Anticoagulant
and antiplatelet medications save lives in typical settings by
preventing embolic stroke, pulmonary emboli, coronary thrombosis, and
more. But these therapies in the surgical setting risk major or
catastropic bleeding. The goal of managing these medications around the
time of surgery is to minimize the risk of serious bleeding while
minimizing the risk of being off these medications. Management is
guided by considering the risk of bleeding in surgery compared to the
risk to the patient while on reduced or discontinued medication. The
general approach is to be off blood-thinning medications for a
relatively short amount of time to permit safe surgery and then resume
when wounds are hemostatic and bleeding risk has fallen.
For
warfarin, this generally involves stopping 5-7 days before surgery.
During the time when the patient is off warfarin, the highest clot-risk
patients are placed on a "bridging heparin" to maintain anticoagulation
until just before surgery, while lower-risk patients receive no
bridging.
For aspirin and
clopidogrel (and other P2Y12 inhibitors), discontinuation depends on the
indication of use. When used for primary prevention (CAD, CVA, PVD),
risk of thrombosis is so low that the agent is simply discontinued 5, 7,
or 10 days before surgery. However, when used in combination (DAPT)
after PCI, the risk of thrombosis off medication(s) is higher and
warrants careful consideration of risk and benefit of continuing both
agents, delaying surgery, cutting back to one agent temporarily, or
discontinuing both.
For DOAC's,
the half-lives of these medications is short enough that bridging
anticoagulation with heparin is generally not necessary. The PAUSE
trial protocol is currently the best (and possibly the only)
evidence-based guidance on handling DOAC's perioperatively.
The
best most current guidance on periprocedural management of
anticoagulants and antiplatelet agents can be found in the external apps
and websites offered in this app. Go read about the details pertinent
to your patient at hand.