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American College of Chest PhysiciansInternal Medicine2022advanced

Perioperative Management Of Antithrombotic Therapy

Published by American College of Chest Physicians · GRADE

44Recommendations
295References
2Tables
3Figures
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Summary

AI-generated

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.

antithrombotic therapyACCP2022guidelinesinternal medicineVKADOACASA

Key Takeaways

  • 1
    Recommend against heparin bridging in patients with atrial fibrillation receiving VKA.
  • 2
    Recommend continuation of VKA therapy in patients having a pacemaker or ICD implantation.
  • 3
    Suggest stopping DOACs 1 to 4 days prior to surgery without routine heparin bridging.
  • 4
    Suggest continuation of ASA over interruption in patients undergoing elective non-cardiac surgery.

What's New in This Version

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.

Key Recommendations

Perioperative Interruption and Resumption of VKAs

  • 1

    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.

    ConditionalEvidence: LowManagement
  • 2

    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.

    ConditionalEvidence: LowManagement
  • 3

    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.

    ConditionalEvidence: Very LowManagement
  • 4

    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.

    ConditionalEvidence: Very LowManagement

Bridging Anticoagulation During Interruption of VKA Therapy

  • 5

    In patients receiving VKA therapy for a mechanical heart valve who require VKA interruption for an elective surgery/procedure, we suggest against heparin bridging.

    ConditionalEvidence: Very LowManagement
  • 6

    In patients receiving VKA therapy for atrial fibrillation who require VKA interruption for an elective surgery/procedure, we recommend against heparin bridging.

    StrongEvidence: ModerateManagement
  • 7

    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.

    ConditionalEvidence: Very LowManagement
  • 8

    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.

    ConditionalEvidence: Very LowManagement
  • 9

    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.

    ConditionalEvidence: Very LowManagement

Management of Patients Who Are Receiving a VKA and Need Minor Procedures

  • 10

    In patients receiving VKA therapy who need a dental procedure, we suggest continuation of VKA over VKA interruption.

    ConditionalEvidence: LowManagement
  • 11

    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.

    ConditionalEvidence: LowIntervention
  • 12

    In patients receiving VKA therapy who require a minor dermatologic procedure, we suggest continuation of VKA over VKA interruption.

    ConditionalEvidence: Very LowManagement
  • 13

    In patients receiving VKA therapy who require a minor ophthalmologic procedure, we suggest continuation of VKA over VKA interruption.

    ConditionalEvidence: Very LowManagement
  • 14

    In patients receiving VKA therapy who require a pacemaker or ICD implantation, we recommend continuation of VKA over VKA interruption and heparin bridging.

    StrongEvidence: ModerateManagement
  • 15

    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.

    ConditionalEvidence: Very LowManagement

Perioperative Use of IV UFH as Bridging Anticoagulation

  • 16

    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.

    ConditionalEvidence: Very LowManagement
  • 17

    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.

    ConditionalEvidence: Very LowManagement

Perioperative Use of LMWH as Bridging Anticoagulation

  • 18

    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.

    ConditionalEvidence: Very LowManagement
  • 19

    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.

    ConditionalEvidence: Very LowManagement
  • 20

    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.

    ConditionalEvidence: Very LowManagement
  • 21

    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.

    ConditionalEvidence: Very LowManagement

Perioperative Interruption and Resumption of DOACs

  • 22

    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.

    ConditionalEvidence: Very LowManagement
  • 23

    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.

    ConditionalEvidence: Very LowManagement
  • 24

    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.

    ConditionalEvidence: Very LowManagement
  • 25

    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.

    ConditionalEvidence: Very LowManagement
  • 26

    In patients who require DOAC interruption for an elective surgery/procedure, we suggest against perioperative heparin bridging.

    ConditionalEvidence: Very LowManagement
  • 27

    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.

    ConditionalEvidence: Very LowManagement

Perioperative Laboratory Measurement of DOAC Therapy

  • 28

    In patients who had DOAC interruption for an elective surgery/procedure, we suggest against routine DOAC coagulation function testing to guide perioperative DOAC management.

