Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
BACKGROUND
This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure.


METHODS
The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement.


RESULTS
In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C).


CONCLUSIONS
Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
Department of Medicine, McMaster University, Hamilton, ON, Canada.
James D
JD
Douketis
Department of Medicine, University of Rochester, Rochester, NY.
Alex C
AC
Spyropoulos
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Frederick A
FA
Spencer
Medical Outpatient Department, University Hospital Basel, Basel, Switzerland.
Michael
M
Mayr
Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL.
Amir K
AK
Jaffer
Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH.
Mark H
MH
Eckman
Department of Medicine, Mount Sinai School of Medicine, New York, NY.
Andrew S
AS
Dunn
Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland. Electronic address: RKunz@uhbs.ch.
Regina
R
Kunz
D015906:Angioplasty, Balloon, Coronary; D001241:Aspirin / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000097:blood / Q000150:complications / Q000188:drug therapy; D004334:Drug Administration Schedule; D017558:Elective Surgical Procedures; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects* / Q000493:pharmacokinetics; D006350:Heart Valve Prosthesis; D006801:Humans; D019990:Perioperative Care; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects* / Q000493:pharmacokinetics; D011183:Postoperative Complications / Q000097:blood / Q000188:drug therapy / Q000517:prevention & control; D012307:Risk Factors; D012955:Societies, Medical; D015607:Stents; D013927:Thrombosis / Q000097:blood / Q000188:drug therapy* / Q000517:prevention & control*; D014481:United States; D014812:Vitamin K / Q000037:antagonists & inhibitors
D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D014812:Vitamin K; D001241:Aspirin