PREOPERATIVE MANAGEMENT OF PATIENTS ON CHRONIC ANTITHROMBOTIC THERAPY WHO REQUIRE ELECTIVE NON-CARDIAC SURGERY
English
Abstract
Preoperative management of antithrombotic therapy (antiplatelet and anticoagulant therapy) is challenging since discontinuation of therapy carries a risk of the thromboembolic event and surgery carries a risk of bleeding. An optimal balance between thromboembolic and bleeding risk must be reached and the decision whether to stop antithrombotic therapy or not be made. Each patient requires an individual assessment. That means estimating bleeding and thromboembolic risk for each patient. Bleeding risk is based on patient-related risk factors and risk associated with the surgical procedure. Thromboembolic risk is more complex to calculate. If the decision is to stop antithrombotic therapy, the next question is how long before the surgery it should be stopped and whether the bridging therapy is required.
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Arepally B, Bauer KA, Bhatt DL, Merli GJ, Naccarelli GV, Carter RD et al. The use of antithrombotic ther-apies in the prevention and treatment of arterial and venous thrombosis: a survey of current knowledge and practice supporting the need for clinical education. Crit Pathw Cardiol 2010;9(1):41-48. [CrossRef] [PubMed]
Baron TH, Kamath PS, McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl Med 2013;368(22):2113-24. [CrossRef] [PubMed]
Bhattad V, Gaddam S, Lassiter MA, Jagadish PS, Ardeshna D, Cave B et al. Intravenous cangrelor as a peri-procedural bridge with applied uses in ischemic events. Ann Transl Med 2019;7(17):408. [CrossRef][PubMed]
Brilakis ES, Patel VG, Banerjee S. Medical manage-ment after coronary stent implantation: a review. J Am Med Assoc 2013;310:189-98. [CrossRef] [PubMed]
Capodanno D, Milluzzo RP, Angiolillo DJ. Intravenous antiplatelet therapies (glycoprotein IIb/IIIa receptor inhibitors and cangrelor) in percutaneous coronary intervention:from pharmacology to indications for clinical use. Ther Adv Cardiovasc Dis 2019;13: 1753944719893274. [CrossRef] [PubMed]
Chassot PG, Marcucci C, Delabays A, Spahn D. Peri-operative Antiplatelet Therapy. Am Fam Physician 2010;82(12):1484-89. [PubMed]
Dangas GD, Weitz JI, Giustino G, Makkar R, Mehran R. Prosthetic heart valve thrombosis. J Am Coll Cardiol 2016;68(24):2670-89. [CrossRef] [PubMed]
Douketis JD, Foster GA, Crowther MA, Prins MH, Ginsberg JS. Clinical risk factors and timing of recur-rent venous thromboembolism during the initial 3 months of anticoagulant therapy. Arch Intern Med 2000;160(22):3431-6. [CrossRef] [PubMed]
Douketis JD, Spyropoulos AC, Duncan J, Carrier M , Le Gal G, Tafur AJ et al. Perioeprative Management of Patients With Atrial Fibrilation Receiving a Direct Oral Anticoagulant. JAMA Inten Med 2019;179(11):1469-78. [CrossRef] [PubMed]
Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH et al. Perioperative manage-ment of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2):e326s-e350s. [CrossRef] [PubMed]
Duminda N, Wijeysundera DN, Wijeysundera HC, Yun L, Wąsowicz M, Beattie WS et al. Risk of elective major noncardiac surgery after coronary stent in-sertion: a population-based study. Circulation 2012; 126(11):1355-62. [CrossRef] [PubMed]
Dunn AS, Spyropoulus A, Turpie AG. Bridging therapy in patients on long-term anticoagulants who require surgery: the prospective perioperative enoxaparin co-hort trial (PROSPECT). J Thromb Haemost 2007; 5(11):2211-8. [CrossRef] [PubMed]
Gallego P, Apostolakis S, Lip GY. Bridging evidence-based practice and practice-based evidence in peri-procedural anticoagulation. Circulation 2012;126(13): 1573-6. [CrossRef] [PubMed]
Gažová A, Leddy JJ, Rexová M, Hlivák P, Hatala R, Kyselovič J. Predictive value of CHA2DS2-VASc scores regarding the risk of stroke and all-cause mortality in patients with atrial fibrillation (CONSORT compliant). Medicine (Baltimore) 2019;98(31):e16560. [CrossRef] [PubMed]
