- ACRONYMS AND DEFINITIONS
- A fib - Atrial fibrillation
- ACC- American College of Cardiology
- ACCP- American College of Chest Physicians
- 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 management can be a conundrum for providers. Guidelines vary between professional organizations and are mostly based on "expert opinion" since there are few randomized controlled trials to help guide decision-making. In addition, every patient scenario isn't covered, and in some cases, recent studies do not support current recommendations.
- The guidelines below are grouped by organization. The Spanish Society of Cardiology (SEC) guidelines are included because they provide recommendations for antiplatelet therapy that are not found in other guidelines. A cohort study published in 2019 (see simple A fib protocol) is included because it showed that a simple protocol for DOACs in patients with A fib was highly effective.
- ASPIRIN FOR PRIMARY PREVENTION
- Patients taking aspirin for the primary prevention of any condition should stop aspirin at least 7 days before their procedure [2]
- 2019 SIMPLE A FIB PROTOCOL
- Overview
- In 2019, a 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 below 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 bleeding risk. Outcomes were measured for 30 days after the procedure.
- Arterial thromboembolism and bleeding outcomes are presented in the table below. The protocol for stopping the drugs before surgery is provided below that.
Outcomes in Patients with A fib using Simple Anticoagulant Protocol | ||
---|---|---|
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% |

Procedure Bleeding Risk Categories Used in Study |
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High risk procedures/surgery
|
Low Bleeding Risk Surgery/Procedures
|
- Summary
- This study showed that a simple protocol for discontinuing apixaban, dabigatran, and rivaroxaban that did not involve bridging therapy led to very low bleeding and arterial thromboembolism risks among patients with A fib. The study excluded patients with severe renal impairment. Recommendations from the ACC for patients with severe renal impairment can be found below (Factor Xa inhibitors, dabigatran).
- This study validates the ACC 2017 periprocedural A fib recommendations which do not recommend bridging therapy in patients receiving DOACs
- ACCP 2012 RECOMMENDATIONS
ACCP 2012 Periprocedural Aspirin Recommendations |
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Minor dental procedures, minor dermatological procedures, and cataract surgery
|
Noncardiac surgery
|
Coronary artery bypass graft surgery (CABG)
|
ACCP 2012 Periprocedural Warfarin Recommendations |
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Minor dental procedures
|
Minor dermatological procedures and cataract surgery
|
Other surgeries
|
ACCP 2012 Thromboembolism Risk Categories |
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Atrial fibrillation
|
Venous thromboembolism
|
Mechanical heart valve
|
AHA 2017 Periprocedural Recommendations for Mechanical Heart Valves |
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Minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled
|
Other invasive or surgical procedures
|
- 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
- ASGE 2016 RECOMMENDATIONS FOR ELECTIVE GI ENDOSCOPY
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 |
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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
- SEC 2018 RECOMMENDATIONS FOR ANTITHROMBOTIC THERAPY
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 2018 Recommendations for Anticoagulant Therapy | ||
---|---|---|
TE risk | Procedure bleed risk | Recommendation |
Low / Moderate / High | Low✝ |
|
Low / Moderate | Low / Moderate / High |
|
High | Low / Moderate / High |
|
|
SEC Thromboembolism Risk Categories for Anticoagulant Therapy |
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Atrial fibrillation
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Venous thromboembolism (VTE)
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Mechanical heart valve
|
- WHEN TO HOLD THERAPY
- Aspirin
- Aspirin irreversibly inhibits platelets so platelets must be replenished in order for platelet function to be restored. The maximal antiplatelet effect of aspirin occurs within minutes of consumption.
- In general, 10 - 14% of the normal platelet pool is produced each day which means it takes 7 - 10 days after stopping aspirin for normal platelet function to return
- If aspirin is to be held, most guidelines recommend stopping aspirin 7 - 10 days before a procedure [1,4]
- P2Y12 inhibitors
- P2Y12 inhibitors include the following medications: clopidogrel (Plavix®), prasugrel (Effient®), ticagrelor (Brilinta™), and ticlopidine (Ticlid®)
- Clopidogrel, prasugrel, and ticlopidine irreversibly inhibit platelets. Ticagrelor is a reversible platelet inhibitor.
