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Perioperative management of patients on chronic antithrombotic therapy
1Hemostasis and Thrombosis Center, Duke University Medical Center, Durham, NC 27710, USA. thomas.ortel@duke.edu
Insights
Managing antithrombotic therapy during surgery requires balancing bleeding and clotting risks. New oral anticoagulants present unique challenges, necessitating careful patient and procedure assessment for optimal perioperative care.
Area of Science:
- Cardiology
- Pharmacology
- Surgical Management
Background:
- Perioperative management of antithrombotic therapy is complex, involving patient-specific factors, procedural risks, and diverse anticoagulant/antiplatelet agents.
- Balancing thromboembolic event risk against perioperative bleeding risk is crucial during preoperative assessment.
Purpose of the Study:
- To outline strategies for perioperative management of antithrombotic therapy.
- To address the challenges posed by traditional and novel oral anticoagulants and antiplatelet agents in surgical settings.
Main Methods:
- Categorization of surgical procedures based on bleeding risk (low, intermediate, high).
- Evaluation of strategies for warfarin interruption, including bridging with low-molecular-weight heparin.
- Consideration of new oral anticoagulants (dabigatran, rivaroxaban) and their specific management concerns.
Main Results:
- Low bleeding risk procedures may not require complete antithrombotic reversal.
- Warfarin management involves decisions on withholding versus bridging therapy.
- New oral anticoagulants require careful consideration due to renal insufficiency effects and lack of reversal agents.
Conclusions:
- Perioperative antithrombotic management necessitates individualized approaches based on patient risk, procedure type, and agent properties.
- Special attention is required for patients with coronary artery stents on antiplatelet therapy.
- Further research is needed to address challenges with new oral anticoagulants, including laboratory monitoring and reversal strategies.
Abstract:
Perioperative management of antithrombotic therapy is a situation that occurs frequently and requires consideration of the patient, the procedure, and an expanding array of anticoagulant and antiplatelet agents. Preoperative assessment must address each patient's risk for thromboembolic events balanced against the risk for perioperative bleeding. Procedures can be separated into those with a low bleeding risk, which generally do not require complete reversal of the antithrombotic therapy, and those associated with an intermediate or high bleeding risk. For patients who are receiving warfarin who need interruption of the anticoagulant, consideration must be given to whether simply withholding the anticoagulant is the optimal approach or whether a perioperative "bridge" with an alternative agent, typically a low-molecular-weight heparin, should be used. The new oral anticoagulants dabigatran and rivaroxaban have shorter effective half-lives, but they introduce other concerns for perioperative management, including prolonged drug effect in patients with renal insufficiency, limited experience with clinical laboratory testing to confirm lack of residual anticoagulant effect, and lack of a reversal agent. Antiplatelet agents must also be considered in the perioperative setting, with particular consideration given to the potential risk for thrombotic complications in patients with coronary artery stents who have antiplatelet therapy withheld.
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