CHEST Guidelines-Perioperative-Management-of-Antithrombotic-Therapy

Perioperative-Management-of-Antithrombotic-Therapy - 1

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The American College of Chest Physicians has issued updated guidelines on the perioperative management of antithrombotic therapy, addressing 43 PICO (Patients-Interventions-Comparators-Outcomes) questions to assist clinicians with managing patients receiving long-term oral anticoagulants or antiplatelet therapy who require elective surgery or procedures. The guideline is categorized into four groups based on the therapy patients receive: a vitamin K antagonist (VKA), direct oral anticoagulants (DOACs), antiplatelet drugs, and perioperative heparin bridging for those using VKAs. The recommendations are founded on the evidence graded by the GRADE methodology, which assesses the certainty and quality of the evidence.<br /><br />A multidisciplinary panel developed 44 recommendations, two of which are strong: advising against heparin bridging in patients with atrial fibrillation and continuing VKA therapy during pacemaker or ICD implantation. Notable aspects covered include avoiding routine heparin bridging during VKA interruptions for surgeries, maintaining DOAC therapy interruption protocols specific to surgery bleed risk and patient renal function, and the judicious use of antiplatelet drugs perioperatively.<br /><br />New evidence since the 2012 guidelines has clarified practices, especially around VKA management concerning heparin bridging, DOAC management, and antiplatelet drug handling. The guidelines emphasize practical, individualized care plans with a focus on minimizing thromboembolic and bleeding risks. Additionally, the guidelines outline when and how to suspend or restart antithrombotic therapies surrounding procedures and offer specific recommendations for bridging therapy and the use of laboratory tests.<br /><br />The guidelines also address the perioperative interruption of antiplatelet drugs and recommend personalized management depending on specific procedural bleed risks and thromboembolism risks. Lastly, the guidelines advocate for standardized patient care paths and reiterate the need for research on special patient populations and for procedures requiring urgent surgery. Such comprehensive planning aims to optimize clinical outcomes for patients requiring surgical interventions while on antithrombotic therapy.

Keywords

perioperative management

antithrombotic therapy

oral anticoagulants

antiplatelet therapy

vitamin K antagonist

direct oral anticoagulants

heparin bridging

GRADE methodology

thromboembolic risk

bleeding risk