This is the current release of the guideline.

The grades of recommendation (1A, 1B, 1C, 2A, 2B, 2C) are defined at the end of the "Major Recommendations" field.

Perioperative Management of Patients Who Are Receiving Vitamin K Antagonists (VKAs)

1. In patients who require temporary interruption of a VKA before surgery or a procedure and require normalization of the international normalized ratio (INR) for the surgery or procedure, the guideline developers recommend stopping VKAs approximately 5 days before surgery over stopping VKAs within a shorter time interval before surgery to allow adequate time for the INR to normalize (Grade 1B).
2. In patients who have had temporary interruption of a VKA before surgery or a procedure, the guideline developers recommend resuming VKAs approximately 12 to 24 hours (the evening of or the next morning) after surgery and when there is adequate hemostasis over resumption of VKAs closer to surgery (Grade 1C).
3. In patients who require temporary interruption of a VKA before surgery or a procedure and whose INR is still elevated (i.e., >1.5) 1 to 2 days before surgery, the guideline developers suggest administering low-dose (i.e., 1 to 2 mg) oral vitamin K to normalize the INR instead of not administering vitamin K (Grade 2C).
4. In patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE) at high risk for thromboembolism, the guideline developers recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) low-molecular-weight heparin (LMWH) or intravenous (IV) unfractionated heparin (UFH) over no bridging during temporary interruption of VKA therapy (Grade 1C); the guideline developers suggest therapeutic-dose SC LMWH over IV UFH (Grade 2C). In patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, the guideline developers suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade 2C); the guideline developers suggest therapeutic-dose SC LMWH over other management options (Grade 2C). In patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, the guideline developers suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C).

   Underlying values and preferences: In patients at high or moderate risk for thromboembolism, the recommendations reflect a relatively high value on preventing thromboembolism and a relatively low value is on preventing bleeding; in patients at low risk for thromboembolism, the recommendations reflect a relatively high value on preventing bleeding and a relatively low value on preventing thromboembolism.

Perioperative Management of Patients Who Are Receiving Bridging Anticoagulation

1. In patients who require temporary interruption of VKAs and are to receive bridging anticoagulation, from a cost-containment perspective the guideline developers recommend the use of subcutaneous (SC) low-molecular-weight heparin (LMWH) administered in an outpatient setting where feasible instead of inpatient administration of intravenous (IV) unfractionated heparin (UFH) (Grade 1C).

   Underlying values and preferences: This recommendation reflects a consideration not only of the trade-off between the advantages and disadvantages of SC LMWH and IV UFH as reflected in their effects on clinical outcomes (LMWH at least as good, possibly better), but also the implications in terms of resource use (costs) in a representative group of countries (substantially less resource use with LMWH).

2. In patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH, the guideline developers recommend administering the last dose of LMWH 24 hours before surgery or a procedure over administering LMWH closer to surgery (Grade 1C); for the last preoperative dose of LMWH, the guideline developers recommend administering approximately half the total daily dose instead of 100% of the total daily dose (Grade 1C). In patients who are receiving bridging anticoagulation with therapeutic-dose IV UFH, the guideline developers recommend stopping UFH approximately 4 hours before surgery over stopping UFH closer to surgery (Grade 1C)
3. In patients undergoing a minor surgical or other invasive procedure and who are receiving bridging anticoagulation with therapeutic-dose LMWH, the guideline developers recommend resuming this regimen approximately 24 hours after (e.g., the day after) the procedure when there is adequate hemostasis over a shorter (e.g., < 12 hours) time interval (Grade 1C). In patients undergoing major surgery or a high bleeding risk surgery/procedure and for whom postoperative therapeutic-dose LMWH/UFH is planned, the guideline developers recommend either delaying the initiation of therapeutic-dose LMWH/UFH for 48 to 72 hours after surgery when hemostasis is secured, administering low-dose LMWH/UFH after surgery when hemostasis is secured, or completely avoiding LMWH or UFH after surgery over the administration of therapeutic-dose LMWH/UFH in close proximity to surgery (Grade 1C). The guideline developers recommend considering the anticipated bleeding risk and adequacy of postoperative hemostasis in individual patients to determine the timing of LMWH or UFH resumption after surgery instead of resuming LMWH or UFH at a fixed time after surgery in all patients (Grade 1C).
4. In patients who are receiving bridging anticoagulation with LMWH, the guideline developers suggest against the routine use of anti-factor Xa levels to monitor the anticoagulant effect of LMWHs (Grade 2C).

