J Korean Med Assoc.  2014 May;57(5):419-426. 10.5124/jkma.2014.57.5.419.

Periprocedural antithrombotic management

• Joo J

• KMID: 2194885
• DOI: http://doi.org/10.5124/jkma.2014.57.5.419

Abstract

The periprocedural management of patients on long-term antithrombotic therapy (antiplatelet agents or vitamin K antagonists) who may require temporary disruption, given that an invasive procedure is always a dilemma for clinicians. Discontinuation of antithrombotic therapy can place patients at an increased risk of thromboembolic complications while the continuation of antithrombotic therapy can increase the procedure-related bleeding risk. Therefore, it is imperative for clinicians to be proficient in making thoughtful and individualized decisions on the appropriate management of periprocedural anticoagulants, drawing from recent evidence-based guidelines.

Keyword

Antithrombotic therapy; Antiplatelet therapy; Bridging therapy; Heparin; Vitamin K antagonist

MeSH Terms

Anticoagulants
Hemorrhage
Heparin
Humans
Vitamin K
Anticoagulants
Heparin
Vitamin K

Figure

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  Figure 1 A management algorithm of antiplatelet therapy in the periprocedural period. Modified from Douketis JD, et al. Chest 2012;141(2 Suppl):e326S-e350S [1] and Kushner FG, et al. Circulation 2009;120:2271-2306 [8].

• 

  Figure 2 A management algorithm of vitamin K antagonist therapy in the periprocedural period. VKA, vitamin K antagonist; LMWH, low molecular weight heparin. Modified from Douketis JD, et al. Chest 2012;141(2 Suppl):e326S-e350S [1].

Reference

1. Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. American College of Chest Physicians. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Throm-bosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141:2 Suppl. e326S–e350S.

2. Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Son-nenberg FA, Alonso-Coello P, Akl EA, Lansberg MG, Guyatt GH, Spencer FA. American College of Chest Physicians. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141:2 Suppl. e637S–e668S.

3. Assia EI, Raskin T, Kaiserman I, Rotenstreich Y, Segev F. Effect of aspirin intake on bleeding during cataract surgery. J Cataract Refract Surg. 1998; 24:1243–1246.

4. Burger W, Chemnitius JM, Kneissl GD, Rucker G. Low-dose aspirin for secondary cardiovascular prevention: cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation: review and meta-analysis. J Intern Med. 2005; 257:399–414.

5. Herth FJ, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest. 2002; 122:1461–1464.

6. Khalifeh MR, Redett RJ. The management of patients on anticoagulants prior to cutaneous surgery: case report of a thromboembolic complication, review of the literature, and evidence-based recommendations. Plast Reconstr Surg. 2006; 118:110e–117e.

7. Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, O'Gara P, Whitlow P. American Heart Association; American College of Cardiology. Society for Cardiovascular Angiography and Interventions. American College of Surgeons; American Dental Association. American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Dent Assoc. 2007; 138:652–655.

8. Kushner FG, Hand M, Smith SC Jr, King SB 3rd, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE Jr, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009; 120:2271–2306.

9. Holmes DR Jr, Dehmer GJ, Kaul S, Leifer D, O'Gara PT, Stein CM. ACCF/AHA clopidogrel clinical alert: approaches to the FDA "boxed warning": a report of the American College of Cardiology Foundation Task Force on clinical expert consensus documents and the American Heart Association endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2010; 56:321–341.

10. Bavry AA, Kumbhani DJ, Helton TJ, Borek PP, Mood GR, Bhatt DL. Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials. Am J Med. 2006; 119:1056–1061.

11. Daemen J, Wenaweser P, Tsuchida K, Abrecht L, Vaina S, Morger C, Kukreja N, Jüni P, Sianos G, Hellige G, van Domburg RT, Hess OM, Boersma E, Meier B, Windecker S, Serruys PW. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet. 2007; 369:667–678.

12. Eisenstein EL, Anstrom KJ, Kong DF, Shaw LK, Tuttle RH, Mark DB, Kramer JM, Harrington RA, Matchar DB, Kandzari DE, Peterson ED, Schulman KA, Califf RM. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA. 2007; 297:159–168.

13. Roberts JR, Hedges JR, Chanmugam AS. Clinical procedures in emergency medicine. 4th ed. Philadelphia: W. B. Saunders;2004.

14. Fink MP. Textbook of critical care. 5th ed. Philadelphia: Elsevier Saunders;2005.

15. Gohlke-Barwolf C, Acar J, Oakley C, Butchart E, Burckhart D, Bodnar E, Hall R, Delahaye JP, Horstkotte D, Kremer R. Study Group of the Working Group on Valvular Heart Disease of the European Society of Cardiology. Guidelines for prevention of thromboembolic events in valvular heart disease. Eur Heart J. 1995; 16:1320–1330.

16. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, Mallery JS, Raddawi HM, Vargo JJ 2nd, Waring JP, Fanelli RD, Wheeler-Harbough J. American Society for Gastrointestinal Endoscopy. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc. 2002; 55:775–779.

17. Douketis JD. Perioperative anticoagulation management in patients who are receiving oral anticoagulant therapy: a practical guide for clinicians. Thromb Res. 2002; 108:3–13.

18. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008; 52:e1–e142.

19. Jafri SM. Periprocedural thromboprophylaxis in patients receiving chronic anticoagulation therapy. Am Heart J. 2004; 147:3–15.

20. Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med. 1997; 336:1506–1511.

21. Tiede DJ, Nishimura RA, Gastineau DA, Mullany CJ, Orszulak TA, Schaff HV. Modern management of prosthetic valve anticoagulation. Mayo Clin Proc. 1998; 73:665–680.

22. Gage BF, van Walraven C, Pearce L, Hart RG, Koudstaal PJ, Boode BS, Petersen P. Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation. 2004; 110:2287–2292.

23. Pharmacology Weekly. Why is the low molecular weight he-parin, enoxaparin (Lovenox) dosed in mg while the other LMWH's (dalteparin (Fragmin) and tinzaparin (Innohep)) are dosed in IU/kg and is this difference clinically relevant? [Internet]. San Antonio: Pharmacology Weekly;2014. cited 2014 Apr 17. Available from: http://www.pharmacologyweekly.com/articles/lmwh-enoxaparin-lovenox-dalteparin-fragmin-dosing-differences.

24. Douketis JD, Woods K, Foster GA, Crowther MA. Bridging anticoagulation with low-molecular-weight heparin after interruption of warfarin therapy is associated with a residual anticoagulant effect prior to surgery. Thromb Haemost. 2005; 94:528–531.

25. O'Donnell MJ, Kearon C, Johnson J, Robinson M, Zondag M, Turpie I, Turpie AG. Brief communication: preoperative anticoagulant activity after bridging low-molecular-weight heparin for temporary interruption of warfarin. Ann Intern Med. 2007; 146:184–187.

26. Landefeld CS, Beyth RJ. Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention. Am J Med. 1993; 95:315–328.

27. Spyropoulos AC, Turpie AG, Dunn AS, Spandorfer J, Douketis J, Jacobson A, Frost FJ. REGIMEN Investigators. Clinical outcomes with unfractionated heparin or low-molecular-weight heparin as bridging therapy in patients on long-term oral anticoagulants: the REGIMEN registry. J Thromb Haemost. 2006; 4:1246–1252.