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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. Careful consideration of patient factors, procedure type, and specific anticoagulant or antiplatelet agents is crucial for optimal outcomes.
Area of Science:
- Cardiology
- Pharmacology
- Surgical Management
Background:
- Perioperative management of antithrombotic therapy is complex, involving numerous anticoagulant and antiplatelet agents.
- Balancing thromboembolic event risk against perioperative bleeding risk is essential for patient safety.
Purpose of the Study:
- To review the considerations for perioperative management of antithrombotic therapy.
- To outline strategies for managing patients on various antithrombotic agents undergoing procedures.
Main Methods:
- Literature review and synthesis of current guidelines on antithrombotic therapy management.
- Categorization of procedures based on bleeding risk (low, intermediate, high).
- Discussion of specific anticoagulant agents (warfarin, new oral anticoagulants) and antiplatelet agents.
Main Results:
- Procedures with low bleeding risk may not require complete antithrombotic reversal.
- Warfarin management may involve simple withholding or bridging with low-molecular-weight heparin.
- New oral anticoagulants present challenges due to renal clearance, limited lab testing, and lack of reversal agents.
- Antiplatelet therapy management requires careful consideration, especially for patients with coronary artery stents.
Conclusions:
- Individualized patient assessment, procedure-specific bleeding risk, and agent-specific properties are key to safe perioperative antithrombotic management.
- Further research is needed for optimal management of newer oral anticoagulants in the perioperative setting.
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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