Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra North Shore/LIJ School of Medicine, North Shore/LIJ Health System, Manhasset, NY, USA.
Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
J Thromb Haemost. 2016 May;14(5):875-85. doi: 10.1111/jth.13305. Epub 2016 Apr 7.
The periprocedural management of patients receiving chronic therapy with oral anticoagulants (OACs), including vitamin K antagonists (VKAs) such as warfarin and direct OACs (DOACs), is a common clinical problem. The optimal perioperative management of patients receiving chronic OAC therapy is anchored on four key principles: (i) risk stratification of patient-related and procedure-related risks of thrombosis and bleeding; (ii) the clinical consequences of a thrombotic or bleeding event; (iii) discontinuation and reinitiation of OAC therapy on the basis of the pharmacokinetic properties of each agent; and (iv) whether aggressive management such as the use of periprocedural heparin bridging has advantages for the prevention of postoperative thromboembolism at the cost of a possible increase in bleeding risk. Recent data from randomized trials in patients receiving VKAs undergoing pacemaker/defibrillator implantation or using heparin bridging therapy for elective procedures or surgeries can now inform best practice. There are also emerging data on periprocedural outcomes in the DOAC trials for patients with non-valvular atrial fibrillation. This review summarizes the evidence for the periprocedural management of patients receiving chronic OAC therapy, focusing on recent randomized trials and large outcome studies, to address three key clinical scenarios: (i) can OAC therapy be safely continued for minor procedures or surgeries; (ii) if therapy with VKAs (especially warfarin) needs to be temporarily interrupted for an elective procedure/surgery, is heparin bridging necessary; and (iii) what is the optimal periprocedural management of the DOACs? In answering these questions, we aim to provide updated clinical guidance for the periprocedural management of patients receiving VKA or DOAC therapy, including the use of heparin bridging.
接受口服抗凝剂（OAC），包括华法林等维生素 K 拮抗剂（VKA）和直接 OAC（DOAC），长期治疗的患者的围手术期管理是一个常见的临床问题。接受长期 OAC 治疗的患者的最佳围手术期管理基于以下四个关键原则：（i）对患者相关和手术相关血栓形成和出血风险的风险分层；（ii）血栓形成或出血事件的临床后果；（iii）根据每种药物的药代动力学特性停止和重新开始 OAC 治疗；（iv）是否积极管理，例如使用围手术期肝素桥接，以预防术后血栓栓塞，但可能增加出血风险。最近来自接受 VKA 的患者接受起搏器/除颤器植入或使用肝素桥接治疗择期手术或手术的随机试验的数据现在可以为最佳实践提供信息。也有关于非瓣膜性心房颤动患者接受 DOAC 试验的围手术期结果的新数据。这篇综述总结了接受慢性 OAC 治疗的患者围手术期管理的证据，重点关注最近的随机试验和大型结局研究，以解决三个关键临床情况：（i）OAC 治疗能否安全用于小手术或手术；（ii）如果需要暂时中断 VKA（尤其是华法林）治疗择期手术/手术，是否需要肝素桥接；（iii）DOAC 的最佳围手术期管理是什么？在回答这些问题时，我们旨在为接受 VKA 或 DOAC 治疗的患者的围手术期管理提供最新的临床指导，包括肝素桥接的使用。
