Guideline sources The following summarized guidelines for the evaluation and management of perioperative management of antithrombotic therapy are prepared by our editorial team based on guidelines from the American College of Chest Physicians (ACCP 2022), the American College of Gastroenterology (ACG/CAG 2022), the European Society of Gastrointestinal Endoscopy (ESGE/BSG 2021), the Society of Interventional Radiology (SIR 2019), the American Heart Association (AHA/HRS/ACC 2019), the National Heart Foundation of Australia (NHFA 2018), and the Canadian Cardiovascular Society (CCS 2014). 1 2 3 4 5 6 7 Guidelines 1. Diagnostic investigations Coagulation tests: Do not obtain screening coagulation laboratory testing in patients with minimal risk factors for bleeding undergoing procedures carrying risk for bleeding. Consider obtaining coagulation testing in patients receiving warfarin or UFH or in patients with an inherently higher risk of bleeding. Correct INR to within the range of 2.0-3.0 and consider administering platelet transfusion if the platelet count is < 20 10 /L. Correct INR to < 1.8 for femoral access and < 2.2 for radial access in patients undergoing low bleeding risk procedures requiring arterial access. D Obtain appropriate preprocedural coagulation testing in patients undergoing procedures with high bleeding risk. Correct INR to within the range of 1.5-1.8 and consider administering https://web.pathway.md/diseases/recfNAeCwjrsCzIVy 1/5 6/29/23, 11:03 PM Perioperative management of antithrombotic therapy Pathway platelet transfusion if the platelet count is < 50 10 /L. B 2. Perioperative care General principles: ensure a multidisciplinary, shared decision-making approach for planning periprocedural management in patients at high risk for thromboembolic or bleeding events. Involve specialists in cardiology, hematology, or vascular or internal medicine in order to provide optimal periprocedural medical management in high-risk patients. B Patients on VKAs (elective surgeries/procedures): consider stopping vitamin K antagonists (warfarin) 5 days before an elective surgery/procedure in patients requiring vitamin K antagonist (warfarin) interruption for an elective surgery/procedure. C Show 8 more Patients on VKAs, minor procedures: As per ACCP 2022 guidelines, consider continuing vitamin K antagonists in patients receiving vitamin K antagonist therapy and requiring a dental, C minor dermatologic, or ophthalmologic procedure. C Show 3 more As per CAG/ACG 2022 guidelines, consider continuing warfarin rather than temporarily interrupting (1-7 days) in patients on warfarin undergoing elective/planned endoscopic gastrointestinal procedures. C Show 2 more As per ESGE/BSG 2021 guidelines, consider continuing warfarin therapy for low-risk endoscopic procedures. C Ensure that the INR does not exceed the therapeutic range in the week before the procedure. B Show 2 more Patients on heparins: consider stopping UFH 4 hours before a surgery/procedure in patients receiving therapeutic-dose IV UFH bridging for an elective surgery/procedure. C Show 5 more Patients on DOACs: As per ACCP 2022 guidelines, consider stopping apixaban, edoxaban, and rivaroxaban for 1- 2 days before surgery/procedure in patients receiving any of these agents requiring elective surgery/procedure. C Show 4 more As per ACG 2022 guidelines: Consider interrupting direct OACs temporarily in patients on direct OACs undergoing elective/planned endoscopic gastrointestinal procedures. C Insufficient evidence to recommend for or against resuming the direct OAC on the same day of the procedure versus 1-7 days after the procedure in patients interrupted the direct OAC in the periprocedural period for elective endoscopic gastrointestinal procedures. I As per BSG 2021 guidelines: Consider omitting the morning dose of direct OACs on the day of the procedure for low-risk endoscopic procedures. C https://web.pathway.md/diseases/recfNAeCwjrsCzIVy 2/5 6/29/23, 11:03 PM Perioperative management of antithrombotic therapy Pathway Instruct patients on direct OACs to take the last dose of direct OACs 3 days before the procedure for high-risk endoscopic procedures. Instruct patients on dabigatran with a CrCl (or eGFR) of 30-50 mL/min to take the last dose 5 days before the procedure. Consult a hematologist for any patient with rapidly deteriorating renal function. B Patients on antiplatelets: As per ACCP 2022 guidelines, consider continuing aspirin in patients on aspirin therapy undergoing elective non-cardiac surgery. C Show 15 more As per ACG 2022 guidelines, consider interrupting the P2Y12 inhibitor temporarily while continuing aspirin in patients on dual antiplatelet therapy for secondary cardiovascular prevention undergoing