Special article
Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEUManejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso de SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT y AEU

https://doi.org/10.1016/j.rec.2018.01.029Get rights and content

Abstract

During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.

Resumen

En los últimos años, el número de pacientes anticoagulados y antiagregados está aumentando significativamente. Al ser un tratamiento crónico, es de esperar que a lo largo de su vida necesiten un procedimiento quirúrgico o intervencionista que pueda requerir la interrupción del fármaco antitrombótico. La decisión de retirar o mantener dicho tratamiento estará determinada, por un lado, por el riesgo trombótico y, por otro, por el hemorrágico. De la interacción entre estos 2 factores dependerá la actitud ante la anticoagulación y la antiagregación. El objetivo de este documento de consenso, coordinado desde el Grupo de Trabajo de Trombosis Cardiovascular de la Sociedad Española de Cardiología y certificado por un amplio número de sociedades científicas que participan en el proceso asistencial del paciente durante el periodo perioperatorio o periprocedimiento, consiste en proponer una serie de recomendaciones prácticas y sencillas con el fin de homogeneizar la práctica clínica diaria.

Section snippets

INTRODUCTION

The number of patients on anticoagulant therapy has risen significantly in recent years. In Spain alone, over 800 000 patients are estimated to be taking anticoagulants, mainly for atrial fibrillation (AF).1 Use of antiplatelet drugs is also rising because these drugs are prescribed for the secondary prevention of atherosclerotic disease and because there has been a rise in the number of percutaneous coronary interventions (PCIs) and stent implantations.2, 3, 4, 5, 6 As most patients on

Anticoagulant Therapy

Thromboembolic risk associated with the indication for anticoagulant therapy (a mechanical heart valve, AF, or venous thromboembolism) is classified as high when the annual risk of arterial or venous thromboembolism is greater than 10%, moderate when it is between 5% and 10%, and low when it is less than 5%.18 Recent recommendations that use CHA2DS2-VASc rather than CHADS2 scores for stroke risk assessment were taken into account for patients with AF.16 The risk stratification for

BLEEDING RISK

Bleeding risk, like thrombotic risk, is stratified into 3 levels according to the characteristics of the procedure the patient is to undergo.7, 10, 13, 16 Procedures with a low bleeding risk are those in which adequate hemostasis can be achieved and in which bleeding would not jeopardize the patient's life, affect the outcome of surgery, or require transfusion. Procedures with a moderate bleeding risk, in turn, are those in which it may be difficult to secure hemostasis or in which bleeding

RECOMMENDATIONS FOR STOPPING AND RESTARTING ANTICOAGULANT THERAPY

We have established a series of simple recommendations to guide perioperative/periprocedural anticoagulation strategies according to the risk of thromboembolism and bleeding. These recommendations are summarized in the algorithm shown in Figure 2.9, 16, 30, 34

RECOMMENDATIONS FOR STOPPING AND RESTARTING ANTIPLATELET THERAPY

Decisions regarding antiplatelet strategies during the perioperative/periprocedural period depend not only on the balance between thrombotic and bleeding risks but also on the type of antiplatelet therapy and the corresponding indication.5, 9, 10 It is important to note that antiplatelet therapy is currently not recommended for primary prevention.7 A simple algorithm based on a series of questions designed to facilitate decisions on antiplatelet strategies is presented in Figure 3.

ANTICOAGULATION AND EMERGENCY SURGERY

Patients in need of emergency surgery or an emergency invasive procedure do not have the luxury of time associated with an elective procedure. In such cases, it is important to determine the following aspects as quickly as possible (Figure 4)40, 48:

  • The coagulation status of the patient via laboratory tests (INR for patients on VKA therapy). Quantitative tests offer greater precision in the case of DOACs, but as these are often not available, routine qualitative tests, such as activated partial

ANTIPLATELET THERAPY AND EMERGENCY SURGERY

Generally speaking, treatment with an antiplatelet agent before an emergency operation or procedure is of little consequence, even in elderly patients scheduled for neurosurgery.10, 56 It is widely agreed that, following an evaluation of the risk of bleeding versus the need for the procedure, deferral of surgery because of antiplatelet therapy is not justified (even in patients on DAPT).57

Some clinical guidelines suggest considering platelet function tests in selected cases as detection of

CONCLUSIONS

Variations in antithrombotic management strategies during the perioperative or periprocedural period are a common problem in everyday clinical practice. The aim of this consensus document, which draws on the opinions of experts across Spanish scientific societies involved in perioperative care, is to synthesize the most important findings on how to manage anticoagulant and antiplatelet drugs and present our recommendations in a simple, practical, and easy-to-apply format. It is essential to

CONFLICTS OF INTEREST

None declared.

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