Background

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

Methods

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

Results

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

Conclusions

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

中文翻译：

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执行摘要

背景

美国胸科医师学会关于抗血栓治疗围手术期管理的临床实践指南解决了 43 个与接受长期口服抗凝剂或抗血小板治疗并需要接受长期口服抗凝剂或抗血小板治疗的患者的围手术期管理相关的患者-干预-比较-结果 (PICO) 问题。择期手术/程序。该指南分为四大类，涵盖正在接受治疗的患者的管理： (1) 维生素 K 拮抗剂 (VKA)，主要是华法林；(2) 如果接受 VKA，则使用围手术期肝素桥接，通常使用低分子量肝素；(3)直接口服抗凝剂(DOAC)；(4)抗血小板药。

方法

使用临床实践指南的建议分级、评估、开发和评估 (GRADE) 方法，根据高、中、低和极低确定性证据生成强或有条件的实践建议。

结果

一个多学科小组针对 VKA、肝素桥接、DOAC 和抗血小板药物的围手术期管理提出了 44 条指南建议，其中两项是强烈建议：(1) 反对在房颤患者中使用肝素桥接；(2) 植入起搏器或心内除颤器的患者继续 VKA 治疗。对于正在进行小手术的患者的围手术期管理有单独的建议，包括牙科、皮肤科、眼科、起搏器/体内心脏除颤器植入和胃肠道（内窥镜）手术。

结论

自 2012 年迭代这些指南以来，已经出现了大量新证据，特别是为接受 VKA 并可能需要肝素桥接的患者的围手术期管理、接受 DOAC 的患者以及接受肝素治疗的患者的围手术期管理提供最佳实践。正在接受一种或多种抗血小板药物的人。尽管有了这些新知识，但大多数围手术期管理问题的最佳实践仍然存在不确定性。