Guidelines for Perioperative Management of Antithrombotics

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The American College of Chest Physicians has updated its clinical practice guidelines on the perioperative management of anticoagulant and an­tiplatelet therapy.¹ And although many of the recommendations are general and speak to a broad medical audience, some are specific to ophthalmology.

A continuing concern. The scope of the problem relating to if and when to stop or continue antithrombotic therapy in patients about to undergo an elective surgery/procedure is considerable, given the widespread use of anticoagulant and antiplatelet drugs, particularly in an ag­ing population. Approximately 15% to 20% of patients receiving anticoagulant therapy will undergo surgery each year, the report noted.

A how-to guide. The report offers 44 evidence-based recommendations cov­ering 43 scenarios to assist the surgeon in decisions relating to perioperative management of antithrombotic ther­apy. The clinical guidance is anchored on the strongest available evidence that will inform best practices in patients who are receiving a vitamin K antago­nist (VKA), a direct oral anticoagulant, or antiplatelet drugs.

“We provide practical advice on how to manage such patients, taking into ac­count the surgeon’s perspective when­ever possible,” said lead author James D. Douketis, MD, FCCP, at St. Joseph’s Healthcare and McMaster University in Hamilton, Ontario, Canada.

Of interest to ophthalmologists. Recommendations tailored to minor ophthalmological procedures cover phacoemulsification, iridotomy, vitrec­tomy, and panretinal photocoagulation. The preponderance of evidence was related to cataract surgery.

“A lot of our conditional recom­mendations would apply to minor eye surgeries, but we tried to make com­ments for specific procedures such as cataract surgery,” Dr. Douketis said. “Eye procedures are very common in the older population, many of whom are taking an anticoagulant or anti­platelet drug, so we felt it important to single out these procedures.”

Managing your patients. Two recommendations reached the level of “strong,” one of which is applicable to eye surgery. It advises against the use of perioperative heparin bridging in patients with atrial fibrillation who are receiving warfarin and require its inter­ruption around the time of surgery.

Two additional recommendations specific to ophthalmology state the following:

• In patients receiving VKA therapy who require a minor ophthalmologic procedure, the report supports con­tinuation of VKA over VKA interrup­tion. (Very low certainty of evidence.) Warfarin is the primary drug in this class, as most evidence has addressed warfarin-treated patients.
• In patients receiving an antiplatelet drug who are undergoing a minor ophthalmologic procedure, the report sug­gests continuing the antiplatelet drug throughout the surgery, versus stopping the agent before the procedure. (Low certainty of evidence.) Drugs in this class include aspirin and P2Y12 inhibi­tors such as Plavix.

Bottom line. When the report men­tions eye procedures, it focuses on the most common ones, Dr. Douketis said. “The ones we don’t highlight specifical­ly, we leave to the surgeon’s discretion.”

His overall advice: first, decide the patient’s level of risk for bleeding. If it is minimal, the surgeon might be able to continue anticoagulant or antiplatelet therapy. On the other hand, if the risk for bleeding is low/moderate or high, anticoagulant/antiplatelet interruption will be required—and the level of bleed risk will determine the duration of interruption. “All in all, management is very patient- and procedure-centric,” he said.

—Miriam Karmel

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1 Douketis JD et al. Chest. Published online Aug. 11, 2022.

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Relevant financial disclosures: Dr. Douketis—Canadian Institute of Health Research: S; Heart and Stroke Foundation of Canada: S; Janssen: C; Leo Pharma: L; Merck Manual: PS; Pfizer: L; PhaseBio: C; Sanofi: L; Servier: C; UpToDate: PS.

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