Hall R, Mazer CD. Antiplatelet drugs: A review of their pharmacology and management in perioperative pe-riod. Anesth Analg 2011;112(2):292-318. [CrossRef] [PubMed]
Jaffer AK. Perioperative management of warfarin and antiplatelet therapy. Cleve Clin J Med 2009;76(4):s37-44. [CrossRef] [PubMed]
Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997; 336(21):1506. [CrossRef] [PubMed]
Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJR et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022;39:100-32. [CrossRef] [PubMed]
Kiran U, Makhija N. Patient with Recent Coronary Artery Stent Requiring Major Non Cardiac Surgery. Indian J Anaesth 2009;53(5):582-91. [PubMed]
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart sur-vey on atrial fibrilation. Chest 2010;137(2):263-72. [CrossRef] [PubMed]
Oprea AD, Popescu WM. Perioperative management of antiplatelet therapy. Br J Anaesth 2013;111(1):i3-i17. [CrossRef] [PubMed]
Ortel TL. Perioperative management of patients on chronic antithrombotic therapy. Blood 2012;120(24): 4699-705. [CrossRef] [PubMed]
Park SJ, Park DW, Kim YH, Kang SJ, Lee SW, Lee CW. Duration of dual antiplatelet therapy after implantation of drug-eluting stents. N Engl Med 2010;362(15): 1374-82. [CrossRef] [PubMed]
Plümer L, Seiffert M, Punke MA, Kersten JF, Blankenberg S, Zöllner C et al. Aspirin Before Elective Surgery-Stop or Continue? Dtsch Arztebl Int 2017; 114(27-28):473-80. [CrossRef] [PubMed]
Prendergast BD. Management of patients with pro-sthetic heart valves during non-cardiac surgery. Przegl Lek 2004;61:556-9.
Shah Z, Masoomi R, Tadors P. Managing antiplatelet therapy and Anticoagulants in Patients with Coronary Artery Disease and Atrial Fibrillation. J Atr Fibrillation 2015;8(4):1318. [CrossRef] [PubMed]
Siegal D, Yudin J, Kaatz S, Doukites JD, Lim W, Spyropoulus AC. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thrombo-embolic rates. Circulation 2012;126(13):1630-9. [CrossRef] [PubMed]
Stangier J, Rathgen K, Stähle H, Mazur D. Influence of renal impairment on the pharmacokinetics and pharmacodynamics of oral dabigatran etexilate:an open-label, parallel-group single-centre study. Clin pharmacokinet 2010;49(4):259-68. [CrossRef] [PubMed]
Tafur A, Clark N, Spyropoulos A, Li N, Kaplovitch E, MacDougall K. Predictors of Bleeding in the Perioperative Anticoagulant Use for Surgery Evaluation Study. J Am Heart Assoc 2020;9:e017316. [CrossRef] [PubMed]
Thachil J. Antiplatelet therapy- a summary for the general physicians .Clin Med (Lond) 2016;16(2):152-160. [CrossRef] [PubMed]
Torn M, Rosendaal FR. Oral anticoagulation in surgical procedures:risk and recomandations. Br J Haematol 2003;123(4):676-82. [CrossRef] [PubMed]
Watson RDS, Chin BSP, Lip GYH. Antithrombotic therapy in acute coronary syndromes. BMJ 2002; 325(7376):1348-51. [CrossRef] [PubMed]
Whitlock RP, Sun JC, Fremes SE, Robens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis, 9th Ed: American College of Chest Physi-cians evidence-based clinical practice guidelines. Chest 2012;141(2 Suppl):e576S-600S. [CrossRef] [PubMed]
Woods K, Douketis JD, Kathirgamanathan K, YI Q, Crowther MA. Low dose vitamin K to normalize the international normalized ratio prior to surgery in pa-tients who require temporary interruption of warfarin. J Thromb Thrombolysis 2007;24(2):93-7. [CrossRef] [PubMed]
Zhu W, He W, Guo L, Wang X, Hong K. The HAS-BLED Score for Predicting Major bleeding risk in anticoagu-lated patients with atrial fibrillation: A systemic review and meta-analysis. Clin Cardiol 2015;38(9):555-61. [CrossRef] [PubMed]
Zwart B, Godschalk TC, Kelder JC, Ten Berg JM. High risk of stent thrombosis in the first 6 months after coronary stenting: Do not discontinue clopidogrel early after ACS. J Interv Cardiol 2017;30(5):421-6. [CrossRef] [PubMed]