Review
Use of oral anticoagulation for patients who undergo invasive procedures
Uso de la anticoagulación oral en el paciente sometido a un procedimiento invasivo
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Sánchez Fuentes, M.A. Budiño Sánchez, M.P. López Sánchez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Sánchez Fuentes" "email" => array:1 [ 0 => "dfuentes@saludcastillayleon.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.A." "apellidos" => "Budiño Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M.P." "apellidos" => "López Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Complejo Asistencial de Ávila , Ávila, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Medicina Familiar y Comunitaria, ABS Santa Coloma de Farnés, Gerona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Uso de la anticoagulación oral en el paciente sometido a un procedimiento invasivo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The use of long-term oral anticoagulation (OAC) for patients who require invasive procedures is a challenge. On one hand, the risk of hemorrhaging increases if the anticoagulation is maintained, and on the other, the risk of thromboembolism increases if the anticoagulation is temporarily suspended.</p><p id="par0010" class="elsevierStylePara elsevierViewall">For patients who are anticoagulated and will undergo surgery or an invasive procedure, the following questions need to be answered: Does the anticoagulation need to be suspended? If yes, when and for how long? Is bridge therapy (e.g., the administration of short-acting parenteral anticoagulants) required while anticoagulation is being suspended? Unfortunately, these questions need to be answered despite a current lack of sufficient evidence. The hemorrhagic and thromboembolic risks are not well established for these conditions, and few studies have assessed the efficacy of the various proposed alternatives. Therefore, even the most accepted recommendations on this issue are weak and are followed in a highly disparate manner.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Our objective is to review the evidence published in the 9th edition of the American College of Chest Physicians guidelines (9th ACCP) on the use of OAC in patients who undergo invasive procedures.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> Furthermore, we proposed recommendations, using these guidelines and subsequently published studies as reference.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Recommendations for patients undergoing treatment with vitamin K antagonists</span><p id="par0020" class="elsevierStylePara elsevierViewall">For patients undergoing treatment with vitamin K antagonists (VKAs) who will undergo an invasive procedure, the decision to continue or discontinue the OAC is linked to the estimated hemorrhagic risk during the procedure. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the hemorrhagic risk associated with the most common procedures.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> We also need to consider the patient's hemorrhagic predisposition using scales such as HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs or alcohol).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Except when the condition is considered to have minimal hemorrhagic risk, VKA treatment should be discontinued with sufficient time for the procedure to be conducted without an anticoagulant effect. The length of time will depend on the half-life of the drug employed; thus, warfarin will be discontinued 5 days prior to the surgery, and acenocoumarol will be discontinued 3 days prior.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> According to the classification listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, the following adapted recommendations of the ACCP guidelines may be established<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">For patients who will undergo a procedure with significant hemorrhagic risk (low to high), VKA treatment is discontinued (5 days prior for warfarin and 3 days prior for acenocoumarol) to prevent hemorrhagic complications. It is advisable to check the reversal of the anticoagulant effect using INR prior to the procedure.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">The treatment is reinstated 12–24<span class="elsevierStyleHsp" style=""></span>h after the procedure, provided there is adequate hemostasis.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel"><span class="elsevierStyleItalic">•</span></span><p id="par0040" class="elsevierStylePara elsevierViewall">Patients who will undergo a procedure with minimal hemorrhagic risk do not require discontinuation of the VKA treatment; however, local hemostatic measures should be maximized.</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">The use of bridge therapy will depend on the thromboembolic risk (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The ACCP guidelines recommend the use of bridge therapy for cases of high-risk thromboembolism, while ruling it out for patients with low risk. The guidelines do not establish a specific recommendation for intermediate risk<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients with a low risk of thromboembolism do not require bridge therapy during the temporary suspension of VKA for surgery or an invasive procedure.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">However, it is reasonable to administer bridge therapy to patients with a high risk of thromboembolism during the temporary suspension of VKA for surgery or an invasive procedure.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">For patients with an intermediate risk of thromboembolism, the administration (or not) of bridge therapy should be individualized based on the risks, benefits and predicted time without the effects of the VKA.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel"><span class="elsevierStyleItalic">•</span></span><p id="par0065" class="elsevierStylePara elsevierViewall">Patients who temporarily suspend VKA treatment for surgery should be administered prophylaxis for venous thromboembolism disease (VTE) when indicated.</p></li></ul></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Since the dissemination of the 9th ACCP, several studies have been published that have provided additional information on the use of bridge therapy for patients who undergo invasive procedures. In a systematic review that included 34 studies with more than 12,000 patients, bridge therapy increased the risk of hemorrhage 5 fold and that of major hemorrhage during the periprocedure 3 fold. There were no significant differences (OR, 0.80; 0.42–1.54) in the incidence rate of thromboembolism compared with the patients who did not undergo bridge therapy.