General principles of periprocedural management of antithrombotic therapy

Antithrombotic therapy includes anticoagulant drugs (eg apixaban, rivaroxaban, dabigatran, warfarin) and antiplatelet drugs (eg aspirin, clopidogrel, prasugrel, ticagrelor). Manage patients taking these drugs who require a procedure in conjunction with the surgeon or proceduralist, the clinician who started the antithrombotic therapy, and the clinician supervising the periprocedural care. These clinicians must prepare a plan for managing antithrombotic therapy, including stopping and restarting therapy if requiredSmilowitz, 2020.

The large variety of possible surgical procedures and unique patient-related considerations mean these decisions require clinical judgement, specialist input, and consensus between the treating clinicians. Discuss the risks and expected benefits with the patient.

Periprocedural management of antithrombotic therapy depends on the procedural- and patient-related risk of bleeding and thromboembolic events.

Temporary interruption of antithrombotic therapy may be required to reduce the periprocedural bleeding risk. Consider the potential harm of continuing a drug that may cause or increase the periprocedural bleeding risk, versus the risk that stopping the drug could cause a fatal or incapacitating thromboembolic event. The consequences of a thromboembolic event are generally greater than those of bleeding. However, major bleeding can be life threatening, and can be associated with an increased risk of subsequent myocardial infarction.

Warfarin has a long half-life and therefore a long time to onset and offset of effect. To reduce the risk of a thromboembolic event when interrupting warfarin therapy, bridging therapy (with a subcutaneous low molecular weight heparin [LMWH] or intravenous unfractionated heparin [UFH]) is sometimes given before and/or after the procedure. See Stepwise approach to periprocedural use of warfarin for a guide to deciding whether and when to interrupt warfarin therapy, whether to use bridging therapy, and when to restart warfarin therapy if it is interrupted.

If direct-acting oral anticoagulant (DOAC) therapy or antiplatelet therapy is interrupted, bridging therapy with a parenteral anticoagulant is not recommendedDouketis, 2019Douketis, 2022.For information about management of patients taking antithrombotic therapy who require a gastrointestinal procedure, see Peri-endoscopic use of antithrombotic therapy in adults.

For information about management of patients taking antithrombotic therapy who require a dental procedure, see Antithrombotic drugs: considerations for oral and dental procedures.

Detailed guidance on periprocedural management of antithrombotic therapy is available from the guidelines produced by the European Society of Cardiology and the American College of Chest Physicians.