ACRONYMS AND DEFINITIONS

A fib - Atrial fibrillation

ACC- American College of Cardiology

ACCP- American College of Chest Physicians

AHA - American Heart Association

ASA - Acetylsalicylic acid (aspirin)

ASGE - American Society for Gastrointestinal Endoscopy

AHA - American Heart Association

CABG - Coronary artery bypass grafting

CAD - Coronary artery disease

DAPT - Dual antiplatelet therapy (ASA + P2Y12 inhibitor)

DOAC - Direct oral anticoagulant (Factor Xa inhibitors and dabigatran)

DVT - Deep vein thrombosis

GI - Gastrointestinal

NSAIDs - Nonsteroidal anti-inflammatory drugs

PE - Pulmonary embolism

SEC - Spanish Society of Cardiology

TE - Thromboembolism

TIA - Transient ischemic attack

Triple therapy - anticoagulation + P2Y12 inhibitor + aspirin (see triple therapy for more)

VTE - Venous thromboembolism

OVERVIEW

Periprocedural antithrombotic recommendations from the AHA, ACCP, ASGE, and SEC are presented below. Antiplatelet recommendations are grouped together, while anticoagulant guidelines are organized by indication. Endoscopy-specific guidance from the ASGE is also covered.

ASPIRIN FOR PRIMARY PREVENTION

Patients taking aspirin for the primary prevention of any condition should stop it at least 7 days before their procedure [2]

Reference [17]
ACCP 2022 Antiplatelet Recommendations
Minor dental, dermatologic, or ophthalmologic procedure Continue antiplatelet drug (aspirin or PY212 inhibitor)
Elective noncardiac surgery Aspirin Continue aspirin If the patient requires aspirin interruption, it should be stopped ≤ 7 days before surgery The guidelines state that the decision to continue or interrupt aspirin should be made on a case-by-case basis STUDY: A large, randomized controlled trial published in 2014 found that aspirin had no benefit in high-risk patients undergoing noncardiac surgery. See POISE-2 study for more. P2Y12 inhibitor Clopidogrel: stop 5 days before surgery Ticagrelor: stop 3 - 5 days before surgery Prasugrel: stop 7 days before surgery Resumption of antiplatelet therapy In patients who require drug interruption, antiplatelet therapy should be resumed ≤ 24 hours after surgery
Coronary artery bypass graft surgery (CABG) Aspirin Continue aspirin STUDY: A large, randomized controlled trial published in 2016 found that preoperative aspirin had no benefit in high-risk patients undergoing CABG. See ATACAS trial for more. P2Y12 inhibitor Clopidogrel: stop 5 days before surgery Ticagrelor: stop 3 - 5 days before surgery Prasugrel: stop 7 days before surgery Resumption of antiplatelet therapy Antiplatelet therapy should be resumed ≤ 24 hours after surgery
Dual antiplatelet therapy (DAPT) Minor dental, dermatologic, or ophthalmologic procedure Continue aspirin and interrupt the P2Y12 inhibitor Clopidogrel: stop 5 days before surgery Ticagrelor: stop 3 - 5 days before surgery Prasugrel: stop 7 days before surgery Elective surgery / procedure Surgery/procedure should be delayed if possible Stents placed within the last 6 - 12 weeks: continue both agents or stop one agent within 7 to 10 days of surgery Stents placed within the last 3 to 12 months: stop the P2Y12 inhibitor prior to surgery Clopidogrel: stop 5 days before surgery Ticagrelor: stop 3 - 5 days before surgery Prasugrel: stop 7 days before surgery

Reference [12]
SEC 2018 Recommendations for Antiplatelet Therapy
TE risk	Procedure bleed risk	Recommendation
Low	Low / Moderate	Continue ASA Stop P2Y12 inhibitor^✝ and replace with ASA if possible
Low	High	Continue ASA except when contraindicated (e.g. neurosurgery)* Stop P2Y12 inhibitor^✝ and replace with ASA if possible
Moderate / High	Low	Continue ASA Continue P2Y12 inhibitors
Moderate / High	Moderate	Individualize therapy based on patient risk factors Continue ASA Assess withdrawal of P2Y12 inhibitor
Moderate / High	High	Individualize therapy based on patient risk factors Continue ASA unless contraindicated* Stop P2Y12 inhibitor^✝ and replace with ASA if possible Assess bridging therapy
^✝Stop clopidogrel 5 days before surgery; Stop ticagrelor 3 - 5 days before surgery; Stop prasugrel 7 days before surgery If necessary, withdraw ASA 3 days before surgery Restart antiplatelet therapy within 24 hours of surgery if bleeding risk is low or moderate. Restart 48 - 72 hours when bleeding risk is high NOTE: A large, randomized controlled trial published in 2014 found that aspirin had no benefit in high-risk patients undergoing noncardiac surgery. (see POISE-2 study). Also, a large, randomized controlled trial published in 2016 found that preoperative aspirin had no benefit in high-risk patients who were undergoing CABG (see ATACAS trial* for more).

BMS - bare metal stent; CRF - chronic renal failure; DEB - drug-eluting balloon; DES - drug-eluting stent

^✝Associated risk factors: history of stroke/TIA, DM, CRF, complex procedure (long, multiple, or overlapping stents, bifurcation or left main stents, or stents in single vessels, vessels < 2.5 mm or saphenous vein grafts)

Reference [12]
SEC Thromboembolism Risk Categories for Heart Disease
Time on treatment	Acute coronary syndrome	Stable coronary disease
High risk
< 3 months	Medical treatment	PCI + BMS/DES/DEB or CABG
< 6 months	PCI + BMS/DES/DEB or CABG	PCI + BMS/DES/DEB or CABG + associated risk factors^✝
< 12 months	PCI + BMS/DES/DEB or CABG + associated risk factors^✝ PCI + first-generation DES (rapamycin, paclitaxel) and bioabsorbable vascular scaffold	PCI + first-generation DES (rapamycin, paclitaxel) and bioabsorbable vascular scaffold
Moderate risk
3 - 6 months	Medical treatment	PCI + BMS/DES/DEB or CABG
6 - 12 months	PCI + BMS/DES/DEB or CABG	CI + BMS/DES/DEB or CABG + associated risk factors^✝
> 12 months	PCI + BMS/DES/DEB or CABG + associated risk factors^✝ PCI + first-generation DES (rapamycin, paclitaxel) and bioabsorbable vascular scaffold	PCI + first-generation DES (rapamycin, paclitaxel) and bioabsorbable vascular scaffold
Low risk
> 6 months	Medical treatment	PCI + BMS/DES/DEB or CABG
> 12 months	PCI + BMS/DES/DEB or CABG	PCI + BMS/DES/DEB or CABG + associated risk factors^✝

