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Perioperative management of the chronically anticoagulated patient
1Mayo Clinic Thrombophilia Center, Mayo Clinic and Foundation, Rochester, MN 55905, USA.
Insights
Managing patients on chronic anticoagulation for surgery involves stopping oral anticoagulants 4-5 days prior and restarting them post-procedure. Bridging therapy with low molecular weight heparin is an option for high-risk patients.
Area of Science:
- Cardiology
- Hematology
- Surgical Management
Background:
- Chronic anticoagulation is crucial for conditions like mechanical prosthetic heart valves, atrial fibrillation, and venous thromboembolism.
- Perioperative management of anticoagulated patients presents challenges including surgical urgency, thromboembolic risk, and bleeding concerns.
Purpose of the Study:
- To outline strategies for the safe perioperative management of patients on chronic anticoagulation.
- To delineate procedures that can be performed with or without anticoagulation interruption.
Main Methods:
- Review of current guidelines and clinical practices for managing anticoagulation around surgical procedures.
- Categorization of surgical procedures based on bleeding risk and need for anticoagulation interruption.
- Assessment of risks and benefits of bridging therapy with low molecular weight heparin.
Main Results:
- Most patients can safely stop oral anticoagulants 4-5 days before surgery and resume their usual dose post-procedure.
- Dental procedures and cataract extraction may not require anticoagulation interruption.
- For high-thrombosis-risk patients, bridging therapy with low molecular weight heparin is effective. Urgent procedures can utilize oral vitamin K to rapidly lower INR.
Conclusions:
- Perioperative anticoagulation management requires careful consideration of individual patient risk factors and surgical procedure type.
- Standard protocols involving temporary cessation and resumption of anticoagulation, or bridging therapy, ensure patient safety.
- Minimizing anticoagulation interruption and utilizing vitamin K for urgent cases are key strategies.
Abstract:
Common indications for chronic anticoagulation include mechanical prosthetic heart valve, non-rheumatic atrial fibrillation, and venous thromboembolism. Perioperative management of the chronically anticoagulated patient is a complex medical problem, and includes the following issues: urgency of surgery, risk of thromboembolism in the absence of anticoagulation, bleeding risk, consequences of bleeding, ability to control bleeding physically, and duration of bleeding risk after the procedure. Most patients can be managed safely by stopping oral anticoagulants 4-5 days before surgery and restarting anticoagulation after the procedure at the patient's usual daily dose. In general, dental procedures and cataract extraction can be performed without interrupting anticoagulation. Most other procedures can be safely performed with an INR < or = 1.4. For patients with double-wing prosthetic valves (e.g., St. Jude, Carbomedics) in the aortic position, uncomplicated atrial fibrillation, or a remote (>3 months) history of venous thromboembolism, oral anticoagulants can be stopped 4-5 days before surgery and restarted at the usual daily dose immediately after surgery. For other patients at higher risk of thrombosis, "bridging therapy" with outpatient low molecular weight heparin is safe and effective. For urgent procedures, a small dose of oral vitamin K usually will reduce the INR within 24-36 hours to a level sufficient for surgery and avoids exposure to transfused blood products.