elective endoscopic gastrointestinal procedures. C Show 3 more As per BSG 2021 guidelines, continue aspirin for all endoscopic procedures B , with the exception of ampullectomy. Discontinue aspirin, if considered, on an individual basis depending on the risks of thrombosis versus hemorrhage. B Show 3 more 3. Specific circumstances Patients with chronic liver disease: Administer plasma and platelet transfusion in patients with chronic liver disease because of rebalanced hemostasis, used judiciously given the potential for increased portal pressure and transfusion-related adverse events. E Consider adjusting the INR and platelet count thresholds in patients with chronic liver disease undergoing invasive procedures to higher and lower, respectively, than in the general population to minimize unnecessary transfusions. Consider measuring the fibrinogen level and administering cryoprecipitate for replacement if the level is low. E Patients with atrial fibrillation (preprocedural interruption): balance the risks of a thromboembolic event (as indicated by a higher CHADS2 score, mechanical heart valve, or rheumatic heart disease) against a bleeding event (as indicated by a higher HASBLED score and procedures with higher bleeding risks) in patients with atrial flutter/AF to decide on interrupting antithrombotic therapy for an invasive procedure. B Show 6 more Patients with atrial fibrillation, preprocedural bridging: As per HRS/ACC/AHA 2019 guidelines: Bridge with UFH or LMWH in patients with AF and a mechanical heart valve undergoing procedures requiring interruption of warfarin. Recognize that decisions on bridging therapy should balance the risks of stroke and bleeding. B Recognize that decisions about bridging therapy (UFH or LMWH) in patients with AF without mechanical heart valves requiring interruption of warfarin for procedures should balance the risks of stroke and bleeding and the duration of time the patient will not be anticoagulated. B https://web.pathway.md/diseases/recfNAeCwjrsCzIVy 3/5 6/29/23, 11:03 PM Perioperative management of antithrombotic therapy Pathway As per NHFA 2018 guidelines, avoid bridging with LMWH or UFH in patients treated with warfarin, at low-to-moderate risk of stroke undergoing planned surgical intervention. D Show 2 more As per CCS 2014 guidelines, consider bridging with LMWH or UFH when the INR is below the therapeutic INR target when a decision to interrupt warfarin therapy for an invasive procedure has been made in patients with atrial flutter/AF at high risk of thromboembolic events (CHADS2 score 3, mechanical heart valve, stroke or TIA within 3 months, rheumatic heart disease). C Show 2 more Patients with atrial fibrillation (postprocedural resumption): Consider restarting therapy once hemostasis is established when warfarin, acetylsalicylic acid, or clopidogrel have been withdrawn for an invasive procedure (usually 24-48 hours for procedures at low risk of bleeding). C Consider restarting therapy after the procedure 1 day after hemostasis is established when apixaban, dabigatran, or rivaroxaban have been withdrawn for an invasive procedure. C 4. Patient education General counseling: Counsel all patients on antiplatelets or anticoagulants about the increased risk of postprocedural hemorrhage. B Counsel all patients on the thrombotic risks of discontinuing antiplatelets or anticoagulants, as well as the hemorrhagic risks of continuing therapy. B Studies 2018 EPCAT II In patients who underwent total hip arthroplasty or total knee arthroplasty and received once- daily oral rivaroxaban 10 mg until postoperative day 5, aspirin was noninferior to rivaroxaban with respect to VTE. Anderson DR et al. N Engl J Med. 2018 Feb 22. 2015 BRIDGE In patients with AF who need an interruption in warfarin treatment (5 days before the procedure) for an elective operation or other elective invasive procedure, avoiding routine bridging was noninferior to routine bridging therapy with respect to arterial thromboembolism at 30 days after the procedure. Douketis JD et al. N Engl J Med. 2015 Aug 27. 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Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline Executive Summary. Chest. 2022 Aug 10;S0012 3692 22 01364 2. Open 5. Neena S Abraham, Alan N Barkun, Bryan G Sauer et al. American College of Gastroenterology- Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol. 2022 Mar 17. Open 6. January CT, Wann LS, Calkins H et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Jul 9;74 1 104 132. Open 7. Brieger D, Amerena J, Attia JR et al. 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Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160 6):e545-e608. Open https://web.pathway.md/diseases/recfNAeCwjrsCzIVy 5/5