Reference [12]
SEC Thromboembolism Risk Categories for Cerebrovascular disease
High risk Ischemic stroke within 3 months Carotid stent placement within 3 months Moderate risk Ischemic stroke within 3 - 6 months Carotid stent placement within 3 - 6 months Low risk Ischemic stroke > 6 months ago Carotid stent placement > 6 months ago
SEC Thromboembolism Risk Categories for Peripheral Vascular Disease
High risk Within 3 months of acute peripheral vascular event + revascularization with DES or stents used in chronic occlusions Moderate risk Within 3 - 6 months of acute peripheral vascular event + revascularization with DES or stents used in chronic occlusions Low risk > 6 months since acute peripheral vascular event + revascularization with DES or stents used in chronic occlusions

Reference [11]
AHA 2016 DAPT Recommendations
Elective, noncardiac surgery Drug-eluting stents (DES) < 3 months since DES implantation Delay surgery 3 - 6 months since DES implantation Proceeding with surgery may be considered If having surgery, discontinue DAPT before surgery (aspirin should be continued if possible) After surgery, restart DAPT as soon as possible if still indicated There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial ≥ 6 months since DES implantation Proceed with surgery Discontinue DAPT before surgery (aspirin should be continued if possible) After surgery, restart DAPT as soon as possible if still indicated There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial [11] Bare metal stents (BMS) < 30 days since BMS implantation Delay surgery ≥ 30 days since BMS implantation Proceed with surgery If having surgery, discontinue DAPT before surgery (aspirin should be continued if possible) After surgery, restart DAPT as soon as possible if still indicated There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial [11]
Coronary artery bypass graft surgery (CABG) Urgent on-pump CABG Aspirin - do not stop aspirin before surgery P2Y12 inhibitor: Clopidogrel - stop clopidogrel 24 hours before surgery if possible Ticagrelor - stop ticagrelor 24 hours before surgery if possible [7] Elective CABG Aspirin Do not stop aspirin before surgery P2Y12 inhibitor: Clopidogrel - stop clopidogrel 5 days before surgery Ticagrelor - stop ticagrelor 5 days before surgery Prasugrel - stop prasugrel 7 days before surgery [3]

Reference [17]
ACCP 2022 Warfarin Recommendations in Atrial Fibrillation
Procedures with minimal bleeding risk (procedure bleeding risk categories) Continue warfarin
Procedures with low-to-moderate or high bleeding risk (procedure bleeding risk categories) Patients at high risk of VTE: Stop warfarin ≥ 5 days before the procedure and bridging therapy is suggested High risk of VTE defined as any of the following: CHA2DS2-VASc score ≥ 7 CHADS2 score of 5 or 6 Recent (within 3 months) stroke or TIA Rheumatic valvular heart disease Patients with low-to-moderate risk of VTE: Stop warfarin ≥ 5 days before the procedure and do not provide bridging therapy Warfarin can be resumed on the evening of the procedure for most patients, or the day after the procedure at the patient’s usual maintenance dose Moderate risk of VTE defined as the following: CHA2DS2-VASc score of 5 or 6 or CHADS2 score of 3 or 4 Low risk of VTE defined as the following: CHA2DS2-VASc score of 1 - 4 or CHADS2 score of 0 - 2 (and no prior stroke or TIA)

ACCP 2022 DOAC Recommendations in Atrial Fibrillation

The 2022 ACCP recommendations for perioperative DOAC management are largely based on a cohort study (PAUSE study) published in 2019 that used a simple protocol for stopping apixaban, dabigatran, and rivaroxaban before procedures (see PAUSE study for more). The illustration below outlines the recommended management of each drug based on the procedure bleeding risk and, in the case of dabigatran, creatinine clearance. Procedure bleed-risk categories as defined by the ACCP are available here - ACCP procedure bleed risk - and the ones used in the PAUSE study are listed here - PAUSE study procedure bleed risk. The ACCP does not recommend bridging therapy for DOACs because their short half-lives limit therapy interruptions. They do state, however, that select patients at high risk for VTE (see A fib VTE risk categories) may receive low-dose anticoagulants (e.g. enoxaparin 40 mg daily or dalteparin 5,000 IU daily) for the first 48 - 72 hours post-procedure.

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ACCP 2022 protocol for the periprocedural management of Factor Xa inhibitors and dabigatran

Reference [17]
ACCP 2022 Atrial Fibrillation VTE Risk Categories
High risk Any of the following: CHA2DS2-VASc score ≥ 7 CHADS2 score of 5 or 6 Recent (within 3 months) stroke or TIA Rheumatic valvular heart disease
Moderate risk CHA2DS2-VASc score of 5 or 6 or CHADS2 score of 3 or 4
Low risk CHA2DS2-VASc score of 1 - 4 or CHADS2 score of 0 - 2 (and no prior stroke or TIA)

PAUSE study

In 2019, the Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) cohort study was published that looked at the risks of using a simple protocol to manage periprocedural apixaban, rivaroxaban, and dabigatran in patients with A fib. The study enrolled 3007 consecutive patients with A fib who were to undergo an elective surgery or procedure. Study drugs were stopped according to the protocol outlined in the ACCP recommendations above, and bridging therapy was not used. The only pertinent exclusion criteria for entry into the study were CrCl < 25 ml/min for apixaban users and CrCl < 30 ml/min for dabigatran and rivaroxaban users.
The average age of the cohort was 72.5 years, and there were 1257 apixaban users, 668 dabigatran users, and 1082 rivaroxaban users. The average CHADS2-VA2Sc was 3.4, the average modified HAS-BLED score (modified version omits labile INR and alcohol use) was 1.9, and 33.5% of the procedures were considered high bleed risk. Outcomes were measured for 30 days after the procedure and are presented in the table below. [PMID 31380891]

^✝Top number is overall risk. Bottom number is risk among subgroup of patients who underwent high-bleeding-risk procedure.

