A Review of the Literature and Practical Approach for the Hospitalist Physician

REVIEW-NARRATIVE CME Periprocedural Antithrombotic Management: A Review of the Literature and Practical Approach for the Hospitalist Physician 1,2 1 Russell Vinik, MD Department of Internal Medicine, General Medicine Hospitalist Group, University of Utah, Salt Lake City, Utah. 1,2 Nathan Wanner, MD 2 1,2 University Healthcare Thrombosis Service, University of Utah, Salt Lake City, Utah. Robert C. Pendleton, MD Disclosure: Nothing to report. Many patients who are on long-term antithrombotic therapy (e.g. warfarin and/or antiplatelet agents) must be assessed for temporary discontinuation for a procedure or surgery, making this a salient topic for the hospitalist physician. Discontinuation of antithromhotic therapy can place patients at increased risk of thromboembolic complications while continuing antithrombotic therapy can increase procedure-related bleeding risk. Bridging anticoagulation with heparin or low molecular weight heparins is often used in the periprocedural period, but a great deal of uncertainty exists about how and when to use bridging anticoagulation. Because there is very little Level 1 evidence to define optimal care, both clinical practice and expert consensus guideline opinions vary. For the hospitalist, it is of critical importance to understand the available data, controversies, and management options in order to approach patient care rationally. This review provides a step-wise literature-based discussion addressing the following four questions: (1) What is the optimal management of antiplatelet therapy in the periprocedural period? (2) Are there very low bleeding risk procedures that do not require interruption of oral anticoagulation? (3) Are there low thromboembolic risk populations who do not require periprocedural bridging? (4) How do you manage patients who must discontinue anti-coagulants but are at an increased thrombotic risk? Journal of Hospital Medicine 2009;4:551–559. VC 2009 Society of Hospital Medicine. KEYWORDS: anticoagulants, antiplatelet, bridging therapy, major hemorrhage, periprocedural, thrombosis. The management of patients on long-term antithrombotic antiplatelet agents, identifying low bleeding risk procedures therapy (vitamin K antagonists [VKA] or antiplatelet agents) wherein interruption of anticoagulants is unnecessary, and who may require temporary disruption for an invasive pro- recognizing patients with a low short-term thromboembolic cedure is challenging. Management is controversial due to risk where anticoagulants can be disrupted without the methodologically limited prospective data and varied con- need for heparin or low molecular weight heparin (LMWH) sensus opinions. Yet periprocedural anticoagulation man- in the periprocedural period (defined as bridging therapy). agement is a commonly encountered clinical problem. It is Further, all other clinical scenarios require both a careful estimated that there are 2.5 million patients on long-term individualized assessment of the patient’s risk of periproce- VKA therapy in North America1 and 41% of the U.S. popula- dural bleeding and thromboembolism and a thoughtful dis- tion over age 40 years is on antiplatelet therapy.2 Further, cussion with all involved parties. This discussion may the need for temporary disruption of these therapies for an involve the person performing the procedure, the anesthesi- invasive procedure is frequent. As an example, in 1 Euro- ologist, and the patient. The purpose of this work is to pean study, approximately 15% of patients on long-term explore these relevant areas through a review of the litera- VKA required a major surgical procedure in 4 years of fol- ture with a particular focus on the recently published 2008 low-up.3 The role of the hospitalist physician in managing American College of Chest Physicians (ACCP) evidence- these patients is increasing as hospitalists care for an based clinical practice guidelines. increasing number of surgical patients and provide peripro- We reviewed medical literature from 1990 through May cedural consultation both in and out of the hospital. 2008 with the following key words: ‘‘bridging,’’ ‘‘anticoagula- Therefore, it is imperative for the hospitalist physician to be tion,’’ ‘‘perioperative,’’ ‘‘antiplatelet,’’ ‘‘heparin,’’ and ‘‘low proficient in making thoughtful and individualized recom- molecular weight heparin.’’ Individual studies were then in- mendations on the appropriate management of periproce- dependently reviewed by the authors. Studies that were felt dural anticoagulants, drawing from the available literature relevant to a hospitalist physician were retrieved and and evidence-based practice guidelines. Importantly, the So- reviewed. If there was uncertainty regarding applicability to ciety of Hospital Medicine has cited perioperative manage- a hospitalist setting, a second author’s opinion was ren- ment as an important core competency.4 dered. Additionally, we reviewed 1 author’s personal refer- The hospitalist physician is likely to encounter numerous ence list of articles relating to periprocedural anticoagula- periprocedural scenarios, including the management of tion that has been compiled over the past 10 years. This list 2009 Society of Hospital Medicine DOI 10.1002/jhm.514 Published online in wiley InterScience (www.interscience.wiley.com). Journal of Hospital Medicine Vol 4 No 9 November/December 2009 551 and the reference lists of retrieved articles were also catastrophic. To guide clinicians in managing these patients reviewed. Data were summarized to answer 4 clinically rele- in the periprocedural period, recent consensus guidelines vant questions: recommend the following:1,12 1. What is the optimal management of antiplatelet therapy 1. In patients who are expected to need an invasive surgical in the periprocedural period? procedure in the next 12 months, consideration should 2. Are there very low-bleeding risk procedures that do not be given to avoiding drug-eluting stents. require interruption of oral anticoagulation? 2. Elective procedures which have an increased risk of 3. Are there low thromboembolic risk populations who do bleeding should be deferred for at least 6 weeks after not require periprocedural bridging? bare metal stent implantation and 12 months after drug- 4. How do you manage patients who must discontinue anti- eluting stent implantation. coagulants but are at an increased thrombotic risk? 3. For patients undergoing a surgical procedure within 6 weeks of bare metal stent implantation and 12 months of drug-eluting stent implantation, continuation of aspirin Clinical Question #1: What Is the Optimal Management of and clopidogrel is recommended. If bleeding risk prohib- Antiplatelet Therapy in the Periprocedural Period? its this, then a cardiologist should be consulted. The optimal management of oral antiplatelet therapy in the 4. In patients with a drug-eluting stent who need to undergo periprocedural period is not well studied. Most reviews, a procedure whereby the thienopyridine needs to be dis- expert recommendations, and consensus statements either continued, aspirin should be continued if at all possible, do not comment on periprocedural antiplatelet manage- and the thienopyridine should be resumed as soon as pos- ment or recommend the routine discontinuation of therapy sibleaftertheprocedure.Itmaybereasonabletoconsider at least 7 days prior to surgery.3,5,6 However, as the 2008 a loading dose of clopidogrel, up to 600 mg, in this setting, ACCP guidelines highlight, the recommendation to routinely although prospective supportive data is lacking.1 discontinue antiplatelet therapy 7 days prior to the procedure is an oversimplification.1 In the era of both bare metal It is important to recognize that delayed stent thrombosis cardiac stents and drug-eluting stents, the optimal manage- is now reported well beyond 1 year after drug-eluting stent ment of these patients requires that 2 primary questions be implantation, and that there may not be a diminution in asked: (1) Is this a low-bleeding risk procedure whereby risk after the initial 12 months.15–17 Until additional data is antiplatelet therapy can be continued? (2) Does the patient available, it seems prudent, if possible, to at least continue have a coronary stent whereby the continuation of antipla- aspirin in the periprocedural period in these patients. If telet therapy or delay of the intervention is necessary? bleeding concerns obviate this, then antiplatelet therapy In the context of ongoing aspirin therapy, certain proce- should be discontinued and resumed as soon as possible. dures have a low risk of significant hemorrhagic complica- For patients on chronic antiplatelet therapy who do not tions. These low bleeding risk procedures include cataract have a cardiac stent and who are not undergoing a low- surgery, cutaneous surgery, oral surgery, and endoscopic pro- bleeding-risk procedure, the risks and benefits of the contin- cedures, including those with mucosal biopsies.7–10 Patients uation or discontinuation of antiplatelet therapy in the peri- undergoing these procedures may safely continue low dose procedural period are uncertain as absolute risks in the aspirin therapy, especially if they have a high-risk indication periprocedural period have not been well studied. Relative for their aspirin such as recent myocardial infarction, stroke, risks/benefits, however, can be estimated from prior studies. or the presence of a coronary stent.5,7–10 Whether these proce- Aspirin leads to an approximate 25% relative risk reduction dures can be safely performed

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