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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only ArticlesPerioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Section snippets
Summary of Recommendations
Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.
2.1. In patients who require temporary interruption of a VKA before surgery, we recommend stopping VKAs
Data Sources
The Medline English-language database was searched from January 1970 to January 2010 using multiple keywords and standardized terminology, where applicable, as outlined in Appendix S1. This search was done in two parts. The first was a systematic review of the literature from 1970 to January 2007, which was used in AT8.6 The second search updated this search strategy to include studies up until January 2010. We supplemented these literature searches by conducting Internet-based searches of //ClinicalTrials.gov
Interruption of VKAs Before Surgery
In patients undergoing major surgery or procedures, interruption of VKAs, in general, is required to minimize perioperative bleeding,64, 65, 66, 67, 68 whereas VKA interruption may not be required in minor procedures as discussed in subsequent sections of this article. Interruption of VKAs before surgery with the intent of achieving normal or near-normal hemostasis at the time of surgery is based on the residual pharmacodynamic effects of VKAs and the associated time required for the
Interruption of Antiplatelet Drugs Before Surgery
Antiplatelet drugs that irreversibly inhibit platelet function—making their short half-lives clinically irrelevant—include ASA, clopidogrel, ticlopidine, and prasugrel.136 For each day after interruption of any of these agents, ∼10% to 14% of normal platelet function is restored; later, it takes 7 to 10 days for an entire platelet pool to be replenished.137, 138
Antiplatelet drugs that reversibly inhibit platelet function, with self-limiting effects depending on their elimination half-lives,
Anticoagulants and Anticoagulant Dose Regimens Considered for Bridging
There is no established single heparin bridging regimen. Variability exists in the type of anticoagulant (LMWH or UFH), intensity of anticoagulation (therapeutic dose, low dose, or intermediate dose), and timing of perioperative administration. In considering which regimen and administration approach to use, there are several points to consider:
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Anticoagulant intensity to prevent thromboembolism. In the absence of randomized trials assessing the efficacy of different intensities of
Research Recommendations
Additional research is necessary to establish best practices for patients who are receiving antithrombotic therapy and require surgery. Efforts to bridge these gaps in knowledge are ongoing. The randomized placebo-controlled trials PERIOP-2 (A Safety and Effectiveness Study of LMWH Bridging Therapy Versus Placebo Bridging Therapy for Patients on Long Term Warfarin and Require Temporary Interruption of Their Warfarin),215 BRIDGE (Effectiveness of Bridging Anticoagulation for Surgery),216
Acknowledgments
Author contributions: As Topic Editor, Dr Kunz oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.
Dr Douketis: contributed as Deputy Editor for this topic.
Dr Spyropoulos: contributed as a panelist.
Dr Spencer: contributed as a panelist.
Dr Mayr: contributed as a frontline clinician.
Dr Jaffer: contributed as a panelist.
Dr Eckman: contributed as a resource consultant.
Dr Dunn: contributed as a panelist.
Dr Kunz:
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Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.
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