Perioperative Management of Antiplatelet and Anticoagulant Therapy

Antiplatelet Therapy Management

The American College of Chest Physicians recommends continuing aspirin throughout the perioperative period for patients at moderate to high cardiovascular risk undergoing noncardiac surgery, rather than stopping it 7-10 days before surgery 1
For patients with coronary stents, prior myocardial infarction, or secondary cardiovascular prevention, the American College of Chest Physicians suggests continuing aspirin perioperatively, as the thrombotic risk of discontinuation exceeds bleeding risk in most surgical settings 1, 2
The American College of Chest Physicians advises stopping aspirin 7-10 days preoperatively only in patients at low cardiovascular risk undergoing procedures where bleeding would occur in closed spaces, such as intracranial surgery, spinal canal surgery, or posterior chamber eye surgery 1
For minor procedures, such as dental, dermatologic, or cataract surgery, the American College of Chest Physicians recommends continuing aspirin without interruption 1

The American College of Chest Physicians recommends stopping warfarin 5 days before surgery to allow INR normalization, and not using bridging anticoagulation during warfarin interruption for patients at low thrombotic risk 1
For patients at high thrombotic risk, the American College of Chest Physicians suggests using therapeutic-dose subcutaneous low-molecular-weight heparin (LMWH) or IV unfractionated heparin as bridging anticoagulation 1
The American College of Chest Physicians advises administering the last preoperative dose of therapeutic-dose LMWH approximately 24 hours before surgery, and resuming it 48-72 hours postoperatively for high-bleeding-risk surgery 1

For minor bleeding risk procedures, such as dental, dermatologic, or cataract surgery, the American College of Chest Physicians recommends continuing both aspirin and clopidogrel if the patient has a coronary stent, and continuing warfarin with local hemostatic measures 1, 3
For intermediate bleeding risk procedures, the American College of Chest Physicians suggests continuing aspirin and stopping clopidogrel 5 days preoperatively, and stopping warfarin 5 days preoperatively 1, 3
For major bleeding risk procedures, the American College of Chest Physicians advises continuing aspirin in stent patients whenever possible, stopping clopidogrel 5 days preoperatively, and stopping warfarin 5 days preoperatively, considering bridging only for high thrombotic risk 1, 3

The American College of Chest Physicians warns against discontinuing both aspirin and clopidogrel simultaneously in patients with coronary stents placed within the past 6-12 months (drug-eluting stents) or 4-6 weeks (bare-metal stents) 2, 3
The American College of Chest Physicians advises against using heparin or LMWH as a substitute for antiplatelet therapy in stent patients, as it does not prevent stent thrombosis 3, 4
The American College of Chest Physicians recommends avoiding routine bridging for low-risk patients on warfarin, as bridging increases bleeding without reducing thrombotic events 1
The American College of Chest Physicians suggests avoiding vitamin K for routine warfarin reversal before elective surgery, and instead stopping warfarin 5 days preoperatively and allowing natural INR decline 1