What is the best way to manage different anticoagulants and antiplatelet drugs for patients undergoing therapy?
This guideline, and its very helpful figures, provides useful guidance for primary care physicians. Unfortunately, only 2 of the recommendations are classified as "strong": the one against the use of LMWH bridging in patients with atrial fibrillation, and the one to continue warfarin in patients undergoing pacemaker or implantable cardioverter-defibrillator placement. There are a lot of subtleties in this guideline, and it is worth consulting, especially for patients at high risk of thrombosis or who are undergoing a high-risk procedure.
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).
Mark H. Ebell, MD, MS
University of Georgia