Anticoagulation and perioperative bridging: A cardiologist’s perspective

Perioperative management of anticoagulant-treated patients undergoing a surgical or invasive procedure is a challenge for treating physicians. On one hand, bleeding complications caused by the intervention must be avoided; on the other hand, after discontinuation of anticoagulants the risk of severe thromboembolic complications, such as myocardial infarction, stroke, or pulmonary embolism, is increased. For optimal bridging therapy and prior to surgery, all participating physicians must collaborate to estimate the risks of bleeding and thromboembolism. The risk of thromboembolism is determined by both the underlying disease that led to anticoagulation therapy and also by the surgery itself. The risk of bleeding is influenced by the type and extent of surgery, as well as by individual patient characteristics. Localization and compressibility of bleeding must be considered. Finally, the risks of bleeding and thromboembolism should be classified as low, medium, or high; and then evaluated in comparison with each other. During perioperative interruption of vitamin K antagonist treatment, unfractionated or low molecular weight heparin can be used for bridging. Owing to their short duration of action, new oral anticoagulants do not require preoperative bridging with heparin. When planning a surgical intervention in patients with one or two antiplatelet drugs, the risk of thromboembolism has to be compared to the risk of bleeding. The risk of thromboembolism depends crucially on whether the coronary heart disease (CHD) is stable or unstable; whether a stent has recently been implanted; and, if so, whether this is coated or uncoated. Depending on the risk of bleeding and the urgency of surgery, it must be assessed whether the overall risk can be reduced by delaying surgery. In principle and wherever possible in patients with known CHD, one antiplatelet drug should be maintained perioperatively. © 2016, Springer-Verlag Berlin Heidelberg.