Outcomes were measured for 30 days after the procedure

Reference [15]
PAUSE Study Outcomes
Drug	Major bleeding^✝	Arterial thromboembolism
Apixaban	1.35% 2.96%	0.16%
Dabigatran	0.90% 0.88%	0.60%
Rivaroxaban	1.85% 2.95%	0.37%

ACC 2017 ATRIAL FIBRILLATION RECOMMENDATIONS

The American College of Cardiology released periprocedural guidelines for anticoagulation management in patients with nonvalvular atrial fibrillation in 2017
The recommendations are presented in a number of algorithms that are buried inside the publication
Below is a link to a pdf file of the publication along with the pages where the algorithms and other pertinent information can be found

2017 ACC periprocedural anticoagulation recommendations for patients with nonvalvular A fib (pdf)

Important pages in the document:

Vitamin K antagonist therapy: algorithm for deciding whether to interrupt therapy - page 880
Bridging therapy: algorithm for deciding when and how to use bridging therapy - page 884
Direct thrombin inhibitors and Factor Xa inhibitors: algorithm for deciding whether to interrupt therapy - page 881
Direct thrombin inhibitors and Factor Xa inhibitors: table with recommended duration for withholding therapy - page 882
Restarting therapy: algorithm for deciding when to restart therapy - page 890
Procedural bleeding risk - link to pdf with extensive list of procedures classified by their bleeding risk

Reference [12]
SEC 2018 Recommendations for Atrial Fibrillation
TE risk	Procedure bleed risk	Recommendation
Low / Moderate / High	Low^✝	Continue anticoagulation
Low / Moderate	Low / Moderate / High	Discontinue anticoagulation Do not use bridging therapy
High	Low / Moderate / High	Discontinue anticoagulation Consider bridging therapy
See warfarin, factor Xa inhibitors, and dabigatran for recommendations on timing the discontinuation ^✝Guidelines do not state specifically which procedures are okay to continue anticoagulation. Other guidelines state minor procedures such as dental extractions, minor derm procedures, and cataract surgery are okay for continued anticoagulation. For procedures with a low or moderate bleeding risk, restart anticoagulation 24 hours after surgery and consider bridging therapy in patients taking warfarin with high thromboembolic risk For procedures with a high bleeding risk, restart anticoagulation 48 - 72 hours after surgery without bridge therapy

Reference [12]
SEC Thromboembolism Risk Categories for A Fib
High risk CHA2DS2-VASc score of 7 - 9 Stroke/TIA in last 3 months Rheumatic mitral valve disease Moderate risk CHA2DS2-VASc score of 5 - 6 Stroke/TIA > 3 months ago Low risk CHA2DS2-VASc score of 1 - 4 No history of stroke/TIA NOTE: A recent study found no benefit of bridging therapy in patients with an average CHADS₂ score of 2.3 (see BRIDGE study for more)

Reference [17]
ACCP 2022 Warfarin Recommendations for Mechanical Heart Valves
Procedures with minimal bleeding risk (procedure bleeding risk categories) Continue warfarin
Procedures with low-to-moderate or high bleeding risk (procedure bleeding risk categories) Patients at high risk of thromboembolism: Stop warfarin ≥ 5 days before the procedure and bridging therapy is suggested High risk of thromboembolism defined as any of the following: Mitral valve with major risk factors for stroke (e.g. multiple prior strokes, prior perioperative stroke, or prior valve thrombosis) Caged ball or tilting-disc valve in mitral/aortic position Recent (within 3 months) stroke or TIA or other high-risk stroke situations (e.g. atrial fibrillation, prior stroke or transient ischemic attack (TIA), hypertension, diabetes, congestive heart failure, and age > 75 years) Patients with low-to-moderate risk of thromboembolism: Stop warfarin ≥ 5 days before the procedure and do not provide bridging therapy Warfarin can be resumed on the evening of the procedure for most patients, or the day after procedure at the patient’s usual maintenance dose Moderate risk of thromboembolism defined as the following: Bileaflet AVR with major risk factors for stroke (e.g. multiple prior strokes, prior perioperative stroke, or prior valve thrombosis) Low risk of thromboembolism defined as the following: Bileaflet AVR without major risk factors for stroke (e.g. multiple prior strokes, prior perioperative stroke, or prior valve thrombosis)

Reference [6,16]
AHA 2020 Mechanical Heart Valve Recommendations
Immediate/emergency noncardiac surgery or invasive procedure Administration of 4-factor prothrombin complex concentrate (or its activated form) is reasonable is patients receiving a vitamin K antagonist
Minor procedures (e.g. dental extractions, cataract removal) where bleeding is easily controlled Continue warfarin with a therapeutic INR
Other invasive or surgical procedures Patients with bileaflet mechanical aortic valve replacement (AVR) and no other risk factors for thrombosis Temporary interruption of warfarin without bridging agents while the INR is subtherapeutic - warfarin is stopped 2 to 4 days before the procedure (so the INR falls to < 1.5 for major surgical procedures) and restarted as soon as bleeding risk allows, typically 12 to 24 hours after surgery. Patients with mechanical AVR and any thromboembolic risk factor, older-generation mechanical AVR, or mechanical mitral valve replacement Bridging therapy is reasonable. Risks of bleeding should be weighed against the benefits of thromboembolism prevention.

Reference [12]
SEC 2018 Recommendations for Mechanical Heart Valves
TE risk	Procedure bleed risk	Recommendation
Low / Moderate / High	Low^✝	Continue anticoagulation
Low / Moderate	Low / Moderate / High	Discontinue anticoagulation Do not use bridging therapy
High	Low / Moderate / High	Discontinue anticoagulation Consider bridging therapy
See warfarin, factor Xa inhibitors, and dabigatran for recommendations on timing the discontinuation ^✝Guidelines do not state specifically which procedures are okay to continue anticoagulation. Other guidelines state minor procedures such as dental extractions, minor derm procedures, and cataract surgery are okay for continued anticoagulation. For procedures with a low or moderate bleeding risk, restart anticoagulation 24 hours after surgery and consider bridging therapy in patients taking warfarin with high thromboembolic risk For procedures with a high bleeding risk, restart anticoagulation 48 - 72 hours after surgery without bridge therapy

Reference [12]
SEC Thromboembolism Risk Categories for Mechanical Heart Valves
High risk Mitral valve Tricuspid valve (including biological valve) Aortic valve (monoleaflet) Stroke/TIA in last 6 months Moderate risk Aortic valve + any of the following risk factors: Atrial fib Stroke/TIA > 6 months ago Diabetes Heart failure Age > 75 years Low risk Aortic valve without other risk factors

