Anticoagulant and Antiplatelet Therapy

Peri-operative management of anticoagulation and antiplatelet therapy 7 October 2016

British Journal of Haematology Volume 175, Issue 4
Peri-operative management of anticoagulation and antiplatelet therapy 7 October 2016

WARFARIN
Recommendations
Warfarin should be stopped for 5 days before an elective procedure if anticoagulation needs to be discontinued (1C).
Patients with venous thromboembolism (VTE) more than 3 months earlier can usually be given post-operative prophylactic dose low molecular weight heparin (LMWH) (or a suitable alternative) rather than bridging therapy (2C).
Patients at very high risk of recurrent VTE, such as patients with a previous VTE whilst on therapeutic anticoagulation who now have a target International Normalized Ratio (INR) of 3·5, and patients who have had VTE less than 3 months previously should be considered for bridging (2D)
Patients with atrial fibrillation who have a CHADS2 score of ≤4 and who have not had a stroke or transient ischaemic attack (TIA) in last three months should not receive bridging (1A)
Patients with a bileaflet aortic mechanical heart valve (MHV) with no other risk factors do not require bridging whilst it should be considered in all other MHV patients (2C).
We recommend that post-operative bridging is not started until at least 48 h after high bleeding risk surgery (1C).

DOACs
Recommendations
Patients with normal renal function undergoing planned low risk procedures should not take a direct oral anticoagulant (DOAC) for 24 h before the procedure (2B)
Patients with normal renal function undergoing planned higher risk procedures should not take a DOAC for 48 h before the procedure (2B)
For patients with renal impairment see Table 2 (2D).
Following minor or low risk procedures in patients with low bleeding risk, anticoagulation can be recommenced 6–12 h post-procedure if haemostasis has been fully secured (2C)
Following high risk procedures and in patients with an increased bleeding risk or in any situation where any increased risk of bleeding is unacceptable, DOACs should not be re-introduced at full dose until at least 48 h post-procedure (2C)
In patients with high thrombosis risk it is appropriate to consider prophylactic doses of anticoagulation before re-introducing full therapeutic dose DOAC (2D)
DOAC measurement by indirect methods using dilute thrombin time, ecarin clotting time and calibrated anti-Xa assays should currently be interpreted with caution in the management of patients receiving a DOAC who require emergency surgery (2B)
A normal thrombin time can be interpreted as indicating that there is a minimal circulating concentration of dabigatran. Normal prothrombin time (PT) and activated partial thromboplastin time (APTT) do not exclude significant concentrations of dabigatran, rivaroxaban or apixaban (1A)
If an anticoagulant effect cannot be excluded, neuroaxial anaesthesia should be avoided (1C).
Prothrombin complex concentrates should not be routinely used in patients on DOACs prior to emergency surgery (2D)
Tranexamic acid is likely to reduce bleeding in patients who have a residual anticoagulant effect (1C).
Drugs and colloids that impair the haemostatic mechanism should be avoided in the peri-surgical management of patients receiving DOACs (2D)
Idarucizumab should be used to reverse dabigatran therapy prior to emergency invasive procedures and surgery where the bleeding risk is considered significant (1C)
Andexanet, when available, should be used to reverse apixaban, rivaroxaban or edoxaban prior to emergency invasive procedures and surgery where the bleeding risk is considered significant (2C)
ANTIPLATELETS
Recommendations
When being used for secondary prevention of cardiovascular disease, aspirin monotherapy can be continued for most invasive non-cardiac procedures (including neuroaxial anaesthesia) but, if the perceived bleeding risk is high, aspirin can be omitted from day −3 to day +7 with no net detriment (2C)
Aspirin can be continued both before and after coronary artery bypass surgery (1B)
Hip fracture surgery can take place early in patients on clopidogrel (1B)
For urgent low bleeding risk surgery in patients on antiplatelet agents routine platelet transfusion should not be given (2C)
For urgent high-bleeding risk surgery in patients on antiplatelet agents
o Given the uncertain net benefit of platelet transfusion, consider the use of pre-operative intravenous tranexamic acid (2C)
o If, despite tranexamic acid, there is excessive peri- or post-op bleeding, or if the bleeding risk is perceived to be very high, consider infusion of 2 pools of donor platelets. This may improve haemostasis if given at least two h after the last dose of aspirin though even higher doses of donor platelets 12–24 h after the last dose of clopidogrel may have a lesser effect (2C)
In patients with a recent acute coronary syndrome or coronary artery stent on dual antiplatelet therapy low bleeding risk procedures should proceed without interruption of antiplatelet therapy (1C)
In patients with a recent acute coronary syndrome or coronary artery stent on dual antiplatelet therapy elective high bleeding risk procedures should, if possible, be postponed in patients still requiring dual antiplatelet therapy (1C). If surgery cannot be deferred, aspirin should be continued and clopidogrel or ticagrelor interrupted from 5 days pre-op or prasugrel from 7 days pre-op (1C).

For Further reading please click the link below.

Haematology guidelines on perioperative management of anticoagulants

 

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