    ConditionalEvidence: Very LowDiagnostic

Patients Having Non-cardiac Surgery

  • 29a

    In patients receiving ASA who are undergoing elective non-cardiac surgery, we suggest ASA continuation over ASA interruption.

    ConditionalEvidence: ModerateManagement
  • 29b

    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.

    ConditionalEvidence: Very LowManagement
  • 30

    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.

    ConditionalEvidence: Very LowManagement
  • 31

    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.

    ConditionalEvidence: Very LowManagement
  • 32

    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.

    ConditionalEvidence: Very LowManagement
  • 33

    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.

    ConditionalEvidence: Very LowManagement

Patients Having Coronary Artery Bypass Graft Surgery

  • 34

    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.

    ConditionalEvidence: LowManagement
  • 35

    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.

    ConditionalEvidence: LowManagement

Perioperative Measurement of Antiplatelet Therapy

  • 36

    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.

    ConditionalEvidence: Very LowDiagnostic

Patients With Coronary Stents Having Surgery

  • 37

    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.

    ConditionalEvidence: Very LowManagement
  • 38

    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.

    ConditionalEvidence: Very LowManagement
  • 39

    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.

    ConditionalEvidence: LowManagement
  • 40

    In patients with coronary stents who require continued dual antiplatelet therapy, we suggest delaying an elective surgery/procedure over not delaying the surgery/procedure.

    ConditionalEvidence: Very LowManagement

Patients Having a Minor Dental, Dermatologic, or Ophthalmologic Procedure

  • 41

    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.

    ConditionalEvidence: Very LowManagement
  • 42

    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.

    ConditionalEvidence: Very LowManagement
  • 43

    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.

    ConditionalEvidence: LowManagement

Scope & Objectives

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

SurgeonsProceduralistsInternistsCardiologistsHematologistsIntensivistsPharmacistsAnesthesiologistsPrimary care physicians

Patient Criteria & Setting

Therapeutic Area

Antithrombotic Therapy

Guideline Scope

ManagementTreatmentRisk Assessment

Inclusion Criteria

  • Patients receiving long-term (>= 3 months) antithrombotic therapy
  • Focus on VKAs, DOACs, and antiplatelet drugs
  • Patients requiring an elective, non-urgent surgery or procedure

Exclusion Criteria

  • Patients requiring an urgent surgery or procedure
  • Infrequently used anticoagulant or antiplatelet drugs
  • Low-dose DOAC regimens
  • Drugs used for short periods
  • Low-dose LMWHs or DOACs intended as prophylaxis against postoperative VTE

Care Settings

PerioperativeHospitalOutpatient

Special Populations

Atrial fibrillationMechanical prosthetic heart valveVenous thromboembolismCoronary artery diseasePeripheral arterial diseasePatients with coronary stentsImpaired renal function

Evidence Grading

System: GRADE

Evidence Distribution

44total_recommendations
2strong_recommendations
42conditional_recommendations

Evidence Levels

LowLow certainty of evidence.
HighHigh certainty that the effect estimate is adequate to support a recommendation.
ModerateModerate certainty of evidence.
Very LowVery low certainty of evidence.

Recommendation Strength

StrongStrong recommendations, referred to as 'we recommend'.
ConditionalConditional practice recommendations, referred to as 'we suggest'.

Safety & Contraindications

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.

Authors & Contributors

James D. DouketisMDFCCP; Alex C. SpyropoulosMDFCCP; M. Hassan MuradMDMPH; Juan I. ArcelusMD; William E. DagerPharmD; Andrew S. DunnMDMPH; Ramiz A. FargoMDFCCP; Jerrold H. LevyMD; C. Marc SamamaMD; Sahrish H. ShahMBBS; Matthew W. SherwoodMD; Alfonso J. TafurMD; Liang V. TangMD; Lisa K. MooresMDFCCP

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Learning Paths

Perioperative CareAntithrombotic TherapyHeparin BridgingDOAC ManagementAntiplatelet TherapyVKA Management