Reference [17]
ACCP 2022 Warfarin Recommendations for Patients With Venous Thromboembolism
Procedures with minimal bleeding risk (procedure bleeding risk categories) Continue warfarin
Procedures with low-to-moderate or high bleeding risk (procedure bleeding risk categories) Patients at high risk of VTE: Stop warfarin ≥ 5 days before the procedure and bridging therapy is suggested High risk of VTE defined as any of the following: Recent (< 3 months and especially 1 month) VTE Severe thrombophilia (deficiency of protein C, protein S or antithrombin; homozygous factor V Leiden or prothrombin gene G20210A mutation or double heterozygous for each mutation, multiple thrombophilias) Antiphospholipid antibodies Active cancer associated with high VTE risk (e.g. pancreatic cancer, myeloproliferative disorders, primary brain cancer, gastric cancer, and esophageal cancer) Patients with low-to-moderate risk of VTE: Stop warfarin ≥ 5 days before the procedure and do not provide bridging therapy Warfarin can be resumed on the evening of the procedure for most patients, or the day after procedure at the patient’s usual maintenance dose Moderate risk of VTE defined as any of the following: VTE within past 3 - 12 months Recurrent VTE Non-severe thrombophilia (heterozygous factor V Leiden or prothrombin gene G20210A mutation) Active cancer or recent history of cancer Low risk of VTE defined as the following: VTE > 12 months ago

ACCP 2022 DOAC Recommendations for Patients with Venous Thromboembolism

The 2022 ACCP recommendations for perioperative DOAC management in VTE patients are the same as those for A fib. The illustration below outlines the recommended management of each drug based on the procedure bleeding risk and, in the case of dabigatran, creatinine clearance. Procedure bleed-risk categories as defined by the ACCP are available here - ACCP procedure bleed risk - and the ones used in the PAUSE study are listed here - PAUSE study procedure bleed risk. The ACCP does not recommend bridging therapy for DOACs because their short half-lives limit therapy interruptions. They do state, however, that select patients at high risk for VTE (see VTE risk categories) may receive low-dose anticoagulants (e.g. enoxaparin 40 mg daily or dalteparin 5,000 IU daily) for the first 48 - 72 hours post-procedure.

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Reference [17]
ACCP 2022 VTE Risk Categories for VTE Patients
High risk Any of the following: Recent (< 3 months and especially 1 month) VTE Severe thrombophilia (deficiency of protein C, protein S or antithrombin; homozygous factor V Leiden or prothrombin gene G20210A mutation or double heterozygous for each mutation, multiple thrombophilias) Antiphospholipid antibodies Active cancer associated with high VTE risk (e.g. pancreatic cancer, myeloproliferative disorders, primary brain cancer, gastric cancer, and esophageal cancer)
Moderate risk Any of the following: VTE within past 3 - 12 months Recurrent VTE Non-severe thrombophilia (heterozygous factor V Leiden or prothrombin gene G20210A mutation) Active cancer or recent history of cancer
Low risk VTE > 12 months ago

Reference [12]
SEC 2018 Recommendations for Venous Thromboembolism
TE risk	Procedure bleed risk	Recommendation
Low / Moderate / High	Low^✝	Continue anticoagulation
Low / Moderate	Low / Moderate / High	Discontinue anticoagulation Do not use bridging therapy
High	Low / Moderate / High	Discontinue anticoagulation Consider bridging therapy
See warfarin, factor Xa inhibitors, and dabigatran for recommendations on timing the discontinuation ^✝Guidelines do not state specifically which procedures are okay to continue anticoagulation. Other guidelines state minor procedures such as dental extractions, minor derm procedures, and cataract surgery are okay for continued anticoagulation. For procedures with a low or moderate bleeding risk, restart anticoagulation 24 hours after surgery and consider bridging therapy in patients taking warfarin with high thromboembolic risk For procedures with a high bleeding risk, restart anticoagulation 48 - 72 hours after surgery without bridge therapy

Reference [12]
SEC Thromboembolism Risk Categories for VTE
High risk Recent (within 3 months) VTE Severe thrombophilia (homozygous factor V Leiden, prothrombin 20210A, protein C, protein S, or antithrombin deficiency, multiple defects, antiphospholipid syndrome) Moderate risk VTE within the past 3 - 12 months Nonsevere thrombophilia (heterozygous factor V Leiden or prothrombin 20210A gene mutation) Recurrent VTE VTE + active cancer Low risk VTE > 12 months

^✝Ticagrelor should be held for 3 - 5 days, and all other P2Y12 inhibitors should be held for 5 - 7 days

Reference [4]
ASGE 2016 Antiplatelet Recommendations for Elective GI Endoscopy
TE risk	Procedure bleed risk	Recommendation
Low	Low	Continue ASA/NSAIDs Continue P2Y12 inhibitor
Low	High	Continue ASA/NSAIDs Discontinue P2Y12 inhibitors at least 5 days before endoscopy or switch to ASA^✝ For patients taking dual antiplatelet therapy, hold P2Y12 inhibitors for at least 5 days and continue ASA^✝
High	Low	Continue ASA/NSAIDs Continue P2Y12 inhibitors
High	High	Continue ASA/NSAIDs Discontinue P2Y12 inhibitors at least 5 days before endoscopy or switch to ASA^✝ For patients taking dual antiplatelet therapy, hold P2Y12 inhibitors for at least 5 days and continue ASA^✝

Reference [4]
ASGE 2016 Anticoagulant Recommendations for Elective GI Endoscopy
TE risk	Procedure bleed risk	Recommendation
Low	Low	Continue anticoagulation
Low	High	Discontinue anticoagulation Restart warfarin on same day as procedure Restart Factor Xa inhibitors and direct thrombin inhibitors once adequate hemostasis is achieved
High	Low	Continue anticoagulation
High	High	Discontinue anticoagulation Bridging therapy Restart warfarin on same day as procedure Restart Factor Xa inhibitors and direct thrombin inhibitors once adequate hemostasis is achieved

