New oral anticoagulants and perioperative management of anticoagulant/antiplatelet agents

Abstract

Background: The strategy of whether to continue anticoagulation and antiplatelet agents during surgery depends on an evaluation of the thromboembolic risk and haemorrhagic risk of the individual patients. Procedures that carry a significant risk of bleeding may require temporary cessation of the medication.

Objective: We briefly review the use of common oral anticoagulant and antiplatelet agents, including clinical indications and limitations associated with those agents. We also discuss the risks of thromboembolism, and balancing bleeding risk in patients receiving oral anticoagulation therapy, temporary interruption of such therapy and management of such patients undergoing an elective surgical procedure.

Discussion: Generally, patients at high risk of thromboembolism should be considered for a more aggressive perioperative management strategy with bridging therapy. Current recommendations for dual antiplatelet treatment range from 4 weeks in patients undergoing elective stenting with bare metal stents, up to 12 months in patients with drug-eluting stents or patients undergoing coronary stenting for acute coronary syndrome. If a patient is to undergo high-bleeding-risk surgery and an antiplatelet effect is not desired, clopidogrel, prasugrel and ticagrelor should be discontinued 5-7 days before the procedure. Early, effective communication between general practitioners and specialists is useful in managing high-risk patients on anticoagulation/antiplatelet agents during the perioperative periods.