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Editorial article
Perioperative and periprocedural management of antithrombotic therapy: Multidisciplinar consensus document
Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso multidisciplinar
R. Ferrandis Comesa,c,
Corresponding author
raquelferrandis@gmail.com

Corresponding author.
, J.V. Llau Pitarchb,c
a Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
b Servicio de Anestesiología y Reanimación, Hospital Doctor Peset, Valencia, Spain
c Universitat de València, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The perioperative management of patients receiving anticoagulant and anti-platelet drugs has long been the source of controversy&#46; Antithrombotic therapy is a complex&#44; ever changing and expanding field&#44; which in recent years has seen the emergence of new oral anticoagulant and anti-platelet agents together with new scientific evidence that has changed the traditional way of using &#8220;conventional&#8221; drugs&#46; This&#44; coupled with the many possible clinical situations that can arise&#44; has greatly diversified antithrombotic management&#46; In order to standardise clinical practice and improve patient care&#44; the Spanish Society of Cardiology took the initiative to create a multidisciplinary consensus document with the help of experts in anticoagulant and anti-platelet drugs from 23 scientific societies involved in the surgical care process&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The document&#44; together with its supplementary material&#44; is available in full online and is highly recommended reading&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> It contains all the latest information on the different drugs available&#44; together with a table prepared by the different participating scientific societies establishing the estimated haemorrhagic risk of different types of surgery&#46; This classification was based on the algorithm proposed by the Spanish Consensus Forum of the European Society of Regional Anaesthesia &#38; Pain Therapy &#40;ESRA&#41; on haemostasis-altering drugs&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> which shows how to control bleeding and the clinical implications and consequences of intraoperative haemorrhage&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Decisions are conditioned as much by the risk of haemorrhage as the risk of thrombosis&#44; factors inherent to the reason why patients are receiving an antiplatelet or an anticoagulant drug&#46; In the case of antiplatelet drugs&#44; the proposed risk stratification scale is mainly based on the time elapsed since the thrombotic event for which the patient is being medicated&#44; be it an acute myocardial infarction&#44; the placement of a coronary stent&#44; or any other circumstance requiring antiplatelet therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> In the case of anticoagulated patients&#44; the stratification of thrombotic risk is mainly based on the CHADs-Vasc scale for atrial fibrillation stroke risk&#44; the characteristics of the thrombotic event&#44; or the type of valve prosthesis used in the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The guidelines for the perioperative and periprocedural management of antithrombotic therapy were developed using the latest recommendations from experts&#46; As the document addresses many different aspects in detail&#44; it is not easy to summarise and highlight any particular recommendation&#46; Nevertheless&#44; the guidelines draw attention to some aspects that can be considered essential in routine practice and these merit some comments&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">In patients receiving anti-platelet therapy&#44; the document recommends maintaining aspirin until the day before surgery in most cases&#46; In patients on long-term aspirin therapy&#44; the drug should be only be suspended when the risk of bleeding outweighs the expected antithrombotic benefit&#46; If an anti-platelet is given as primary prophylaxis&#44; it should be suspended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">In patients receiving anti-platelets due to a high risk of thrombosis &#40;usually on double anti-platelet therapy&#41;&#44; the scheduled surgery should be postponed for as long as necessary to minimise the risk of arterial thrombosis as a result of suspending the therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In non-urgent procedures that can be deferred&#44; such as hip fracture&#44; there is no need to delay surgery in patients taking thienopyridine derivatives&#44; and the procedure should be scheduled according to the best clinical practice applicable in each case&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">In oral anticoagulation therapy with a vitamin K antagonist&#44; the document questions the need for bridging therapy prior to surgery or an invasive procedure&#46; According to recent studies&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> the systematic administration of a short-acting parenteral anticoagulant such as low-molecular-weight heparin in patients anticoagulated with acenocoumarol or warfarin has a clear tendency to increase bleeding without reducing the incidence of cardioembolic complications&#46; Therefore&#44; this widespread practice should be reserved for very select cases with a high risk of thrombosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">The use of direct-acting oral anticoagulants &#40;DOAC&#41; still varies to a large extent&#44; and the consensus document gives the latest recommendations for their perioperative management&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8&#44;9</span></a> In general&#44; decisions relating to DOACs should not be based on conventional analytical results&#44; and bridging therapy is not indicated in the great majority of cases&#46; The moment each DOAC is stopped before surgery will depend on the risk of bleeding associated with the surgery and the patient&#39;s renal function&#46;</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">We consider it imperative to raise awareness of the importance of this document&#44; which is&#44; at the risk of repeating ourselves&#44; the first consensus document on the management haemostasis-altering drugs endorsed by so many scientific societies&#46; The recommendations have been drafted by a large group of experts&#44; including both prescribers and clinicians who must take the decision to suspend or maintain such drugs before a surgical procedure&#46; We&#44; anaesthesiologists&#44; are the core element of this second group&#44; and the patient&#39;s well-being both before and after the surgical intervention is our responsibility&#46; This is why it is so important for us to master the use of these drugs that are so common in surgical patients&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Like all guidelines and consensus documents relating to the clinical practice of our specialty&#44; it is essential to implement these recommendations in each hospital in order to raise awareness among anaesthesiologists&#46; This will lead to the creation of protocols that take into account local idiosyncrasies and the specific multidisciplinary implication of each specialty&#46; These recommendations are&#44; naturally&#44; dynamic and subject to constant change&#46; Although the document contains the latest available evidence&#44; the rapid evolution of both medicine and knowledge compels us to constantly be on the lookout for new developments&#44; and this is indeed the commitment that all the authors have assumed&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We sincerely hope that this document will be useful to all anaesthesiologists&#44; that it will help standardise the management of antithrombotic therapy&#44; and in doing so improve and unify the healthcare provided to our patients&#46; This is the spirit in which the document has been written&#46;</p></span>"
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ISSN: 23411929
Original language: English
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