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> However, this review should be interpreted with extreme caution because only 1 of the 34 studies was randomized while the remaining were observational, many of which were from retrospective cohorts with no comparative arm. Therefore, it is not surprising that the evaluated groups had differing risk levels, such that bridge therapy would be obviated for patients at low risk of thromboembolism. It is nevertheless clear that, given the incidence rate of hemorrhage, the patients who are recommend bridge therapy should be those with a high risk of thromboembolism.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Moreover, the data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation for patients who are anticoagulated for atrial fibrillation also do not support the systematic use of bridge therapy. This lack of support is due to the fact that patients who were administered the therapy, compared with those who were untreated, had a higher risk of hemorrhage (OR 3.48; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001), thromboembolism (OR, 1.62; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.07) and the combination of hemorrhagic events, thromboembolism and death (OR, 1.94; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.0001).<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> Nevertheless, due to the methodological limitations inherent in an observational study and the low number of patients with a high risk of thromboembolism, we cannot rule out the possibility that bridge therapy can be beneficial in the latter case.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The recently published results from the clinical trial BRIDGE provide valuable information on this topic.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> The trial compared the use of dalteparin, at a dosage of 100<span class="elsevierStyleHsp" style=""></span>IU/kg/12<span class="elsevierStyleHsp" style=""></span>h, to placebo in patients with atrial fibrillation who temporarily suspended their OAC for an invasive procedure.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> The study excluded patients with prosthetic valves and those who had experienced a stroke in the last 12 months. It is important to note that the incidence rate of thromboembolism episodes was similar in the 2 groups (0.3% in the dalteparin branch vs. 0.4% in the placebo branch; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01 for noninferiority), while the rate of major hemorrhage was higher in the treated group (3.2% vs. 1.3%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.005). One of the limitations of the study was that the patients with mitral stenosis and CHADS<span class="elsevierStyleInf">2</span> scores of 5–6 were scarcely represented. Based on this study, it seems clear that patients with an intermediate risk of thromboembolism do not require bridge therapy, while there is insufficient information for those at high risk. Another similar clinical trial (PERIOP-2) is currently underway whose results will probably be made known in 2017.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The newly published results reinforce the ACCP recommendation for omitting bridge therapy for patients with a low risk of thromboembolism and provide insufficient evidence against the recommendation for indicating bridge therapy for patients with a high risk of thromboembolism.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> For an intermediate risk of thromboembolism, bridge therapy may be considered for patients who require discontinuing VKAs for an extended period of time and whose hemorrhagic risk is low.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Bridge therapy can be performed with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Currently, bridge therapy tends to be performed with LMWH because LMWH has the same safety and efficacy as UFH and does not require monitoring or hospitalization for its administration.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">There are no conclusive data as to whether LMWH should be used at therapeutic or prophylactic dosages. We propose the use of therapeutic dosages because they are the most widely used in published studies<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> and have shown efficacy similar to that of OACs in preventing both arterial and venous thromboembolic events. Additionally, prophylactic dosages have shown efficacy only in preventing VTE and not in preventing stroke. The proposed temporary regimen for implementing bridge therapy is shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Recommendations for patients undergoing treatment with direct oral anticoagulants</span><p id="par0100" class="elsevierStylePara elsevierViewall">The 9th ACCP make no references to direct oral anticoagulants (DOAs) because the guidelines were published prior to the widespread use of these drugs.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> If the condition is considered to have a minimal hemorrhagic risk, withdrawal of the DOAs is unnecessary (only the concomitant taking of the drug with the procedure will be omitted). Otherwise, the treatment will be discontinued with sufficient time (depending on the procedure's hemorrhagic risk) to cause a loss of the anticoagulant effect (which, in turn, is related to the creatinine clearance). The restarting of DOAs after the procedure will also depend on the hemorrhagic risk. <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows when to suspend and restart the various DOAs, according to their pharmacokinetics and hemorrhagic risk, as recommended in the data sheet.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10–13</span></a> This protocol has been shown effective and safe in cohorts of patients treated with dabigatran.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14,15</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Considering the short half-life of DOAs and their rapid start of action, their suspension period for an invasive procedure is shorter than that of VKAs. Considering these pharmacokinetic characteristics, widespread opinion (specified in a number of guidelines<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a>) goes against the use of bridge therapy when temporarily suspending the use of DOAs, except for patients in whom oral administration after the procedure is not feasible. However, the safety of this recommendation has not been sufficiently corroborated. In this regard, post hoc substudies have been published on the pivotal trials with DOAs, which have evaluated the presence of complications during the periprocedure period. The results show that the incidence rate of hemorrhagic and thromboembolic events was similar for the patients treated with warfarin or DOAs.