- 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]
ACCP 2022 Antiplatelet Recommendations |
---|
Minor dental, dermatologic, or ophthalmologic procedure
|
Elective noncardiac surgery
|
Coronary artery bypass graft surgery (CABG)
|
Dual antiplatelet therapy (DAPT)
|
SEC 2018 Recommendations for Antiplatelet Therapy | ||
---|---|---|
TE risk | Procedure bleed risk | Recommendation |
Low | Low / Moderate |
|
Low | High |
|
Moderate / High | Low |
|
Moderate / High | Moderate |
|
Moderate / High | High |
|
|
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✝ |
ACCP 2022 Warfarin Recommendations in Atrial Fibrillation |
---|
Procedures with minimal bleeding risk (procedure bleeding risk categories)
|
Procedures with low-to-moderate or high bleeding risk (procedure bleeding risk categories)
|
- 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.

ACCP 2022 Atrial Fibrillation VTE Risk Categories |
---|
High risk
|
Moderate risk
|
Low risk
|
- 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]
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
- 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
SEC 2018 Recommendations for Atrial Fibrillation | ||
---|---|---|
TE risk | Procedure bleed risk | Recommendation |
Low / Moderate / High | Low✝ |
|
Low / Moderate | Low / Moderate / High |
|
High | Low / Moderate / High |
|
|
SEC Thromboembolism Risk Categories for A Fib |
---|
High risk
|
ACCP 2022 Warfarin Recommendations for Mechanical Heart Valves |
---|
Procedures with minimal bleeding risk (procedure bleeding risk categories)
|
Procedures with low-to-moderate or high bleeding risk (procedure bleeding risk categories)
|
AHA 2020 Mechanical Heart Valve Recommendations |
---|
Immediate/emergency noncardiac surgery or invasive procedure
|
Minor procedures (e.g. dental extractions, cataract removal) where bleeding is easily controlled
|
Other invasive or surgical procedures
|
SEC 2018 Recommendations for Mechanical Heart Valves | ||
---|---|---|
TE risk | Procedure bleed risk | Recommendation |
Low / Moderate / High | Low✝ |
|
Low / Moderate | Low / Moderate / High |
|
High | Low / Moderate / High |
|
|
ACCP 2022 Warfarin Recommendations for Patients With Venous Thromboembolism |
---|
Procedures with minimal bleeding risk (procedure bleeding risk categories)
|
Procedures with low-to-moderate or high bleeding risk (procedure bleeding risk categories)
|
- 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.

ACCP 2022 VTE Risk Categories for VTE Patients |
---|
High risk
|
Moderate risk
|
Low risk
|
SEC 2018 Recommendations for Venous Thromboembolism | ||
---|---|---|
TE risk | Procedure bleed risk | Recommendation |
Low / Moderate / High | Low✝ |
|
Low / Moderate | Low / Moderate / High |
|
High | Low / Moderate / High |
|
|
SEC Thromboembolism Risk Categories for VTE |
---|
High risk
|
ASGE 2016 Antiplatelet Recommendations for Elective GI Endoscopy | ||
---|---|---|
TE risk | Procedure bleed risk | Recommendation |
Low | Low |
|
Low | High |
|
High | Low |
|
High | High |
|
ASGE 2016 Anticoagulant Recommendations for Elective GI Endoscopy | ||
---|---|---|
TE risk | Procedure bleed risk | Recommendation |
Low | Low |
|
Low | High |
|
High | Low |
|
High | High |
|
ASGE Thromboembolism Risk Categories |
---|
Nonvalvular atrial fibrillation
|
Venous thromboembolism (VTE)
|
Mechanical heart valve
|
Recent cardiac stent (antiplatelet therapy)
|
- 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
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.
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
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
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
ACCP 2022 Procedure Bleeding Risk Categories |
---|
High-bleed-risk surgery / procedures (30-day risk of major bleeding ≥ 2%)
|
Low-to-moderate-bleed-risk surgery/procedure (30-day risk of major bleed 0 - 2%)
|
Minimal-bleed-risk surgery / procedure (30-day risk of major bleed approximately 0%)
|
Procedure Bleeding Risk Categories Used in The PAUSE Study |
---|
High-risk procedures/surgery
|
Low-bleeding-risk surgery/procedures
|
- 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)
Bridging therapy recommendations |
---|
Pre-operative
|
Bridging regimens
|
Before procedure
|
Post-operative
|
- 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
Duration: 30 days | |||
Outcome | Bridging therapy | No bridging | Comparisons |
---|---|---|---|
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
- 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
Duration: 30 days | |||
Outcome | Aspirin | Placebo | Comparisons |
---|---|---|---|
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
- 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
Duration: 30 days | |||
Outcome | Aspirin | Placebo | Comparisons |
---|---|---|---|
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 |
|
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
- 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.
- 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
- 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.
- 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)