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How I treat anticoagulated patients undergoing an elective procedure or surgery
Alex C Spyropoulos1, James D Douketis
1Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, Rochester, NY, USA. Alex_Spyropoulos@URMC.Rochester.edu
Insights
Managing patients on long-term anticoagulation therapy during procedures is challenging. This review offers practical guidance on periprocedural anticoagulant management, balancing thromboembolic and bleeding risks.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Periprocedural management of oral anticoagulant therapy presents a significant clinical challenge.
- High-quality evidence guiding best practices for these patients is limited.
- Balancing thromboembolic risk and procedural bleeding risk is crucial.
Observation:
- Thromboembolic risk dictates the intensity of periprocedural strategies, including heparin bridging.
- Procedural bleed risk influences the timing of resuming postprocedural anticoagulation.
- Warfarin may be continued for minor procedures; heparin bridging is considered for high-risk major procedures.
Findings:
- Novel oral anticoagulants (dabigatran, rivaroxaban, apixaban) show potential for simplified periprocedural use due to their pharmacokinetic profiles.
- Heparin bridging therapy is a key consideration for high-thromboembolic risk patients undergoing major procedures requiring warfarin interruption.
- A minority of moderate-risk patients may also benefit from heparin bridging.
Implications:
- This review provides a clinician-focused, practical approach to periprocedural anticoagulant management.
- Understanding the nuances of anticoagulant management is vital for patient safety during procedures.
- Emerging data on novel oral anticoagulants may refine future periprocedural guidelines.
Abstract:
The periprocedural management of patients receiving long-term oral anticoagulant therapy remains a common but difficult clinical problem, with a lack of high-quality evidence to inform best practices. It is a patient's thromboembolic risk that drives the need for an aggressive periprocedural strategy, including the use of heparin bridging therapy, to minimize time off anticoagulant therapy, while the procedural bleed risk determines how and when postprocedural anticoagulant therapy should be resumed. Warfarin should be continued in patients undergoing selected minor procedures, whereas in major procedures that necessitate warfarin interruption, heparin bridging therapy should be considered in patients at high thromboembolic risk and in a minority of patients at moderate risk. Periprocedural data with the novel oral anticoagulants, such as dabigatran, rivaroxaban, and apixaban, are emerging, but their relatively short half-life, rapid onset of action, and predictable pharmacokinetics should simplify periprocedural use. This review aims to provide a practical, clinician-focused approach to periprocedural anticoagulant management.
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