Perioperative Management of Patients Who Are Receiving Antiplatelet Therapy

1. In patients who require temporary interruption of aspirin-or clopidogrel-containing drugs before surgery or a procedure, the guideline developers suggest stopping this treatment 7 to 10 days before the procedure over stopping this treatment closer to surgery (Grade 2C).
2. In patients who have had temporary interruption of aspirin therapy because of surgery or a procedure, the guideline developers suggest resuming aspirin approximately 24 hours (or the next morning) after surgery when there is adequate hemostasis instead of resuming aspirin closer to surgery (Grade 2C). In patients who have had temporary interruption of clopidogrel because of surgery or a procedure, we suggest resuming clopidogrel approximately 24 hours (or the next morning) after surgery when there is adequate hemostasis instead of resuming clopidogrel closer to surgery (Grade 2C).
3. In patients who are receiving antiplatelet drugs, the guideline developers suggest against the routine use of platelet function assays to monitor the antithrombotic effect of aspirin or clopidogrel (Grade 2C).
4. For patients who are not at high risk for cardiac events, the guideline developers recommend interruption of antiplatelet drugs (Grade 1C). For patients at high risk of cardiac events (exclusive of coronary stents) scheduled for noncardiac surgery, the guideline developers suggest continuing aspirin up to and beyond the time of surgery (Grade 2C); if patients are receiving clopidogrel, the guideline developers suggest interrupting clopidogrel at least 5 days and, preferably, within 10 days prior to surgery (Grade 2C). In patients scheduled for coronary artery bypass grafting (CABG), the guideline developers recommend continuing aspirin up to and beyond the time of CABG (Grade 1C); if aspirin is interrupted, the guideline developers recommend it be reinitiated between 6 hours and 48 hours after CABG (Grade 1C). In patients scheduled for CABG, the guideline developers recommend interrupting clopidogrel at least 5 days and, preferably, 10 days prior to surgery (Grade 1C). In patients scheduled for percutaneous coronary intervention (PCI), the guideline developers suggest continuing aspirin up to and beyond the time of the procedure; if clopidogrel is interrupted prior to PCI, the guideline developers suggest resuming clopidogrel after PCI with a loading dose of 300 to 600 mg (Grade 2C).
5. In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, the guideline developers recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C). In patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, the guideline developers recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C). In patients with a coronary stent who have interruption of antiplatelet therapy before surgery, the guideline developers suggest against the routine use of bridging therapy with UFH, LMWH, direct thrombin inhibitors, or glycoprotein IIb/IIIa inhibitors (Grade 2C).

   Underlying values and preferences: These recommendations reflect a relatively high value placed on preventing stent-related coronary thrombosis, a consideration of complexity and costs of administering bridging therapy in the absence of efficacy and safety data in this clinical setting, and a relatively low value on avoiding the unknown but potentially large increase in bleeding risk associated with the concomitant administration of aspirin and clopidogrel during surgery.

Perioperative Management of Antithrombotic Therapy in Patients Who Require Dental, Dermatologic, or Ophthalmologic Procedures

1. In patients who are undergoing minor dental procedures and are receiving VKAs, the guideline developers recommend continuing VKAs around the time of the procedure and coadministering an oral prohemostatic agent (Grade 1B). In patients who are undergoing minor dental procedures and are receiving aspirin, the guideline developers recommend continuing aspirin around the time of the procedure (Grade 1C). In patients who are undergoing minor dental procedures and are receiving clopidogrel, please refer to the recommendations outlined in (See recommendations 5 and 6 in the "Perioperative Management of Patients Who Are Receiving Antiplatelet Therapy" section above.)
2. In patients who are undergoing minor dermatologic procedures and are receiving VKAs, the guideline developers recommend continuing VKAs around the time of the procedure (Grade 1C). In patients who are undergoing minor dermatologic procedures and are receiving aspirin, the guideline developers recommend continuing aspirin around the time of the procedure (Grade 1C). In patients who are undergoing minor dermatologic procedures and are receiving clopidogrel, (please refer to recommendations 5 and 6 in the "Perioperative Management of Patients Who Are Receiving Antiplatelet Therapy" section above.)
3. In patients who are undergoing cataract removal and are receiving VKAs, the guideline developers recommend continuing VKAs around the time of the procedure (Grade 1C). In patients who are undergoing cataract removal and are receiving aspirin, the guideline developers recommend continuing aspirin around the time of the procedure (Grade 1C). In patients who are undergoing cataract removal and are receiving clopidogrel, please refer to recommendations 5 and 6 in the "Perioperative Management of Patients Who Are Receiving Antiplatelet Therapy" section above.)

Perioperative Management of Antithrombotic Therapy Patients Who Require Urgent Surgical or Other Invasive Procedures

1. In patients who are receiving VKAs and require reversal of the anticoagulant effect for an urgent surgical or other invasive procedure, the guideline developers recommend treatment with low-dose (2.5 to 5.0 mg) IV or oral vitamin K (Grade 1C). For more immediate reversal of the anticoagulant effect, the guideline developers suggest treatment with fresh-frozen plasma or another prothrombin concentrate in addition to low-dose IV or oral vitamin K (Grade 2C).
2. For patients receiving aspirin, clopidogrel, or both, are undergoing surgery and have excessive or life-threatening perioperative bleeding, the guideline developers suggest transfusion of platelets or administration of other prohemostatic agents (Grade 2C).