Reference [4]
ASGE Thromboembolism Risk Categories
Nonvalvular atrial fibrillation High risk CHA2DS2-VASc score ≥ 2 NOTE: A recent study found no benefit of bridging therapy in patients with an average CHADS₂ score of 2.3 (see BRIDGE study for more) Medium risk CHA2DS2-VASc score of 1 Low risk CHA2DS2-VASc score of 0
Venous thromboembolism (VTE) High risk Recent (within 3 months) VTE Severe thrombophilia (deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities) Medium risk VTE within the past 3 - 12 months Nonsevere thrombophilia (heterozygous factor V Leiden or prothrombin gene mutation) Recurrent VTE Active cancer (treated within 6 months or palliative) Low risk VTE > 12 months previous and no other risk factors
Mechanical heart valve High risk Any mitral valve prosthesis Any caged-ball or tilting disc aortic valve prosthesis Recent (within 6 months) CVA or TIA Medium risk Bileaflet aortic valve prosthesis and one or more of the following risk factors: A fib, prior CVA or TIA, hypertension, diabetes, congestive heart failure, age ≥ 75 years Low risk Bileaflet aortic valve prosthesis without A fib and no other risk factors for CVA
Recent cardiac stent (antiplatelet therapy) High risk Placement of drug-eluting stent ≤ 12 months Placement of bare metal stent ≤ 1 month Placement of bare metal stent after acute coronary syndrome ≤ 12 months Other conditions that can raise cardiovascular risk include: Prior history of stent occlusion History of acute coronary syndrome or ST-elevation MI Multivessel PCI Diabetes Kidney failure

ASGE procedure bleeding risk categories

High bleeding risk

Polypectomy
Biliary or pancreatic sphincterotomy
Treatment of varices
PEG placement (PEG on aspirin or clopidogrel is low risk. DAPT is high risk)
Therapeutic balloon-assisted enteroscopy
Endoscopic ultrasound (EUS) with FNA (EUS-FNA of solid masses on ASA/NSAIDs is low risk)
Endoscopic hemostasis
Tumor ablation
Cystogastrostomy
Ampullary resection
Endoscopic mucosal resection (EMR)
Endoscopic submucosal dissection
Pneumatic or bougie dilation
Percutaneous endoscopic jejunostomy

Low bleeding risk

Diagnostic (EGD, colonoscopy, flexible sigmoidoscopy) including mucosal biopsy
ERCP with stent (biliary or pancreatic) placement or papillary balloon dilation without sphincterotomy
Push enteroscopy and diagnostic balloon-assisted enteroscopy
Capsule endoscopy
Enteral stent deployment (Controversial)
Endoscopic ultrasound (EUS) without FNA
Argon plasma coagulation
Barrett’s ablation

WHEN TO HOLD THERAPY

Aspirin

Platelets are irreversibly inhibited by aspirin, so they must be replenished before their effects are restored. Typically, 10 - 14% of the normal platelet pool is produced each day, which means it takes 7 - 10 days for normal platelet function to return after stopping aspirin; hence, most guidelines recommend stopping aspirin 7 - 10 days before a procedure. When restarting aspirin, its full antiplatelet effect occurs within minutes of a dose. [1,4]

P2Y12 inhibitors

Clopidogrel, prasugrel, and ticlopidine irreversibly inhibit platelets, while ticagrelor is a reversible inhibitor. When restarting therapy, full antiplatelet effects are seen at the following intervals: (1) within 2 hours for ticagrelor, (2) after 3 days for prasugrel, (3) at 4 - 5 days with maintenance doses (75 mg) of clopidogrel or within 2 to 6 hours if a loading dose is given. [17]
Recommendations from professional organizations and manufacturers for holding P2Y12 inhibitors before procedures are provided in the table below

Reference [4,12,17]
When to hold P2Y12 inhibitors before procedures
Drug	ASGE / SEC / ACCP	Manufacturer
Clopidogrel	5 days	5 days
Prasugrel	7 days	7 days
Ticagrelor	3 - 5 days	5 days
Ticlopidine	N/A	10 - 14 days

Warfarin

Recommendations for stopping warfarin and when to provide bridging therapy vary by organization and indication. The AHA and SEC give INR-specific guidance detailed in the table below.

The hold period may vary depending upon the desired INR for surgery

Reference [12,14]
AHA 2017 A fib recommendations for holding warfarin
INR 5 - 7 days before procedure	Hold warfarin
> 3	≥ 5 days
2 - 3	5 days
1.5 - 1.9	3 - 4 days
SEC recommendations for holding warfarin
INR 7 days before procedure	Hold warfarin
> 3	7 days
2 - 3	6 days
< 2	5 days

Factor Xa inhibitors

ACCP recommendations for holding Factor Xa inhibitors are available here - ACCP 2022 DOAC recommendations
ACC 2017 recommendations are provided in the table below

Recommendations are for apixaban, rivaroxaban, and edoxaban

Anti-Xa level is a lab that measures the concentration of Factor Xa inhibitors in the blood

References [13,14]
ACC 2017 recommendations for holding Factor Xa inhibitors in A fib
CrCl (ml/min)	Procedure bleeding risk	Hold before procedure
≥ 30	Low	≥ 24 hours
15 - 29	Low	≥ 36 hours
< 15	Low	No data. Consider anti-Xa level and/or ≥ 48 hours.
≥ 30	Moderate / High	≥ 48 hours
< 30	Moderate / High	No data. Consider anti-Xa level and/or ≥ 72 hours.

Dabigatran

ACCP recommendations for holding dabigatran are available here - ACCP 2022 DOAC recommendations
ACC 2017 recommendations are provided in the table below

dTT - dilute thrombin time assay (not widely available). A normal aPTT usually excludes clinically relevant levels if a sensitive reagent is used. A normal thrombin time (TT) excludes clinically relevant levels.

References [13,14]
ACC 2017 recommendations for holding dabigatran in A fib
CrCl (ml/min)	Procedure bleeding risk	Hold before procedure
≥ 80	Low	≥ 24 hours
50 - 79	Low	≥ 36 hours
30 - 49	Low	≥ 48 hours
15 - 29	Low	≥ 72 hours
< 15	Low	No data. Consider dTT and/or ≥ 96 hours.
≥ 80	Moderate / High	≥ 48 hours
50 - 79	Moderate / High	≥ 72 hours
30 - 49	Moderate / High	≥ 96 hours
15 - 29	Moderate / High	≥ 120 hours
< 15	Moderate / High	No data. Consider dTT.

