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Published on: July 31, 2016
Perioperative management of anticoagulant therapy
Johanna Wagner1, Johan F Lock2, Carolin Kastner2
1Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Medical Center Julius-Maximilians, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany.
Insights
Managing oral anticoagulant therapy during invasive procedures requires balancing bleeding and thromboembolic risks. Physicians must tailor anticoagulant management, including potential bridging therapy, based on individual patient factors and procedural bleeding risk.
Area of Science:
- Cardiology
- Pharmacology
- Internal Medicine
Background:
- Chronic oral anticoagulant therapy is common, but 10% of patients need invasive procedures.
- These procedures increase the risk of peri-interventional or perioperative bleeding.
- Decisions on continuing or interrupting anticoagulation depend on thromboembolic and bleeding risks.
Purpose of the Study:
- To outline strategies for managing oral anticoagulant therapy during invasive procedures.
- To guide physicians in balancing anticoagulation needs with bleeding risks.
- To differentiate management based on anticoagulant type and procedural risk.
Main Methods:
- Review of current guidelines and clinical practices for perioperative anticoagulation.
- Consideration of patient-specific factors like age, renal function, and drug interactions.
- Categorization of procedures based on bleeding risk (minor vs. increased).
Main Results:
- Minor bleeding risk procedures may not require pausing anticoagulation.
- Increased bleeding risk procedures necessitate pausing oral anticoagulants.
- Bridging therapy with low molecular weight heparin is recommended for coumarin users with high thromboembolic risk.
- Bridging therapy is not advised for low thromboembolic risk patients or those on non-vitamin K oral anticoagulants.
Conclusions:
- Perioperative anticoagulation management must be individualized.
- Bridging therapy decisions depend on the type of anticoagulant and thromboembolic risk.
- Non-vitamin K oral anticoagulants generally do not require bridging due to their pharmacokinetic profiles.
Abstract:
About 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an increased risk for peri-interventional or perioperative bleeding. Depending on the risk for thromboembolism and the risk for bleeding, the physician has to decide whether the anticoagulant therapy should be interrupted or continued. Patient characteristics such as age, renal function and drug interactions must be considered. The perioperative handling of the oral anticoagulant therapy differs according to the periprocedural bleeding risk. Patients requiring a procedure with a minor risk for bleeding do not need to pause their anticoagulant therapy. For procedures with an increased risk for perioperative bleeding, the anticoagulant therapy should be adequately paused. For patients on a coumarin derivative with a high risk for a thromboembolic event, a perioperative bridging therapy with a low molecular weight heparin is recommended. Due to an increased risk for perioperative bleeding in patients on a bridging therapy, it is not recommended in patients with a low risk for thromboembolism. For patients taking a non-vitamin K oral anticoagulant, a bridging therapy is not recommended due to the fast onset and offset of the medication.
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