Definitions:

*The guideline developers use the wording recommend for strong (Grade 1) recommendations and suggest for weak (Grade 2) recommendations.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2008 Jun

American College of Chest Physicians - Medical Specialty Society

American College of Chest Physicians

American College of Chest Physicians (ACCP) Expert Panel on Antithrombotic and Thrombolytic Therapy

Primary Authors: James D. Douketis, MD, FRCP(C); Peter B. Berger, MD, FACP; Andrew S. Dunn, MD, FACP; Amir K. Jaffer, MD; Alex C. Spyropoulos, MD, FACP, FCCP; Richard C. Becker, MD, FACP, FCCP; and Jack Ansell, MD, FACP, FCCP

Committee Co-Chairs: Jack Hirsh, MD, FCCP (Chair); Gordon H. Guyatt, MD, FCCP; Gregory W. Albers, MD; Robert A. Harrington, MD, FCCP; Holger J. Schünemann, MD, PhD, FCCP

Participants: Giancarlo Agnelli, MD; Pierre Amarenco, MD; Jack E. Ansell, MD; Collin Baigent; Shannon M. Bates, MD; Kenneth A. Bauer, MD; Richard C. Becker, MD; Peter B. Berger, MD; David Bergqvist, MD, PhD; Rebecca J. Beyth, MD; Christopher P. Cannon, MD; Elizabeth A. Chalmers, MB, ChB, MD; Anthony K.C. Chan, MBBS; Clifford W. Colwell, Jr., MD; Anthony J. Comerota, MD; Deborah Cook, MD; Mark A. Crowther, MD; James E. Dalen, MD; Gabrielle deVeber, MD, MHSc; Maria Benedetta Donati, MD, PhD; James D. Douketis, MD; Andrew Dunn, MD; J. Donald Easton, MD; Michael Ezekowitz, MD; Margaret Fang; William H. Geerts, MD, FCCP; Alan S. Go, MD; Samuel Z. Goldhaber, MD, FCCP; Shaun D. Goodman, MD; Michael Gould, MD, FCCP; Ian A. Greer, MD; Andreas Greinacher, MD; David Gutterman, MD, FCCP, HSP; Jonathan L. Halperin, MD; John A. Heit, MD; Elaine M. Hylek, MD; Alan Jacobson, MD; Roman Jaeschke, MD, PhD; Amir K. Jaffer, MD; Susan Kahn; Clive Kearon, MBBCh, PhD; Fenella Kirkham, MBBC; Andreas Koster, MD, PhD; Michael R. Lassen, MD; Mark N. Levine, MD, MSc; Sandra Zelman Lewis, PhD; A. Michael Lincoff, MD; Gregory YH Lip, MD; Christopher Madias, MD; Warren J. Manning, MD; Daniel B. Mark, MD; M. Patricia Massicotte, MD, MSc; David Matchar, MD; Thomas W. Meade, DM, FCCP; Venu Menon, MD; Tracy Minichiello, MD; Paul Monagle, MBBS, MSc, MD, FCCP; Christopher M. O'Connor, MD; Patrick O'Gara, MD; E. Magnus Ohman, MD; Ingrid Pabinger, MD; Gualtiero Palareti, MD; Carlo Patrono, MD; Stephen G. Pauker, MD; Graham F. Pineo, MD; Jeffrey J. Popma, MD; Gary Raskob, PhD; Gerald Roth, MD; Ralph L. Sacco, MD; Deeb N. Salem, MD, FCCP; Charles-Marc Samama, MD, FCCP; Meyer Michel Samama, MD; Sam Schulman, MD, PhD; Daniel Singer, MD; Michael Sobel, MD; Shoshanna Sofaer, DrPH; Alex C. Spyropoulos, MD FCCP; Ph. Gabriel Steg, MD; Philip Teal, MD; Raymond Verhaeghe, MD; David A. Vorchheimer, MD; Theodore E. Warkentin, MD; Jeffrey Weitz, MD

Dr. Ansell discloses that he has received consultant fees from Bristol-Myers Squibb, Roche Diagnostics, and International Technidyne Corporation. He is also on the speakers bureau for Roche Diagnostic Corporation and Sanofi-Aventis, and is the past president of the Anticoagulation Forum.

Dr. Douketis reveals no real or potential conflicts of interest or commitment.

Dr. Dunn discloses that he received grant monies from and is on the speakers bureau for Sanofi-Aventis. He has also served on advisory committees for Sanofi-Aventis, Eisai, and Roche Diagnostics.

Dr. Jaffer discloses that he has received consultant fees from Sanofi-Aventis and AstraZeneca, and that he is on the speakers bureau for Sanofi-Aventis.

Dr. Becker reveals no real or potential conflicts of interest or commitment.

Dr. Spyropoulos discloses that he has received consultant fees from Boehringer Ingelheim, and has served on the speakers bureau for Sanofi-Aventis and Eisai.

Dr. Berger discloses that he has spoken at Council on Medical Education-approved scientific symposia supported by Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, Astra-Zeneca, Medtronic, Schering-Plough, Lilly, and Daiichi Sankyo. He has served as a consultant for PlaCor, Lilly, Daiichi Sankyo, Molecular Insight Pharmaceuticals, and CV Therapeutics. Dr. Berger also owns equity in Lumen, Inc (a company that is developing an embolic protection device).

American College of Clinical Pharmacy - Medical Specialty Society
American Society of Health-System Pharmacists - Professional Association

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on December 3, 2008. The information was verified by the guideline developer on January 7, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.