Periprocedural Management of Patients on a Vitamin K Antagonist or a Direct Oral Anticoagulant Requiring an Elective Procedure or Surgery.
J Thromb Haemost. 2016 Mar 14;
Authors: Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD
Abstract
The periprocedural management of patients on chronic oral anticoagulants (OACs) including vitamin K antagonists (VKA) such as warfarin and direct oral anticoagulants (DOACs) is a common clinical problem. The optimal perioperative management of patients on chronic OAC is anchored on four key principles: 1) risk stratification of patient- and procedure-related risks of thrombosis and bleeding; 2) clinical consequences of a thrombotic and bleeding event; 3) discontinuation and re-initiation of an OAC based on pharmacokinetic properties of each agent; and 4) whether aggressive management such as use of periprocedural heparin bridging has advantages for the prevention of post-operative thromboembolism at the cost of a possible increase in bleeding risk. Recent data from randomized trials in patients on VKA undergoing pacemaker/defibrillator implantation or using heparin bridging therapy for elective procedures or surgeries can now inform best practice. There are also emerging data on periprocedural outcomes in the DOAC trials for patients with non-valvular atrial fibrillation. This review summarizes the evidence for the periprocedural management of patients on chronic OAC, focusing on recent randomized trials and large outcome studies, to address three key clinical scenarios: 1) Can OACs be safely continued for minor procedures or surgeries?; 2) If VKA (especially warfarin) needs to be temporarily interrupted for an elective procedure/surgery, is heparin bridging necessary?; and 3) What is the optimal periprocedural management of the DOACs? In answering these questions we aim to provide updated clinical guidance for the periprocedural management of patients on a VKA or DOAC, including the use of heparin bridging This article is protected by copyright. All rights reserved.
PMID: 26988871 [PubMed - as supplied by publisher]