title: Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery.
abstract: The periprocedural management of patients receiving chronic therapy with oral anticoagulants (OACs), including vitamin K antagonists (VKAs) such as warfarin and direct OACs (DOACs), is a common clinical problem. The optimal perioperative management of patients receiving chronic OAC therapy is anchored on four key principles: (i) risk stratification of patient-related and procedure-related risks of thrombosis and bleeding; (ii) the clinical consequences of a thrombotic or bleeding event; (iii) discontinuation and reinitiation of OAC therapy on the basis of the pharmacokinetic properties of each agent; and (iv) whether aggressive management such as the use of periprocedural heparin bridging has advantages for the prevention of postoperative thromboembolism at the cost of a possible increase in bleeding risk. Recent data from randomized trials in patients receiving VKAs undergoing pacemaker/defibrillator implantation or using heparin bridging therapy for elective procedures or surgeries can now inform best practice. There are also emerging data on periprocedural outcomes in the DOAC trials for patients with non-valvular atrial fibrillation. This review summarizes the evidence for the periprocedural management of patients receiving chronic OAC therapy, focusing on recent randomized trials and large outcome studies, to address three key clinical scenarios: (i) can OAC therapy be safely continued for minor procedures or surgeries; (ii) if therapy with VKAs (especially warfarin) needs to be temporarily interrupted for an elective procedure/surgery, is heparin bridging necessary; and (iii) what is the optimal periprocedural management of the DOACs? In answering these questions, we aim to provide updated clinical guidance for the periprocedural management of patients receiving VKA or DOAC therapy, including the use of heparin bridging.
authors.affiliation: Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra North Shore/LIJ School of Medicine, North Shore/LIJ Health System, Manhasset, NY, USA.
authors.forename: A C
authors.initials: AC
authors.lastname: Spyropoulos
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
authors.forename: A
authors.initials: A
authors.lastname: Al-Badri
authors.affiliation: Durham VA Medical Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: M W
authors.initials: MW
authors.lastname: Sherwood
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: J D
authors.initials: JD
authors.lastname: Douketis
mesh_terms: D000074:Acenocoumarol / Q000008:administration & dosage; D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage*; D001021:Aortic Valve / Q000000981:diagnostic imaging; D001281:Atrial Fibrillation / Q000188:drug therapy; D017558:Elective Surgical Procedures / Q000009:adverse effects*; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006470:Hemorrhage / Q000209:etiology*; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D019990:Perioperative Care; D010644:Phenprocoumon / Q000008:administration & dosage; D011516:Prothrombin / Q000008:administration & dosage; D016032:Randomized Controlled Trials as Topic; D012955:Societies, Medical; D013923:Thromboembolism / Q000517:prevention & control; D013927:Thrombosis / Q000209:etiology*; D014481:United States; D014812:Vitamin K / Q000037:antagonists & inhibitors*; D014859:Warfarin / Q000008:administration & dosage
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D014812:Vitamin K; D014859:Warfarin; D011516:Prothrombin; D006493:Heparin; D000074:Acenocoumarol; D010644:Phenprocoumon
keywords: direct oral anticoagulants; hemorrhage; perioperative care; thromboembolism; warfarin