Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update

Abstract

Purpose of Review Multiple guidelines and recommendations have been written to address the perioperative management of antiplatelet and anticoagulant drugs. In this review, we evaluated the recent guidelines in non-cardiac, cardiac, and regional anesthesia. Furthermore, we focused on unresolved problems and novel approaches for optimized perioperative management. Recent Findings Vitamin K antagonists should be stopped 3 to 5 days before surgery. Preoperative laboratory testing is recommended. Bridging therapy does not decrease the perioperative thromboembolic risk and might increase perioperative bleeding risk. In patients on direct-acting oral anticoagulants (DOAC), a discontinuation interval of 24 and 48 h in those scheduled for surgery with low and high bleeding risk, respectively, has been shown to be saved. Several guidelines for regional anesthesia recommend a conservative interruption interval of 72 h for DOACs before neuraxial anesthesia. Finally, aspirin is commonly continued in the perioperative period, whereas potent P2Y12 receptor inhibitors should be stopped, drug-specifically, 3 to 7 days before surgery. Summary Many guidelines have been published from various societies. Their applicability is limited in emergent or urgent surgery, where novel approaches might be helpful. However, their evidence is commonly based on small series, case reports, or expert opinions.

Removal of Apixaban during Emergency Cardiac Surgery Using Hemoadsorption with a Porous Polymer Bead Sorbent

“…In the non-cardiac surgical setting, it was shown by the PAUSE trial that stopping DOACs for 1 to 4 days before surgery is safe (one day for a low-risk and 2 days for a high-risk procedure), with prolonged discontinuation necessary in patients with impaired renal function [ 10 ]. However, for cardiac surgery, this interval should be extended to 4 to 5 days, corresponding to an elimination half-life of 10 days [ 10 , 11 , 12 ], especially when drug level monitoring or pharmacodynamic tests specific to DOACs are not available. One observational study even suggests that bleeding risk may extend beyond 4 days and that longer washout periods may be required.…”

Perioperative Management of Patients Receiving Antithrombotic Therapy in Schemes and Algorithms

“…Подробный алгоритм периоперационной отмены двойной антиагрегантной терапии представлен на рис. 4 [27].…”

“…Прием ПОАК возобновляется через 1 сут после процедур с низким риском кровотечения и через 2-3 дня после процедур с высоким геморрагическим риском (рис. 6) [27].…”

“…None. Algorithm for perioperative withdrawal of antithrombotic therapy[27] Таблица 2. Алгоритм периоперационной отмены антитромботической терапии[27]…”

Coagulation and Transfusion Updates From 2021

“…91 These findings were in spite of current recommendations to discontinue P2Y 12 receptor inhibitors ticagrelor, clopidogrel, and prasugrel at 3 days, 5 days, and 7 days, respectively, prior to surgery. 2,92 One key application of these findings is in patients with recent intracardiac stents, in whom interruption of therapy may be harmful. Alternatively, bridging with intravenous antiplatelet agents has been proposed but lacks evidence at this time.…”