- Recommendations for holding P2Y12 inhibitors are given in the table below
When to hold P2Y12 inhibitors before procedures | ||
---|---|---|
Drug | ASGE / SEC | Manufacturer |
Clopidogrel | 5 days | 5 days |
Prasugrel | 7 days | 7 days |
Ticagrelor | 3 - 5 days | 5 days |
Ticlopidine | N/A | 10 - 14 days |
- Warfarin
- The ACCP, AHA, and ACC give recommendations for holding warfarin in their respective guidelines (ACCP guidelines, AHA mechanical heart valve guidelines, ACC A fib guidelines)
- Holding warfarin for 5 days will cause the INR to decrease to < 1.5 in 93% of patients [4]
- The SEC guidelines give recommendations on stopping warfarin based on the INR value drawn 7 days before the procedure. Those recommendations are detailed in the table below
SEC recommendations on holding warfarin before procedures | |
---|---|
INR 7 days before procedure | Hold warfarin |
> 3 | 7 days |
2 - 3 | 6 days |
< 2 | 5 days |
- Factor Xa inhibitors
- Factor Xa inhibitors include the following medications: apixaban (Eliquis®), betrixaban (Bevyxxa®), edoxaban (Savaysa®), and rivaroxaban (Xarelto®)
- Factor Xa inhibitors are excreted renally and the duration of their effect is dependent on kidney function. The table below gives recommendations from the ACC for stopping apixaban, rivaroxaban, and edoxaban based on the creatinine clearance and surgery bleeding risk. Betrixaban is not included in the recommendation and its manufacturer only states that its anticoagulant effect is expected to last at least 72 hours after the last dose.
- A study that used a simple protocol for managing periprocedural rivaroxaban and apixaban in patients with A fib is detailed above (see simple A fib protocol above)
Recommendations for holding Factor Xa inhibitors (apixaban, rivaroxaban, edoxaban) before procedures | ||
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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
- Dabigatran (Pradaxa®) is a direct thrombin inhibitor.
- Dabigatran is excreted renally and the duration of its effect is dependent on kidney function. The table below gives recommendations from the ACC for holding dabigatran before procedures based on the creatinine clearance and surgery bleeding risk.
- A study that used a simple protocol for managing periprocedural dabigatran in patients with A fib is detailed above (see simple A fib protocol above)
Recommendations for holding dabigatran before procedures | ||
---|---|---|
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
- Besides aspirin, none of the guidelines above give specific recommendations for holding NSAIDs
- All NSAIDs (excluding aspirin) reversibly inhibit platelets so their antiplatelet effect is related to their duration of action and half-life. Most drugs are cleared after 4 - 5 half-lives. Guidelines for holding Factor Xa inhibitors and dabigatran are based on 2 - 3 half-lives for procedures with a low bleeding risk and 4 - 5 half-lives for procedures with a moderate to high bleeding risk (adjusted for renal function). These same principles may be applied to holding NSAIDs; although, this has not been validated in clinical trials.
- The table below gives the half-lives of some common NSAIDs
NSAID half-lives | |
---|---|
Drug | Half-life |
Ibuprofen (Motrin®, Advil®) | 2.2 hours |
Naproxen (Aleve®, Anaprox®, etc.) | 12 - 17 hours |
Meloxicam (Mobic®) | 15 - 20 hours |
Celecoxib (Celebrex®)✝ | 11 hours |
Indomethacin (Indocin®) | 4.5 hours |
Ketorolac (Toradol®) | 5 - 6 hours |
Nabumetone (Relafen®)* | 24 hours |
- PROCEDURE BLEEDING RISK
- Procedure bleeding risk categories from various sources are available at the links below
- BRIDGING THERAPY
- Overview
- Bridging therapy is the administration of short-acting anticoagulants (typically unfractionated heparin (UFH) and low molecular weight heparins (LMWH)) during the periprocedural time that anticoagulation is being held. Short-acting anticoagulants help to prevent VTE while anticoagulants are subtherapeutic, and their effect dissipates rapidly so that they may be stopped within 24 hours of surgery. Bridging therapy minimizes the amount of time the patient is without anticoagulation.
- Bridging therapy recommendations vary by organization. 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)
- No short-acting anticoagulants have been FDA-approved for bridging therapy. The regimens presented here are based on expert opinion.
Bridging therapy recommendations |
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Pre-operative
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Bridging regimens
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Before procedure
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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 no benefit and possible harm of bridging anticoagulation 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 (CHADS2 score 4 - 6) for thromboembolism were largely underrepresented. The study was therefore underpowered to find a benefit in this group.
- The 2012 ACCP guidelines recommend that patients at high risk for thromboembolism (CHADS2 score 5 - 6) receive bridging therapy and patients at moderate risk (CHADS2 score 3 - 4) be considered for therapy. The BRIDGE study confirms their recommendation that low-risk patients (CHADS2 score 0 - 2) should not receive bridging therapy.
- A cohort study that used a simple protocol for discontinuing apixaban, dabigatran, and rivaroxaban without bridging therapy is discussed above (see simple A fib protocol)
- 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 - ASGE 2016 "The management of antithrombotic agents for patients undergoing GI endoscopy"
- 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
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- 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)