CHEST Releases New Guidance for Perioperative Management of Antithrombotic Therapy

James Douketis, MD

The American College of Chest Physicians (CHEST) have released new clinical practice guidance for perioperative management of antithrombotic therapy.

Released on August 11, the guidelines, which include 44 evidence-based recommendations related to perioperative management of antithrombotic therapy, were published with the intent of replacing the organization 2012 guideline on the same topic.

“For perioperative antithrombotic management, it’s very important to have standardized approaches and protocols to limit variability in practice and, in turn, to minimize preventable bleeding and thrombotic events. Until now, guidance for clinicians was available only in piecemeal approach—related to specific clinical areas—whereas the CHEST guidelines provide a ‘one-stop’ comprehensive and definitive compilation of evidence to inform best practices in perioperative anticoagulant and antiplatelet management,” said lead of the guideline writing committee James D. Douketis, MD, a staff physician in Vascular Medicine and General Internal Medicine at St. Joseph’s Healthcare Hamilton, in a statement. “These guidelines are also practical, providing clinicians with ‘how to’ approaches for managing patients on warfarin, DOACs and antiplatelet drugs who are undergoing a wide array of surgeries and procedures as well as those who may need heparin bridging.”

Composed by Douketis and 13 other members of the multidisciplinary guideline writing committee, the new guidelines answer 43 population, intervention, comparator, and outcome (PICO) questions compared with 11 PICO questions in the 2012 guideline. Within the guideline, the writing panel addresses topics including new recommendations on use of multiple agents new to the market in 2012, but commonly used in 2022, including vitamin K antagonists, antiplatelet drugs, and direct oral anticoagulants (DOACs). The guideline itself is separated into 4 categories breaking down the management of patients into specific groups defined by use of a vitamin K antagonist, use of perioperative heparin bridging, use of a DOAC, and use of an antiplatelet drug.

Based on a review of data centered around the 43 aforementioned PICO questions, recommendations within the guideline were graded high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. In their release announcing the new guidelines, CHEST highlighted 6 of the recommendations within the guidelines.

• In patients receiving VKA therapy for atrial fibrillation who require VKA interruption for an elective surgery/procedure, the guidelines recommend against heparin bridging.(Strong recommendation)
• In patients receiving VKA therapy who require a pacemaker or ICD implantation, the guidelines recommend continuation of VKA over VKA interruption and heparin bridging. (Strong recommendation)
• In patients receiving VKA therapy for a mechanical heart valve or VTE who require VKA interruption for an elective surgery/procedure, the guidelines suggest against heparin bridging. (Conditional recommendation)
• In patients receiving VKA therapy who require VKA interruption for a colonoscopy with anticipated polypectomy, the guidelines suggest against heparin bridging during the period of VKA interruption. (Conditional recommendation)
• In patients receiving a DOAC (apixaban, dabigatran, edoxaban, rivaroxaban) who require an elective surgery/procedure, the guidelines suggest stopping the DOAC for 1 to 2 days (1 to 4 days for dabigatran) before the surgery/procedure over apixaban continuation. Postoperatively, the guideline suggest resuming the DOAC about 24 hours after a low/moderate-bleed-risk surgery/procedure and 48-72 hours after a high-bleed-risk surgery/procedure. (Conditional recommendation)
• In patients receiving acetylsalicylic acid (ASA) who are undergoing elective noncardiac surgery, the guidelines suggest ASA continuation over ASA interruption. (Conditional recommendation)

The aforementioned release from CHEST noted the guidelines contain separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatological, ophthalmological, pacemaker/ICD implantation, and gastrointestinal procedures.

This guideline, “Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline,” was published in CHEST Journal.