation.
In patients receiving edoxaban who require an elective surgery/procedure, we suggest stopping edoxaban for 1 to 2 days before the surgery/procedure over edoxaban continuation.
In patients receiving rivaroxaban who require an elective surgery/procedure, we suggest stopping rivaroxaban for 1 to 2 days before the surgery/procedure over rivaroxaban continuation.
In patients who require DOAC interruption for an elective surgery/procedure, we suggest against perioperative heparin bridging.
In patients who had DOAC interruption for an elective surgery/procedure, we suggest resuming DOACs > 24 hours after a surgery/procedure over resuming DOACs within 24 hours.
In patients who had DOAC interruption for an elective surgery/procedure, we suggest against routine DOAC coagulation function testing to guide perioperative DOAC management.
In patients receiving ASA who are undergoing elective non-cardiac surgery, we suggest ASA continuation over ASA interruption.
In patients receiving ASA therapy who are undergoing elective non-cardiac surgery and require ASA interruption, we suggest stopping ASA <= 7 days instead of 7 to 10 days before the surgery.
In patients receiving clopidogrel who are undergoing an elective non-cardiac surgery, we suggest stopping clopidogrel 5 days instead of 7 to 10 days before the surgery.
In patients receiving ticagrelor who are undergoing an elective non-cardiac surgery, we suggest stopping ticagrelor 3 to 5 days instead of 7 to 10 days before the surgery.
In patients receiving prasugrel who are undergoing an elective non-cardiac surgery, we suggest stopping prasugrel 7 days instead of 7 to 10 days before the surgery.
In patients who require antiplatelet drug interruption for an elective surgery/procedure, we suggest to resume antiplatelet drugs <= 24 hours instead of > 24 hours after the surgery/procedure.
In patients who are receiving ASA and undergoing CABG surgery, we suggest continuation of ASA over interruption; in patients receiving a P2Y12 inhibitor drug, we suggest interruption of the P2Y12 inhibitor over continuation perioperatively.
In patients receiving ASA or a P2Y12 inhibitor who are undergoing CABG surgery, we suggest resuming the ASA or P2Y12 inhibitor within 24 hours after surgery compared to >= 24 hours after surgery.
In patients receiving antiplatelet drug therapy who are undergoing an elective surgery/procedure, we suggest against the routine use of platelet function testing prior to the surgery/procedure to guide perioperative antiplatelet management.
In patients receiving ASA and a P2Y12 inhibitor with coronary stents placed within the last 6 to 12 weeks who are undergoing an elective surgery/procedure, we suggest either continuation of both antiplatelet agents or stopping one antiplatelet agent within 7 to 10 days of surgery.
In patients receiving ASA and a P2Y12 inhibitor who had coronary stents placed within the last 3 to 12 months and are undergoing an elective surgery/procedure, we suggest stopping the P2Y12 inhibitor prior to surgery over continuation of the P2Y12 inhibitor.
In patients with coronary stents who require interruption of antiplatelet drugs for an elective surgery/procedure, we suggest against routine bridging therapy with a glycoprotein IIb/IIIa inhibitor, cangrelor, or LMWH over routine use of bridging therapy.
In patients with coronary stents who require continued dual antiplatelet therapy, we suggest delaying an elective surgery/procedure over not delaying the surgery/procedure.
In patients receiving an antiplatelet drug (ASA or P2Y12 inhibitor) who are undergoing a minor dental procedure, we suggest continuing the antiplatelet drug (ASA or the P2Y12 inhibitor) over stopping the antiplatelet agent before the procedure.
In patients receiving an antiplatelet drug (ASA or P2Y12 inhibitor) who are undergoing a minor dermatologic procedure, we suggest continuing the antiplatelet drug (ASA or P2Y12 inhibitor) over stopping the antiplatelet drug before the procedure.
In patients receiving an antiplatelet drug (ASA or P2Y12 inhibitor) undergoing a minor ophthalmologic procedure, we suggest continuing the antiplatelet drug (ASA or P2Y12 inhibitor) throughout the ophthalmologic procedure over stopping the antiplatelet agent before the procedure.
Clinical Topic
Perioperative Management of Antithrombotic Therapy
Objectives
To provide evidence-based recommendations for the perioperative management of patients who are receiving antithrombotic therapy; and to provide practical guidance to clinicians for managing such patients in the perioperative period.
Target Patient Population
Patients receiving long-term oral anticoagulant or antiplatelet therapy who require an elective surgery/procedure.
Target Providers
Therapeutic Area
Antithrombotic TherapyGuideline Scope
Inclusion Criteria
Exclusion Criteria
Care Settings
Special Populations
System: GRADE
Evidence Distribution
Evidence Levels
Recommendation Strength
Monitoring Guidance
Suggests against routine measurement of anti-factor Xa levels for LMWH bridging and against routine DOAC coagulation function testing to guide perioperative management.
Difficulty
advanced
Learning Paths