New guideline released on periop management of antithrombotic therapy

The American College of Chest Physicians issued a new clinical practice guideline on perioperative management of antithrombotic therapy.

A multidisciplinary panel generated 44 recommendations, which cover use of vitamin K antagonists (VKAs), heparin bridging, direct oral anticoagulants (DOACs), and antiplatelet drugs in surgical patients. The panelists noted that a substantial amount of new evidence had emerged since the 2012 iteration of the guideline. The guideline and an executive summary were published Aug. 11 by CHEST.

Only two recommendations were strong: one against the use of heparin bridging in patients with atrial fibrillation and one in favor of continuing VKA therapy in patients having a pacemaker or internal cardiac defibrillator implanted.

Conditional recommendations also suggest against heparin bridging in a number of other scenarios, including in patients taking a VKA for a mechanical heart valve or venous thromboembolism and interrupting it for elective surgery, in patients requiring DOAC interruption for an elective surgery, and in patients whose VKA is interrupted for colonoscopy with polypectomy expected.

Other key recommendations from the guideline advise on how long to stop specific DOACs before an elective surgery: one to two days for apixaban, edoxaban, and rivaroxaban, and one to four days for dabigatran. They suggest resuming DOACs more than 24 hours after a surgery but not using coagulation function testing to guide perioperative DOAC management. They also suggest against routine use of platelet function testing in patients taking antiplatelets and undergoing elective surgery.

For patients undergoing elective noncardiac surgery and coronary artery bypass grafting (CABG), the guideline suggests continuing rather than interrupting aspirin. However, they suggest P2Y12 inhibitors be interrupted for CABG. The guideline offers additional specific recommendations for patients with stents and details on use of low-molecular-weight heparin for bridging when appropriate, among other topics.