NSAIDs

See periprocedural NSAID recommendations

Reference [17]
ACCP 2022 Procedure Bleeding Risk Categories
High-bleed-risk surgery / procedures (30-day risk of major bleeding ≥ 2%) Major surgery with extensive tissue injury Cancer surgery, especially solid tumor resection (lung, esophagus, gastric, colon, hepatobiliary, pancreatic) Major orthopedic surgery, including shoulder replacement surgery Reconstructive plastic surgery Major thoracic surgery Urologic or GI surgery, especially anastomosis surgery Transurethral prostate resection, bladder resection, or tumor ablation Nephrectomy, kidney biopsy Colonic polyp resection Bowel resection Percutaneous endoscopic gastrostomy placement, endoscopic retrograde cholangiopancreatography Surgery in highly vascular organs (kidneys, liver, spleen) Cardiac, intracranial, or spinal surgery Any major operation (procedure duration > 45 minutes) Neuraxial anesthesia - includes spinal and epidural anesthesia or any other neuraxial (e.g. pain management) intervention; consider not only absolute risk for major bleeding but potentially devastating consequences of epidural bleeding and associated lower limb paralysis Epidural injections
Low-to-moderate-bleed-risk surgery/procedure (30-day risk of major bleed 0 - 2%) Arthroscopy Cutaneous/lymph node biopsies Foot/hand surgery Coronary angiography - radial approach may be considered minimal-bleed-risk compared with femoral approach GI endoscopy +/- biopsy Colonoscopy +/- biopsy Abdominal hysterectomy Laparoscopic cholecystectomy Abdominal hernia repair Hemorrhoidal surgery Bronchoscopy +/- biopsy
Minimal-bleed-risk surgery / procedure (30-day risk of major bleed approximately 0%) Minor dermatologic procedures (excision of basal and squamous cell skin cancers, actinic keratoses, and premalignant or cancerous skin nevi) Ophthalmologic (cataract) procedures Minor dental procedures (dental extractions, restorations, prosthetics, endodontics), dental cleanings, fillings) Pacemaker or cardioverter-defibrillator device implantation

Reference [15]
Procedure Bleeding Risk Categories Used in The PAUSE Study
High-risk procedures/surgery Any surgery requiring neuraxial anesthesia neuraxial anesthesia/injection epidural anesthesia/injection Major intracranial or neuraxial surgery brain cancer resection laminectomy or neuraxial tumor resection intracranial (subdural, epidural) bleed evacuation Major cardiac surgery coronary artery bypass valve replacement or repair Major vascular surgery aortic aneurysm repair aortobifemoral bypass, popliteal bypass carotid endarterectomy Major orthopedic surgery hip arthroplasty or hip fracture repair knee arthroplasty or tibial osteotomy shoulder arthroplasty metatarsal osteotomy Major thoracic surgery lobectomy, pneumonectomy esophagectomy Major abdominopelvic surgery hepatobiliary cancer resection pancreatic cancer or pseudocyst resection colorectal and gastric cancer resection diverticular disease resection inflammatory bowel disease resection renal cancer resection bladder cancer resection endometrial cancer resection ovarian cancer resection radical prostatectomy Other major cancer or reconstructive surgery head and neck cancer surgery reconstructive facial, abdominal, limb surgery
Low-bleeding-risk surgery/procedures Gastrointestinal procedures colonoscopy gastroscopy sigmoidoscopy endoscopic retrograde pancreaticocholangiography capsule endoscopy push enteroscopy Barrett’s esophagus ablation Cardiac procedures permanent pacemaker implantation or battery change internal cardiac defibrillator implantation or battery change atrioventricular node ablation coronary artery angiography (radial approach) Dental procedures tooth extraction (up to two extractions) endodontic (root canal) procedure Skin procedures skin biopsy Eye procedures phacoemulsification (cataract)

BRIDGING THERAPY

Overview

Bridging therapy is the administration of short-acting anticoagulants (e.g. heparin) during the periprocedural time that long-acting anticoagulants (e.g. warfarin) are being held. Short-acting anticoagulants help to prevent thrombosis while anticoagulation is subtherapeutic, and their effect dissipates rapidly so that they may be stopped within 24 hours of surgery, minimizing the amount of time the patient is without protection.
A standard bridging therapy protocol is presented in the table below. Recommendations on when to provide bridging therapy vary by organization.
STUDY: A study published in 2015 found no benefit of bridging therapy in patients with A fib who had an average CHADS2 score of 2.3 (see BRIDGE study for more)

Reference [1,10,14]
Bridging therapy recommendations
Pre-operative Stop warfarin 5 days prior to scheduled surgery. When INR becomes subtherapeutic, start a bridging regimen. If patient is receiving a Factor Xa inhibitor or dabigatran, start bridging regimen after omitting 2 - 3 doses of the drug
Bridging regimens Enoxaparin (Lovenox®) 1 mg/kg twice a day OR 1.5 mg/kg once daily Dalteparin (Fragmin®) 100 IU/kg twice a day OR 200 IU/kg once daily IV unfractionated heparin to maintain aPTT 1.5 - 2 X the control aPTT NOTE: When patient has a mechanical heart valve, twice daily LMWH regimens are recommended
Before procedure LMWH Twice daily regimen - withhold the last LMWH dose before surgery Once daily regimens - give half the total daily dose the morning of the day before surgery Unfractionated heparin (UFH) Stop UFH 4 - 6 hours before surgery
Post-operative Warfarin Restart warfarin 12 - 24 hours after surgery when adequate hemostasis has been achieved In patients who underwent surgery that has a high bleeding risk, resume LMWH or UFH (without bolus dose) 48 - 72 hours after surgery In patients who underwent surgery that has a moderate or low bleeding risk, resume LMWH or UFH (without bolus dose) 24 hours after surgery Continue bridging therapy until INR is therapeutic NOTE: A study published in 2021 found that post-operative bridging therapy in patients receiving warfarin for A fib or mechanical heart valves was not beneficial [PMID 34108229] Factor Xa inhibitors and dabigatran Confirm that adequate hemostasis has been achieved In patients who underwent surgery that has a high bleeding risk, resume medication 48 - 72 hours after surgery In patients who underwent surgery that has a low bleeding risk, resume medication on the day following the procedure Parenteral anticoagulation is generally not required

BRIDGE study - Periprocedural Bridging Therapy vs No Bridging Therapy in A Fib, NEJM (2015) [PubMed abstract]

