CHEST releases updated guidelines on perioperative management of antithrombotic therapy
USA: The American College of Chest Physicians (CHEST) has released new guidelines for the perioperative management of antithrombotic therapy. The guidelines, published in the CHEST journal with the intent of replacing the organization's 2012 guideline on the same topic, comprise 44 new evidence-based recommendations.
The new guideline is more comprehensive, containing 43 population, intervention, comparator and outcome (PICO) questions compared with 11 PICO questions in 2012. The guideline was composed by James D. Douketis, MD, a Vascular Medicine and General Internal Medicine staff physician at St. Joseph's Healthcare Hamilton, and 13 other multidisciplinary guideline writing committee members.
"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 a 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," Douketis said in a statement. "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 guideline recommendations cover the perioperative management of vitamin K antagonists (VKAs) such as heparin bridging, warfarin, direct oral anticoagulants (DOACs), and antiplatelet drugs were new to the market in 2012 and are commonly used in 2022.
The guideline also includes recommendations on the perioperative management of patients undergoing minor procedures, comprising dental, ophthalmological, dermatological, pacemaker/internal cardiac defibrillator (ICD) implantation and gastrointestinal (endoscopic) procedures.
The guideline includes the following 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 who require VKA interruption for a colonoscopy with anticipated polypectomy, the guidelines suggest against heparin bridging during VKA interruption.
- 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.
- The guidelines suggest ASA continuation over ASA interruption in patients receiving acetylsalicylic acid (ASA) who are undergoing elective noncardiac surgery.
- On 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 suggests 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.
Each PICO question was evaluated based on the certainty of existing evidence following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.
For each PICO, a recommendation is classified as strong, referred to as "recommended," or conditional, referred to as "suggested." Due to non-high-quality evidence in the perioperative area, most recommendations are marked as "conditional" and "suggested."
Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022 Nov;162(5):e207-e243. doi: 10.1016/j.chest.2022.07.025. Epub 2022 Aug 11. PMID: 35964704.
