What are the American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines for perioperative anticoagulation management?

Updated: May 08, 2018
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: William A Schwer, MD  more...
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Answer

Answer

The 8th and 9th edition of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines included the following key recommendations [5, 6] :

  • In patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE):

    • At high risk for thromboembolism, bridging anticoagulation is recommended with therapeutic-dose subcutaneous (SC) low-molecular-weight heparin (LMWH) or intravenous unfractionated heparin (UFH) rather than no bridging during temporary interruption of vitamin K antagonist (VKA) therapy. [7]

    • At moderate risk for thromboembolism, it is proposed to base the plan for bridging versus no bridging on the individual patient rather than a generalized consensus. The bridging anticoagulation can be done with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH based on the patient.

    • At low risk for thromboembolism, low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH is recommended.

  • In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, the ACCP recommends to continue aspirin and clopidogrel in the perioperative period

  • In patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, continuing aspirin and clopidogrel in the perioperative period is also recommended.

  • In patients on VKAs who are undergoing minor dental procedures, continue the VKAs around the time of the procedure as well as coadminister an oral prohemostatic agent.

  • In patients on VKAs who are undergoing minor dermatologic procedures or cataract removal, continue the VKAs perioperatively.

The table below depicts which patients should receive heparin bridging before surgery.

Which patients on warfarin should receive heparin Which patients on warfarin should receive heparin bridging before surgery? Adapted from Cleveland Clinic Journal.

See the list below:


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