Last updated August 12, 2022

Perioperative Management Of Antithrombotic Therapy

Summary of Key Recommendations

In patients receiving VKA therapy for a mechanical heart valve who require VKA interruption for an elective surgery/procedure, we suggest against heparin bridging. (C, VL)
620

In patients receiving VKA therapy for atrial fibrillation who require VKA interruption for an elective surgery/procedure, we recommend against heparin bridging. (S, M)
620

In patients receiving VKA therapy for VTE as the sole clinical indication who require VKA interruption for an elective surgery/procedure, we suggest against heparin bridging. (C, VL)
620

In patients receiving VKA therapy who require a pacemaker or ICD implantation, we recommend continuation of VKA over VKA interruption and heparin bridging. (S, M)
620

In patients receiving VKA therapy who require VKA interruption for a colonoscopy with anticipated polypectomy, we suggest against heparin bridging during the period of VKA interruption. (C, VL)
620

In patients receiving LMWH bridging for an elective surgery/procedure, we suggest against routine measurement of anti-factor Xa levels to guide perioperative LMWH management. (C, VL)
620

In patients receiving apixaban who require an elective surgery/procedure, we suggest stopping apixaban for 1-2 days, before the surgery/procedure over apixaban continuation. (C, VL)
620

In patients receiving dabigatran who require an elective surgery/procedure, we suggest stopping dabigatran for 1-4 days before the surgery/procedure over dabigatran continuation. (C, VL)
620

In patients receiving edoxaban who require an elective surgery/procedure, we suggest stopping edoxaban for 1-2 days before the surgery/procedure over edoxaban continuation. (C, VL)
620

In patients receiving rivaroxaban who require an elective surgery/procedure, we suggest stopping rivaroxaban for 1-2 days before the surgery/procedure over rivaroxaban continuation. (C, VL)
620

In patients who require DOAC interruption for an elective surgery/procedure, we suggest against perioperative heparin bridging. (C, VL)
620

In patients who had DOAC interruption for an elective surgery/procedure, we suggest resuming DOACs >24 hours after a surgery/procedure over resuming DOACs within 24 hours. (C, VL)
620

In patients who had DOAC interruption for an elective surgery/procedure, we suggest against routine DOAC coagulation function testing to guide perioperative DOAC management. (C, VL)
620

In patients receiving ASA who are undergoing elective non-cardiac surgery, we suggest ASA continuation over ASA interruption. (C, M)
620

In patients who are receiving ASA and undergoing CABG surgery, we suggest continuation of ASA over interruption; in patients receiving a P2Y12 inhibitor drug, we suggest interruption of the P2Y12 inhibitor over continuation peri-operatively. (C, L)
620

In patients receiving antiplatelet drug therapy who are undergoing an elective surgery/procedure, we suggest against the routine use of platelet function testing prior to the surgery/procedure to guide perioperative antiplatelet management. (C, VL)
620

In patients receiving ASA and a P2Y12 inhibitor who had coronary stents placed within the last 3-12 months and are undergoing an elective surgery/procedure, we suggest stopping the P2Y12 inhibitor prior to surgery over continuation of the P2Y12 inhibitor. (C, VL)
620

In patients with coronary stents who require interruption of antiplatelet drugs for an elective surgery/procedure, we suggest against routine bridging therapy with a glycoprotein IIb-IIIa inhibitor, cangrelor, or LMWH over routine use of bridging therapy. (C, L)
620

Recommendation Grading

Abbreviations

  • ASA: Acetylsalicylic Acid
  • CABG: Coronary Artery Bypass Graft
  • DOAC: Direct Oral Anticoagulants
  • LMWH: Low Molecular Weight Heparin
  • UFH: Unfractionated Heparin
  • VKA: Vitamin K Antagonist
  • VTE: Venous Thromboembolism
  • aPTT: Activated Partial Thromboplastin Time

Overview

Title

Perioperative Management Of Antithrombotic Therapy

Authoring Organization

Publication Month/Year

August 11, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure.

Target Patient Population

Patients receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Long term care, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D000925 - Anticoagulants, D013502 - General Surgery, D000079645 - Perioperative Medicine, D019990 - Perioperative Care

Keywords

anticoagulation, surgery, perioperative, perioperative care, Antithrombotic Agents, Anticoagulation