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">16–19</span></a> Two of these substudies also presented the results for the patients who underwent bridge therapy with heparin (nonrandomized decision at the investigator's discretion). The substudies observed that the administration of heparin to those patients who suspended the use of DOAs increased the number of hemorrhages without significantly reducing the number of thromboembolic events.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">17,20</span></a> Similar results were reported in a registry of patients undergoing treatment with DOAs.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> Nevertheless, it is worth noting that regardless of a probable bias in the selection of the bridge therapy, the patients with a high risk of thromboembolism were not sufficiently represented in these studies. Therefore, lacking firm data, we cannot rule out a benefit from bridge therapy with heparin during the temporary suspension of DOAs in patients with a high risk of thromboembolism.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres806045" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec804148" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres806046" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec804149" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Recommendations for patients undergoing treatment with vitamin K antagonists" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Recommendations for patients undergoing treatment with direct oral anticoagulants" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec804148" "palabras" => array:3 [ 0 => "Oral anticoagulation" 1 => "Temporary suspension" 2 => "Invasive procedure" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec804149" "palabras" => array:3 [ 0 => "Anticoagulación oral" 1 => "Suspensión temporal" 2 => "Procedimiento invasivo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The performance of invasive procedures in patients undergoing oral anticoagulation represents a risk. Without conclusive data on this issue, the recommendations on managing oral anticoagulation are generally weak, and its management is controversial and heterogeneous.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a review of the evidence on the elective periprocedural management of oral anticoagulation following the publication of the 9th edition of the guidelines of the American College of Chest Physicians.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Except for cases of procedures with minimal hemorrhagic risk, the use of oral anticoagulants is suspended with sufficient time so that it can be performed without a significant anticoagulant effect, which will depend on the half-life of the drug. For direct oral anticoagulants, the half-life is determined by the renal function.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Recent studies have shown that the use of bridge therapy with heparin in patients who temporarily suspended the use of oral anticoagulation provided no benefits and increased the bleeding. However, there is no conclusive evidence against its use in patients with a high thromboembolic risk.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La realización de procedimientos invasivos en pacientes con anticoagulación oral es un riesgo. Sin unos datos concluyentes al respecto, las recomendaciones sobre el manejo, por lo general, son de escasa solidez, y su manejo es controvertido y heterogéneo.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiza una revisión de las evidencias sobre el manejo periprocedimiento electivo de la anticoagulación oral después de la publicación de la 9.ª edición de la guía del American College of Chest Physicians.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Salvo en caso de procedimientos con riesgo hemorrágico mínimo, los anticoagulantes orales serán suspendidos justo con la antelación necesaria para que se realice sin efecto anticoagulante significativo, lo que dependerá de la vida media del fármaco, que en el caso de los anticoagulantes orales de acción directa está condicionada por la función renal.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudios recientes muestran que la utilización de terapia puente con heparina en pacientes que interrumpen temporalmente la anticoagulación oral no aporta beneficios e incrementa los sangrados; sin embargo, no hay evidencia concluyente contra su uso en pacientes con alto riesgo tromboembólico.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sánchez Fuentes D, Budiño Sánchez MA, López Sánchez MP. Uso de la anticoagulación oral en el paciente sometido a un procedimiento invasivo. Rev Clin Esp. 2017;217:103–107.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Source: modified from Heidbuchel et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1. Operations with minimal hemorrhagic risk</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>a. Extraction of ≤3 dental specimens \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>b. Minor dental operations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>c. Cataract surgery with local anesthesia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>d. Minor dermatologic surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>e. Endoscopies without biopsy or extirpation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2. Operations with low hemorrhagic risk</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>a. Endoscopies with biopsy or extirpation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>b. Pacemaker implantation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>c. Right cardiac ablation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">3. Operations with high hemorrhagic risk</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>a. Left cardiac ablation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>b. Spinal or epidural anesthesia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>c. Lumbar puncture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>d. Transurethral resection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>e. Extracorporeal lithotripsy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>f. Hepatic or renal biopsy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>g. Major orthopedic surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>h. Abdominal surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>i. Thoracic surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>j. Neurosurgery \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1352693.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Classification of procedures according to their hemorrhagic risk.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: AF, atrial fibrillation; RF, risk factor; TE, thromboembolic; TIA, transient ischemic attack; VTE, venous thromboembolism disease.