• Sahrish Shah, Tarek Nayfeh, Bashar Hasan, Meritxell Urtecho, Mohammed Firwana, Samer Saadi, Rami Abd-Rabu, Ahmad Nanaa, David N Flynn, Noora S Rajjoub, Walid Hazem, Mohamed O Seisa, Leslie C Hassett, Alex C Spyropoulos, James D Douketis, and M Hassan Murad.
• Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
• Chest. 2023 May 1; 163 (5): 124512571245-1257.

BackgroundThe management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or an invasive procedure is a common clinical scenario.Research QuestionWhat is the best available evidence to support the development of American College of Chest Physicians guidelines on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery or procedures?Study Design And MethodsA literature search including multiple databases from database inception through July 16, 2020, was performed. Meta-analyses were conducted when appropriate.ResultsIn patients receiving VKA (warfarin) undergoing elective noncardiac surgery, shorter (< 3 days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging (mostly with low-molecular-weight heparin [LMWH]) was associated with a statistically significant increased risk of major bleed, representing a very low certainty of evidence (COE). Compared with DOAC interruption 1 to 4 days before surgery, continuing DOACs may be associated with higher risk of bleeding demonstrated in some, but not all studies. In patients who needed DOAC interruption, bridging with LMWH may be associated with a statistically significant increased risk of bleeding, representing a low COE.InterpretationThe certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high-quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery or procedure, or for the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vs short-term interruption of a DOAC in the perioperative period.Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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