Clinical practice guideline for perioperative management of antithrombotic therapy released

The American College of Chest Physicians recently released a new clinical guideline on the perioperative management of antithrombotic therapy. Published in the journal CHEST, the guideline contains 44 evidence-based recommendations using established methodology to improve decision-making and to decrease practice variability.

An update to the 2012 Perioperative Management of Antithrombotic Therapy guideline, the new guideline is more comprehensive, containing 43 population, intervention, comparator and outcome (PICO) questions compared with 11 PICO questions in 2012.

The guideline recommendations cover the perioperative management of vitamin K antagonists (VKAs) such as warfarin, heparin bridging, antiplatelet drugs and direct oral anticoagulants (DOACs), which were new to market in 2012 and are commonly used in 2022.

"For perioperative antithrombotic management, it's very important to have standardized approaches and protocols to limit variability in practice and, in turn, to minimize preventable bleeding and thrombotic events. Until now, guidance for clinicians was available only in piecemeal approach—related to specific clinical areas—whereas the CHEST guidelines provide a 'one-stop' comprehensive and definitive compilation of evidence to inform best practices in perioperative anticoagulant and antiplatelet management," says James D. Douketis, MD, Staff Physician in Vascular Medicine and General Internal Medicine at St. Joseph's Healthcare Hamilton. "These guidelines are also practical, providing clinicians with 'how to' approaches for managing patients on warfarin, DOACs and antiplatelet drugs who are undergoing a wide array of surgeries and procedures as well as those who may need heparin bridging."

The new guideline also includes recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatological, ophthalmological, pacemaker/internal cardiac defibrillator (ICD) implantation and gastrointestinal (endoscopic) procedures.

The guideline includes the following highlighted recommendations:

Strong recommendations:

• In patients receiving VKA therapy for atrial fibrillation who require VKA interruption for an elective surgery/procedure, the guidelines recommend against heparin bridging.
• In patients receiving VKA therapy who require a pacemaker or ICD implantation, the guidelines recommend continuation of VKA over VKA interruption and heparin bridging.

Key conditional recommendations:

• In patients receiving VKA therapy for a mechanical heart valve or VTE who require VKA interruption for an elective surgery/procedure, the guidelines suggest against heparin bridging.
• In patients receiving VKA therapy who require VKA interruption for a colonoscopy with anticipated polypectomy, the guidelines suggest against heparin bridging during the period of VKA interruption.
• In patients receiving a DOAC (apixaban, dabigatran, edoxaban, rivaroxaban) who require an elective surgery/procedure, the guidelines suggest stopping the DOAC for 1 to 2 days (1 to 4 days for dabigatran) before the surgery/procedure over apixaban continuation. Postoperatively the guideline suggest resuming the DOAC about 24 hours after a low/moderate-bleed-risk surgery/procedure and 48-72 hours after a high-bleed-risk surgery/procedure.
• In patients receiving acetylsalicylic acid (ASA) who are undergoing elective noncardiac surgery, the guidelines suggest ASA continuation over ASA interruption.

Following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, each PICO question is evaluated based on the certainty of existing evidence. For each PICO, a recommendation is classified as a strong, referred to as "recommended," or conditional, referred to as "suggested." Due to non-high quality evidence in the perioperative area, the majority of recommendations are marked as "conditional" and "suggested."