Perioperative Management of Patients Receiving
Perioperative Management of Patients Receiving
There is no consensus on whether patients taking oral anticoagulation medications who need to undergo surgery should receive perioperative intravenous heparin or subcutaneous low-molecular-weight heparin (aggressive strategies) or simply have oral anticoagulation withheld and restarted after the procedure (minimalist strategy). This review examines the literature examining perioperative management of oral anticoagulation. Due to the limited quality of prior studies, it is not possible to draw conclusions on the relative efficacy and safety of aggressive and minimalist strategies.The literature suggests that major bleeding on therapeutic oral anticoagulation is rare for certain procedures (e.g., dental). For other procedures, the literature does not provide a reliable estimate of the increase in postoperative bleeding due to therapeutic-dose anticoagulation. Mathematical modeling indicates that for most patients the risk of perioperative stroke is low and that an aggressive strategy is unnecessary and possibly harmful. Further studies are needed to determine which patients at intermediate and high risk of stroke benefit from aggressive management.
The perioperative management of patients on long-term oral anticoagulation (OAC) therapy is problematic. Continuing OAC carries the likelihood of bleeding for most procedures, stopping the medication without substituting parenteral anticoagulation increases the risk of thromboembolism, and administering perioperative intravenous heparin or subcutaneous low-molecular-weight heparin (LMWH) may increase the rate of major bleeding and can be inconvenient and costly. This clinical problem is becoming more common as the population ages and indications for OAC become more prevalent. For example, currently 2 million Americans have atrial fibrillation, and it has been estimated that this number will increase to more than 5 million by the year 2050.
Clinicians have several options when choosing a perioperative strategy. For purposes of this discussion, three strategies will be examined in detail: continuing OAC throughout the perioperative period, withholding warfarin 4 days before the procedure and restarting the night of the procedure (referred to as the minimalist strategy), and withholding warfarin and administering either intravenous heparin or subcutaneous therapeutic-dose LMWH (referred to as aggressive strategies).
There is no consensus on whether patients taking oral anticoagulation medications who need to undergo surgery should receive perioperative intravenous heparin or subcutaneous low-molecular-weight heparin (aggressive strategies) or simply have oral anticoagulation withheld and restarted after the procedure (minimalist strategy). This review examines the literature examining perioperative management of oral anticoagulation. Due to the limited quality of prior studies, it is not possible to draw conclusions on the relative efficacy and safety of aggressive and minimalist strategies.The literature suggests that major bleeding on therapeutic oral anticoagulation is rare for certain procedures (e.g., dental). For other procedures, the literature does not provide a reliable estimate of the increase in postoperative bleeding due to therapeutic-dose anticoagulation. Mathematical modeling indicates that for most patients the risk of perioperative stroke is low and that an aggressive strategy is unnecessary and possibly harmful. Further studies are needed to determine which patients at intermediate and high risk of stroke benefit from aggressive management.
The perioperative management of patients on long-term oral anticoagulation (OAC) therapy is problematic. Continuing OAC carries the likelihood of bleeding for most procedures, stopping the medication without substituting parenteral anticoagulation increases the risk of thromboembolism, and administering perioperative intravenous heparin or subcutaneous low-molecular-weight heparin (LMWH) may increase the rate of major bleeding and can be inconvenient and costly. This clinical problem is becoming more common as the population ages and indications for OAC become more prevalent. For example, currently 2 million Americans have atrial fibrillation, and it has been estimated that this number will increase to more than 5 million by the year 2050.
Clinicians have several options when choosing a perioperative strategy. For purposes of this discussion, three strategies will be examined in detail: continuing OAC throughout the perioperative period, withholding warfarin 4 days before the procedure and restarting the night of the procedure (referred to as the minimalist strategy), and withholding warfarin and administering either intravenous heparin or subcutaneous therapeutic-dose LMWH (referred to as aggressive strategies).