The BRIDGE study enrolled 1884 patients taking warfarin for atrial fibrillation who were to undergo an elective operation or other elective invasive procedure that required interruption of warfarin therapy

Main inclusion criteria

Chronic (permanent or paroxysmal) atrial fibrillation or flutter
At least one CHADS2 criteria

Main exclusion criteria

Mechanical heart valve
Stroke, systemic embolism, or TIA within the previous 12 weeks
Major bleeding within previous 6 weeks
Planned cardiac, intracranial, or intraspinal surgery

Baseline characteristics

Average age 72 years
Average CHADS2 score - 2.3
CHADS2 score of 4 - 10%
CHADS2 score of 5 or 6 - 3%
Mitral valve heart disease - 16%
Concomitant antiplatelet therapy (aspirin or clopidogrel) - 37%

Randomized treatment groups

Group 1 (934 patients) - Bridging therapy
Group 2 (950 patients) - No bridging therapy
Bridging therapy - 1. warfarin stopped 5 days before procedure 2. dalteparin 100 U/kg twice a day starting 3 days before procedure and stopping 24 hours before procedure 3. warfarin restarted on the evening of or the day after the procedure 4. dalteparin resumed 12 to 24 hours after a minor (or low-bleeding-risk) procedure and 48 to 72 hours after a major (or high-bleeding-risk) procedure for 5 - 10 days (until INR was ≥ 2)
No bridging therapy - same as bridging therapy except placebo was given in place of dalteparin

Primary outcome: Arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding within 30 days after the procedure

Results

Outcome	Bridging therapy	No bridging	Comparisons
Duration: 30 days
Arterial thromboembolism	0.3%	0.4%	difference 0.1%, 95%CI [-0.6 to 0.8], p=0.73
Major bleeding	3.2%	1.3%	RR 0.41, 95%CI [0.20 - 0.78], p=0.005

Findings: In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding.

Summary

The BRIDGE study found that bridging therapy offered no benefit and was possibly harmful in patients with atrial fibrillation (average CHADS2 score 2.3) undergoing elective procedures
One major weakness of the study is that patients at high risk for thromboembolism (CHADS2 score 5 or 6) were largely underrepresented (only 3.3% of participants), making the study underpowered to detect a benefit in this group. Current guidelines generally do not recommend bridging therapy in patients at low-to-moderate VTE risk.

STUDIES | Periprocedural aspirin

POISE-2 Study - Stopping vs Continuing Aspirin Before Noncardiac Surgery, NEJM (2014) [PubMed abstract]

The POISE-2 study enrolled 10,010 patients at increased risk for vascular complications who were scheduled to undergo noncardiac surgery

Main inclusion criteria

Undergoing major vascular surgery or a history of CAD, PVD, or stroke. Patients with ≥ 3 risk factors for CVD (e.g. DM, smoking, CHF, HTN, TIA, age ≥ 70 years, etc.) were also eligible.

Main exclusion criteria

Drug-eluting coronary stent < 1 year before surgery
Bare-metal coronary stent < 6 weeks before surgery
Undergoing intracranial surgery, carotid endarterectomy, or retinal surgery

Baseline characteristics

Average age - 69 years
History of CAD - 23%
History of vascular disease - 33%
Undergoing major surgery - 78%
History of hypertension - 86%
Diabetes - 38%

Randomized treatment groups

Group 1 (4998 patients)

Patients not currently taking aspirin - Aspirin 200 mg just before surgery, then 100 mg a day for 30 days
Patients currently taking aspirin - Aspirin 200 mg just before surgery, then 100 mg for 7 days, then resume previous aspirin regimen

Group 2 (5012 patients)

Patients not currently taking aspirin - Placebo for 30 days
Patients currently taking aspirin - Placebo for 7 days, then resume previous aspirin regimen

For all patients who were taking aspirin at randomization, aspirin was required to be stopped at least 3 days before surgery. The median stop time was 7 days before surgery.

Primary outcome: The primary outcome was a composite of death or nonfatal heart attack 30 days after randomization

Results

Outcome	Aspirin	Placebo	Comparisons
Duration: 30 days
Primary outcome	7%	7.1%	HR 0.99, 95%CI [0.86 - 1.15], p=0.92
Overall mortality	1.3%	1.2%	HR 1.05, 95%CI [0.74 - 1.49], p=0.78
Heart attack	6.2%	6.3%	HR 0.98, 95%CI [0.84 - 1.15], p=0.85
Stroke	0.3%	0.4%	HR 0.84, 95%CI [0.43 - 1.64], p=0.62
Major bleeding	4.6%	3.8%	HR 1.23, 95%CI [1.01 - 1.49], p=0.04

Findings: Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding.

StraightHealthcare analysis

The POISE-2 study found that perioperative aspirin did not improve outcomes in high-risk cardiovascular patients undergoing noncardiac surgery. Perioperative aspirin did increase the risk of major bleeding.
The results of this study contradict current ACCP guidelines which recommend that patients on aspirin who are at "moderate to high risk" for cardiovascular disease continue aspirin when they undergo noncardiac surgery

ATACAS trial - Stopping vs Continuing Aspirin Before CABG, NEJM (2016) [PubMed abstract]

The ATACAS trial enrolled 2100 patients at increased risk for complications who were scheduled to undergo CABG (on-pump or off-pump) with or without valve replacement

Main inclusion criteria

Increased risk for major complications related to age or coexisting conditions
Not taking aspirin regularly before the trial or had stopped taking aspirin at least 4 days before CABG surgery

Main exclusion criteria

Warfarin or clopidogrel within 7 days of surgery
Thrombocytopenia or bleeding disorder
CrCl < 25 ml/min
History of thromboembolism

Baseline characteristics

Average age 66 years
Heart attack within 90 days - 7.5%
Received aspirin within 7 days of surgery - 43%
Median number of grafts - 3
On-pump surgery - 97%
CABG + valve surgery - 20%

Randomized treatment groups

Group 1 (1047 patients) - Aspirin 100 mg one to two hours before surgery
Group 2 (1053 patients) - Placebo
Aspirin was administered to all patients postoperatively at a median time of 18.5 hours after surgery
The trial had a 2 X 2 factorial design where half the patients received tranexamic acid (an antifibrinolytic agent)

Primary outcome: Composite of death and thrombotic events (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) during the initial 30 postoperative days

Results

Outcome	Aspirin	Placebo	Comparisons
Duration: 30 days
Primary outcome	19.3%	20.4%	RR 0.94, 95%CI [0.80 - 1.12], p=0.55
Major hemorrhage leading to reoperation	1.8%	2.1%	p=0.75
Cardiac tamponade	1.1%	0.4%	p=0.08
Blood transfusion within 24 hours after surgery	43.9%	42.6%	RR 1.03, 95%CI [0.93 - 1.14], p=0.57
No interaction was observed between aspirin and tranexamic acid either for the primary outcome or bleeding outcomes

Findings: Among patients undergoing coronary artery surgery, the administration of preoperative aspirin resulted in neither a lower risk of death or thrombotic complications nor a higher risk of bleeding than that with placebo.

