Management of peri-operative anti-thrombotic therapy

The management of antithrombotic therapy in the peri-operative setting is a common problem, balancing haemorrhagic risk with continued treatment and thrombotic risk when discontinued. High-quality evidence is lacking regarding the optimal approach for patients on oral anticoagulants or antiplatelet agents. This review discusses the available evidence for the management of patients on warfarin, non-vitamin K antagonist oral anticoagulant drugs, and antiplatelet therapy in the peri-operative setting. Bridging therapy for patients on warfarin should be considered for those at highest risk of thrombosis, whereas it may not be necessary for those on non-vitamin K antagonist oral anticoagulant drugs given the reduced time off anticoagulation and their more predictable pharmacokinetics. Aspirin can be continued for most procedures. Dual antiplatelet agents for patients with a recently inserted coronary artery stent should be continued if possible but decisions should be individualised and taken after multidisciplinary discussion.