Guidelines for the perioperative management of anticoagulants and antiplatelet agents (ACCP)

Référence

Douketis JD, Spyropoulos AC, Murad MH, et al. Executive summary: perioperative management of antithrombotic therapy: an American College of Chest Physicians clinical practice guideline. Chest 2022;162(5):1127-1139.

Sommaire

This guideline from the American College of Chest Physicians identified 43 clinical questions and sought direct evidence to answer those questions. They provide 3 useful graphics that show exactly when to discontinue each agent prior to surgery and when it can be resumed. This varies by the drug class (warfarin, director oral anticoagulants [DOACs], and antiplatelet agents) and by the bleeding risk associated with the procedure (minimal, low, moderate, or high). Warfarin can be continued if the surgery is minimal risk. If the risk of bleeding is higher, warfarin should be discontinued 5 days prior to surgery and resumed at the usual dose no more than 24 hours following surgery. Bridging with a low-molecular-weight heparin (LMWH) is only recommended for those at the highest thrombotic risk, which includes those with an older mechanical heart valve, a mechanical heart valve plus risk factors for stroke, or a recent venous thromboembolism (VTE), and others such as persons with a prior perioperative stroke. Bridging with LMWH is not routinely recommended for most patients who take warfarin because of atrial fibrillation (having a CHA2DS2-VASc score < 7 points) or for patients with a more distant history of VTE. Regarding DOACs, most should be discontinued 2 days prior to surgery with a high bleeding risk and 1 day prior to surgery with low or moderate risk; dabigatran is the exception and should be discontinued 4 days before high-risk surgery and 2 days before low- or moderate-risk surgery. DOACs can be resumed 24 hours after low-to moderate-risk surgery, and 48 to 72 hours after high-risk surgery. Clopidogrel should be discontinued at least 5 days before surgery, ticagrelor discontinued 3 to 5 days before surgery, and prasugrel discontinued 7 days before surgery; they can be resumed at their usual dose between 6 and 24 hours following surgery. Finally, aspirin can be continued for most patients undergoing noncardiac surgery, unless they are undergoing very high-risk surgery (eg, intracranial or spinal).