StraightHealthcare analysis

The ATACAS trial found no benefit or harm of continuing aspirin before CABG surgery
The trial had a 2 X 2 factorial design that also compared tranexamic acid (an antifibrinolytic agent) to placebo. This could have affected the results, although no interaction between tranexamic acid and aspirin was observed.
Aspirin was stopped 4 days before surgery, and it's possible some patients in the placebo group still had some antiplatelet effect from aspirin that was taken prior to 4 days (43% of patients received aspirin within 7 days of surgery). This would bias the study toward the null.
Although slightly flawed, the ATACAS trial found that preoperative aspirin had no effect on CABG outcomes in patients at increased risk for complications

STUDIES | Procedure bleeding risk

Procedure bleeding risk

Bleeding risk of Ultrasound-guided Thoracenteses while taking DOACs or Clopidogrel, Mayo Clin Proc (2019) [PubMed abstract]

Design: Retrospective case series in patients who underwent ultrasound-guided thoracenteses while receiving DOACs (N=43) or clopidogrel (N=69)
Primary outcome: Any significant post-procedure bleeding complication; defined as a hemoglobin decrease of greater than 2 g/dL in 48 hours, hemothorax, chest wall hematoma, and bleeding requiring transfusion, surgery, or chest tube placement
Results:

Primary outcome: All patients used either the DOAC or clopidogrel within 24 hours before the procedure and continued using it daily thereafter. There were no bleeding complications.

Findings: The overall risk of significant hemorrhage in patients taking an NOAC and/or clopidogrel while undergoing ultrasound-guided thoracentesis is very low. Albeit the total number of procedures reviewed may be insufficient to prove definitive safety, it is sufficient to provide a measure of relative risk when assessing benefits of thoracentesis in these patients.

Cold Snare Polypectomy with Continuous Anticoagulants vs Hot Snare Polypectomy with Heparin Bridging, Annals of Internal Medicine (2019) [PubMed abstract]

Design: Randomized controlled trial (N=184 | length = 28 days) in patients receiving anticoagulants who had at least 1 nonpedunculated subcentimeter colorectal polyp
Treatment: Cold Snare Polypectomy + Continuous Anticoagulants (CSP+CA) vs Hot Snare Polypectomy with Periprocedural Heparin Bridging (HSP+HB)
Primary outcome: Incidence of polypectomy-related major bleeding (based on the incidence of poorly controlled intraprocedural bleeding or postpolypectomy bleeding requiring endoscopic hemostasis)
Results:

Primary outcome: CSP+CA - 4.7%, HSP+HB - 12% (difference +7.3%, 95%CI [-1.0% to 15.7%])

Findings: Patients having CSP+CA for subcentimeter colorectal polyps who were receiving oral anticoagulants did not have an increased incidence of polypectomy-related major bleeding, and procedure time and hospitalization were shorter than in those having HSP+HB

Arthrocentesis and Joint Injection in Patients Receiving Direct Oral Anticoagulants, Mayo Clin Proc (2017) [PubMed abstract]

Design: Case series (N=1050)
Exposure: Patients receiving direct oral anticoagulants (DOACs) who underwent joint aspirations and/or injections
Primary outcome: Bleeding complications
Findings: In 1050 consecutive procedures, there were no bleeding complications. Arthrocentesis and joint injections in patients receiving DOAC therapy are safe procedures, and there is no need to withhold anticoagulation treatment before the procedure.

Safety of Lumbar Puncture (LP) Performed on Dual Antiplatelet Therapy (DAPT), Mayo Clin Proc (2018) [PubMed abstract]

Design: Case series (N=100, length = 3 months)
Exposure: Patients receiving DAPT who underwent lumbar puncture
Primary outcome: Number of traumatic and bloody cerebrospinal fluid results as well as the presence of any complications occurring within 3 months of the procedure
Findings: No serious complications occurred. Cerebrospinal fluid analysis was consistent with a traumatic LP, defined as having at least 100 RBCs/mcl, in 8% of cases. Bloody LP, defined as having 1000 RBCs/mcl, occurred in 4% of cases. The percentage of traumatic or bloody LPs was within the range reported previously for LPs performed in any setting. Although this is a small study and additional review is necessary, performing LPs in the setting of dual antiplatelet therapy may not pose an increased risk of serious complications.

BIBLIOGRAPHY

1 - PMID 22315266 - Perioperative Management of Antithrombotic Therapy Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, Chest (2012)
2 - PMID 17650517 - Br Anest GL
3 - PMID 22800849 - 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction
4 - PMID 26621548 - The management of antithrombotic agents for patients undergoing GI endoscopy: ASGE Standards of Practice Committee, Gastrointest Endosc (2016)
5 - PMID 24682347 - 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
6 - PMID 24589853 - 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease
7 - PMID 23247304 - 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
8 - PMID 23625942 - European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation
9 - PMID 23147769 - Periprocedural Management and Approach to Bleeding in Patients Taking Dabigatran
10 - PMID 22825410 - Periprocedural Bridging Management of Anticoagulation
11 - PMID 27026020 - 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease
12 - PMID 29887180 - 2018 Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU
13 - PMID 29203195 - 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants
14 - PMID 28081965 - 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation
15 - PMID 31380891 - Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant, JAMA Internal Medicine (2019)
16 - PMID 33332150 - 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, Circulation (2020)
17 - PMID 35964704 - Perioperative Management of Antithrombotic Therapy, An American College of Chest Physicians Clinical Practice Guideline, Chest (2022)

PERIPROCEDURAL ANTITHROMBOTIC RECOMMENDATIONS

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