美国胸科医师学会关于抗血栓治疗围手术期管理的临床实践指南解决了43例患者-干预-比较-结果(PICO)问题,这些问题与长期接受口服抗凝剂或抗血小板治疗的患者的围手术期管理有关。需要选择性手术/程序。本指南分为四大类,包括接受以下治疗的患者的管理:(1)维生素K拮抗剂(VKA),主要是华法林;(2)如果接受VKA,围手术期肝素桥接的使用,通常使用低分子量肝素;(3)直接口服抗凝剂(DOAC);和(4)抗血小板药物。
基于高,中度,低,使用建议分级的证据确定性非常低,评估,发展,临床实践指南的评估(GRADE)方法。
多学科小组为VKAs的围手术期管理提供了44项指南建议,肝素桥接,DOAC,和抗血小板药物,其中两项是强烈建议:(1)反对在房颤患者中使用肝素桥接;(2)在植入起搏器或心脏内部除颤器的患者中继续使用VKA治疗。关于接受小手术的患者的围手术期管理有单独的建议,包括牙科,皮肤病学,眼科,起搏器/心脏内部除颤器植入,和GI(内窥镜)程序。
自2012年实施这些指南以来,出现了大量新的证据,特别是为接受VKA并可能需要肝素桥接的患者的围手术期管理提供最佳实践,对于接受DOAC的患者的围手术期管理,以及接受一种或多种抗血小板药物的患者。尽管有这些新知识,大多数围手术期管理问题的最佳实践仍然存在不确定性.
The American College of Chest Physicians Clinical Practice
Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This
guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.
Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice
guidelines.
A multidisciplinary panel generated 44
guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.
Substantial new evidence has emerged since the 2012 iteration of these
guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.