Berkowitz Julia L, Taylor Matthew A, Lima Fabio V, Hyder Omar
Department of Medicine Rhode Island Hospital, Providence, RI, USA.
Warren Alpert Medical School at Brown University, Providence, RI, USA.
J Brown Hosp Med. 2023 Jun 22;2(3):81037. doi: 10.56305/001c.81037. eCollection 2023.
The aim of this paper is to provide primary care providers and hospitalists with up-to-date guidance surrounding the management of anticoagulation and antiplatelet agents in periprocedural settings and when unexpected bleeding complications arise.
We searched PubMed, Cochrane CENTRAL, and Web of Science using applicable MeSH terms and keywords. No date limits or filters were applied. Articles cited by recent cardiovascular guidelines were also utilized.
For direct oral anticoagulants (DOACs) and vitamin K agonists (VKAs), a patient's risk for clot and procedural risk of bleeding should be assessed. Generally, patients considered at high risk for venous thromboembolism (VTE) should be bridged, patients at low risk should forgo bridging therapy, and patients in the intermediate range should be evaluated on a case-by-case basis. Emergent anticoagulation reversal treatment is available for both warfarin (i.e., prothrombin complex concentrate, phytonadione) and DOACs (i.e., idarucizumab for dabigatran reversal; andexanet alfa for apixaban and rivaroxaban reversal). DAPT does not need to be held for paracentesis or thoracentesis and is low risk for those needing urgent lumbar punctures. In patients with clinically significant bleeding, those with percutaneous coronary intervention (PCI) performed in the last three months should resume DAPT as soon as the patient is hemodynamically stable, while patients greater than three months out from PCI at high risk of bleed can be de-escalated to single antiplatelet therapy.
Appropriate management of anticoagulation and antiplatelet agents in the periprocedural setting and patients with active bleed remains critical in inpatient management.
本文旨在为基层医疗服务提供者和住院医师提供最新指南，内容涉及围手术期及出现意外出血并发症时抗凝剂和抗血小板药物的管理。
我们使用适用的医学主题词和关键词在PubMed、Cochrane CENTRAL和科学网进行检索。未设置日期限制或筛选条件。还利用了近期心血管指南引用的文章。
对于直接口服抗凝剂（DOACs）和维生素K拮抗剂（VKAs），应评估患者的血栓形成风险和手术出血风险。一般来说，被认为有高静脉血栓栓塞（VTE）风险的患者应进行桥接治疗，低风险患者可放弃桥接治疗，中等风险患者应逐案评估。华法林（即凝血酶原复合物浓缩物、维生素K1）和DOACs（即用于达比加群逆转的依达赛珠单抗；用于阿哌沙班和利伐沙班逆转的andexanet alfa）均有紧急抗凝逆转治疗方法。经皮穿刺引流术（腹腔穿刺术或胸腔穿刺术）时无需停用双联抗血小板治疗（DAPT），对于需要紧急腰椎穿刺的患者，其出血风险较低。对于有临床显著出血的患者，在过去三个月内进行过经皮冠状动脉介入治疗（PCI）的患者，一旦血流动力学稳定应尽快恢复DAPT，而距离PCI超过三个月且出血风险高的患者可降级为单一抗血小板治疗。
在围手术期及有活动性出血的患者中，正确管理抗凝剂和抗血小板药物在住院治疗中仍然至关重要。
