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

Perioperative-Management-of-Antithrombotic-Therapy

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The 9th edition of the American College of Chest Physicians (ACCP) guidelines addresses perioperative management of patients undergoing elective surgery while on antithrombotic therapy, focusing on assessments of thromboembolic and bleeding risks. The guidelines provide several key recommendations:

1. <strong>Vitamin K Antagonists (VKAs):</strong> For patients on VKA therapy requiring surgery, it's recommended to stop VKAs 5 days before the procedure to reduce bleeding risks (Grade 1B). After surgery, VKAs should be resumed 12 to 24 hours later, assuming adequate hemostasis (Grade 2C).

2. <strong>Bridging Anticoagulation:</strong> In high-risk patients, such as those with mechanical heart valves or recent venous thromboembolism (VTE), bridging with low-molecular-weight heparin (LMWH) is suggested instead of no bridging (Grade 2C). For low-risk patients, no bridging is suggested.

3. <strong>Dental and Minor Procedures:</strong> For dental procedures, continuing VKAs with a prohemostatic agent or stopping VKAs 2-3 days before is suggested (Grade 2C).

4. <strong>Acetylsalicylic Acid (ASA):</strong> Patients at moderate to high cardiovascular risk should continue ASA through non-cardiac surgeries to decrease cardiovascular risk, while low-risk patients should stop ASA 7-10 days prior (Grade 2C).

5. <strong>Coronary Stents and Surgery:</strong> Surgery should be deferred at least 6 weeks post bare-metal stent placement and 6 months post drug-eluting stent placement. If surgery is necessary within these periods, dual antiplatelet therapy should be continued (Grade 1C).

6. <strong>High-Bleeding-Risk Surgeries:</strong> Consideration should be given to postponing the resumption of bridging anticoagulation to 48-72 hours post-surgery if it is a high bleeding risk surgery.

The guidelines emphasize individualized patient management based on risk assessment and underline the importance of careful planning and monitoring to minimize thromboembolic and bleeding complications. Key research deficiencies are highlighted, pointing to the need for more robust studies to improve evidence-based practices.

Keywords

ACCP guidelines

perioperative management

antithrombotic therapy

thromboembolic risk

bleeding risk

vitamin K antagonists

bridging anticoagulation

low-molecular-weight heparin

acetylsalicylic acid

coronary stents