Antithrombotics plus surgery: Here’s what to do

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Annually, one in every 10 patients taking antithrombotic therapy will undergo surgery or some other procedure that puts them at risk of bleeding. In a review published May 30 in the New England Journal of Medicine, physicians offer advice on managing these patients, with communication topping the list.

Todd H. Baron, MD, Patrick S. Kamath, MD, and Robert D. McBane, MD, all of the Mayo Clinic in Rochester, Minn., highlighted the goal when a patient on anticoagulation or dual antiplatelet therapy faces elective or emergency surgery or other invasive procedures that may necessitate discontinuation of therapy: minimize the risk of both thromboembolism and hemorrhage during the periprocedural window.

They described a sliding scale of risk. For instance, a patient with a high risk of thromboembolic events whose procedure puts him or her at low risk of bleeding is likely a good candidate for remaining on antithrombotic therapy. On the other end of the scale, a patient who is at low risk of thromboembolic events who is facing a high-risk procedure may be better served by temporarily stopping antithrombotic therapy.

The best course of action becomes less clear-cut in cases where the patients is at moderate-to-high risk for thromboembolic events and is in need of high-risk procedures. The authors recommended that the physician who will handle periprocedural management of antithrombotic agents and coagulation disorders, the primary provider and the specialist who will perform the procedures come to the table and discuss risks, bridging options and timing. “Ideally, this communication should occur well in advance of the procedure to maximize patient safety and facilitate patient education.”

Baron, Kamath and McBane recommended that the patient play a role in decision making, “especially when definitive recommendations cannot be made.” Other recommendations include:

  • Keep communication channels among physicians open;
  • Take a conservative approach;
  • Possibly continue anticoagulation therapy in patients undergoing procedures with a low bleeding risk;
  • Possibly temporarily discontinue anticoagulation therapy in patients undergoing procedures with a high bleeding risk at appropriate intervals without bridging therapy;
  • But using bridging therapy in select high-risk patients undergoing high-risk procedures;
  • Delaying elective surgery in patients recently diagnosed with venous thromboembolism for three months;
  • If that is not possible, consider using a vena cava filter in some circumstances;
  • Postpone high-risk elective procedures in patients on dual antiplatelet therapy with coronary artery stents (six weeks after placement for a bare-metal stent and six months for a drug-eluting stent);
  • If the procedure must be performed, continue dual antiplatelet therapy;
  • Continue aspirin therapy in these patients;
  • Continue aspirin therapy and temporarily discontinue thienopyridine therapy in in patients who completed six weeks of treatment after placement of a bare-metal stent (six months for a drug-eluting stent) who require a high-risk procedure; and
  • Continue full-dose antiplatelet therapy for patients at high risk for cardiovascular atherosclerotic events and those with coronary stents who undergo low-risk procedures.

The authors provided supplementary material and tables to help physicians in the decision-making process.