This article discusses the perioperative management of antithrombotic
therapy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). The primary objectives of this article are the following: (1) to address the perioperative management of patients who are receiving
vitamin K antagonists (VKAs) or
antiplatelet drugs, such as
aspirin and
clopidogrel, and require an elective surgical or other invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with
low-molecular-weight heparin (
LMWH) or
unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery. The recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al, CHEST 2008; 133:123S-131S). Briefly, Grade 1 recommendations are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade 2 recommendations are referred to as suggestions and imply that individual patient values may lead to different management choices. The key recommendations in this article include the following: in patients with a mechanical heart valve or
atrial fibrillation or
venous thromboembolism (VTE) at high risk for
thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC)
LMWH or IV UFH over no bridging during temporary interruption of VKA
therapy (Grade 1C); in patients with a mechanical heart valve or
atrial fibrillation or VTE at moderate risk for
thromboembolism, we 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); in patients with a mechanical heart valve or
atrial fibrillation or VTE at low risk for
thromboembolism, we suggest low-dose SC
LMWH or no bridging over bridging with therapeutic-dose SC
LMWH or IV UFH (Grade 2C). In patients with a bare
metal coronary
stent who require surgery within 6 weeks of
stent placement, we 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, we recommend continuing
aspirin and
clopidogrel in the
perioperative period (Grade 1C). In patients who are undergoing minor dental procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure and co-administering an oral prohemostatic agent (Grade 1B); in patients who are undergoing minor dermatologic procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C); in patients who are undergoing
cataract removal and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C).