CHEST Guidelines-Executive-Summary_2022

Executive-Summary_2022_chest

Pdf Summary

The American College of Chest Physicians' clinical guideline on perioperative management of antithrombotic therapy provides comprehensive directives for patients undergoing elective surgeries while on long-term oral anticoagulant or antiplatelet therapy. This updated guideline answers 43 inquiries pertaining to four primary categories: management of patients on vitamin K antagonists (VKAs, such as warfarin), perioperative heparin bridging when on VKAs, direct oral anticoagulants (DOACs), and antiplatelet drugs.<br /><br />The guideline recommends against heparin bridging in atrial fibrillation patients and advises continuing VKAs during pacemaker or internal cardiac defibrillator implantations. A total of 44 recommendations were made, utilizing the GRADE methodology to ascertain their strength based on evidence certainty levels. The guideline addresses practices for minor procedures, like dental or dermatologic, and surgical operations, such as cardiac surgeries or those involving gastrointestinal procedures. <br /><br />Substantial new evidence since the previous 2012 iteration has enhanced recommendations, especially concerning patients on VKAs requiring heparin bridging, DOACs, and antiplatelet drug management. However, for the majority of perioperative management challenges, uncertainties about optimal practices persist.<br /><br />The guideline is intended primarily for clinicians managing perioperative antithrombotic therapy, with potential use for researchers and policymakers. It articulates methods for interrupting and resuming anticoagulant therapy effectively, evaluating thromboembolic and bleeding risks, and addresses use cases involving procedures with various bleed risks.<br /><br />Illustrative care pathways depict management strategies for perioperative VKA, DOACs, and antiplatelet drug management, assisting in individualized patient care pathway development. The guideline reiterates that personalized assessments remain crucial in the absence of high-quality evidence, with advice that clinical judgment should guide decisions.<br /><br />In summary, this guideline informs clinical practices by synthesizing direct and indirect evidence, providing a flexible yet structured approach to managing antithrombotic therapy in elective surgeries.

Keywords

perioperative management

antithrombotic therapy

oral anticoagulants

antiplatelet therapy

heparin bridging

vitamin K antagonists

direct oral anticoagulants

clinical guidelines

surgical procedures

thromboembolic risks