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High TE risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intermediate TE risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low TE risk \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mechanical valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mitral<br>Aortic, ball or disk<br>Stroke/TIA<span class="elsevierStyleHsp" style=""></span><6<span class="elsevierStyleHsp" style=""></span>months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bivalve aortic<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>AF and another RF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bivalve aortic without AF or other RF \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHADS2: 5–6<br>Stroke/TIA<span class="elsevierStyleHsp" style=""></span><3<span class="elsevierStyleHsp" style=""></span>months<br>Rheumatic valvular heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHADS<span class="elsevierStyleInf">2</span>: 3–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHADS<span class="elsevierStyleInf">2</span> ≤2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VTE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recent episode (<3<span class="elsevierStyleHsp" style=""></span>months)<br>Severe thrombophilia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Episode 3–12 months<br>Nonsevere thrombophilia<br>Recurrent VTE<br>Active cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Episode >12 months<br>Without RF \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1352692.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Gradation of thromboembolic risk for various processes.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a></p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: LMWH, low-molecular-weight heparin; VKA, vitamin K antagonists; VTE, venous thromboembolism disease.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• <span class="elsevierStyleItalic">7–14 days prior to surgery: risk assessment and preparation of a perioperative management plan by a multidisciplinary team (regular doctor, surgeon, anesthesiologist, hematologist).</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• <span class="elsevierStyleItalic">3 days prior to surgery: Patient should not take acenocoumarol (5 days in the case of warfarin).</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• <span class="elsevierStyleItalic">1 day prior to surgery, in the afternoon:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span> Surgery scheduled for the morning of day 0: administer 1 therapeutic dosage of 12<span class="elsevierStyleHsp" style=""></span>h of LMWH (e.g., enoxaparin 1<span class="elsevierStyleHsp" style=""></span>mg/kg). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span> Surgery scheduled for the afternoon of day 0: administer one 24-h dose of LMWH (e.g., enoxaparin 1.5<span class="elsevierStyleHsp" style=""></span>mg/kg).<br>(For warfarin, the LMWH administration is starting on the afternoon of day 3 before surgery). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• <span class="elsevierStyleItalic">Day 0: Surgery.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• <span class="elsevierStyleItalic">12–24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h after surgery (always under conditions of adequate hemostasis): restart VKA. Start LMWH at prophylaxis dosage of VTE if indicated.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• <span class="elsevierStyleItalic">48–72</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h after surgery (24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h if the condition has a low hemorrhagic risk) and always under conditions of adequate hemostasis: restart therapeutic dosage of LMWH (increase dosage if patient was undergoing VTE prophylaxis).</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• <span class="elsevierStyleItalic">Discontinue LMWH when INR ≥2.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1352690.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Suggested schedule for the indication of bridge therapy for the temporary discontinuation of vitamin K antagonists.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Abbreviation: CrCl, creatinine clearance.</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Source: <a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10–13</span></a> (based on these references).</p>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="4" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">A. Discontinuation time prior to procedure in hours</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CrCl (mL/min) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hemorrhagic Risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Apixaban/rivaroxaban \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dabigatran \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≥80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low<br>High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥24<br>≥48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥24<br>≥48 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">50–79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low<br>High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥24<br>≥48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥36<br>≥72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">30–49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low<br>High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥24<br>≥48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥48<br>≥96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15–29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low<br>High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥36<br>≥48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not indicated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not indicated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not indicated \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1352689.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">B. Restart time after the procedure in hours</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hemorrhagic risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Apixaban/dabigatran/rivaroxaban \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48–72 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1352691.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Discontinuation and restart time for direct-acting oral anticoagulants before and after an invasive procedure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "e326S–e350S" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.D. 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