Have you seen the newest perioperative #cvCoag guidelines from @accpchest? I've had some time to digest this exciting new document and wanted to share a few take away points. pubmed.ncbi.nlm.nih.gov/35964704/
First big recommendation that might catch folks off guard: For patients with mech valve and VKA use, "we suggest against heparin bridging". Will this be a big change for your practice? How to implement and get buy-in from clinicians & patients?
A series of recommendations basically endorse the PAUSE protocol of stoping DOACs 1-2 days pre-op (depend on bleeding risk). Dabigatran may need longer hold if low CrCl. No bridging heparin needed for DOAC-treated patients.
Equally important to pre-op management is post-op management. The guidelines suggest holding DOAC for at least 24hrs post-op to minimize bleeding risk. This mirrors PAUSE and BRIDGE trial approaches.
Exciting recommendations for patients with CAD on DAPT. If stent was ≥3 months ago, just stop P2Y12 inhibitor pre-op and continue ASA. Newer generation coronary stents are less thrombogenic than older generation stents.
As with all guidelines, the recommendations need to be considered carefully and applied to patients individually. For instance, while bridging is not necessary for mech valve, those with older generation vales may still need bridging heparin.
Similarly, most patient with AF and VKA use do not need bridging heparin. But it may be appropriate for those with CHADS-VASc ≥7 or recent (<3 months) stroke/TIA.
The guideline document has lots of very practical advice - how to manage meds for dental, ophthalmologic, and endoscopic procedure? And what doses of heparin bridging should be used?
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