Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

The effect of anticoagulation therapy on the surgical outcomes of minimally invasive major gastrointestinal surgery

BACKGROUND

The surgical outcomes of minimally invasive surgery (MIS) for gastrointestinal (GI) cancers in patients receiving anticoagulation therapy (ACT) are unknown. We investigated the effect of ACT on the surgical outcomes of minimally invasive major GI surgery, with a particular focus on postoperative bleeding and thromboembolic complications.

METHODS

A total of consecutive 1290 patients undergoing elective minimally invasive (laparoscopic and robotic) major GI surgery (esophagogastric and colorectal resection for malignancy) between 2014 and 2023 were enrolled. The patients were divided into three groups: patients without receiving anticoagulation therapy (non-ACT, n = 1076), patients receiving direct oral anticoagulants (DOAC, n = 144), and patients receiving warfarin (WF, n = 70). Outcome variables were compared between the groups and the risk factors of postoperative bleeding complications were assessed using logistic multivariate analysis.

RESULTS

The overall rate of thromboembolic complication was 0.5%, and the operative mortality was zero in the whole cohort. The incidences of postoperative bleeding in the non-ACT, DOAC, and WF groups were 1.0%, 6.9% and 11.4%, respectively (P < 0.001). Among 8 DOAC-received patients with postoperative GI bleeding, 75% of cases occurred on postoperative day 5 or later. Multivariate analysis showed DOAC (odds ratio = 5.420, P < 0.001) and perioperative heparinization (odds ratio = 3.770, P = 0.048) were significant risk factors for major postoperative bleeding.

CONCLUSIONS

Although minimally invasive major GI surgery can be safely performed in patients receiving ACT, attention should be paid for the occurrence of delayed GI bleeding especially in the DOAC-received patients. Patients treated with DOAC or perioperative heparinization still represent a challenging group in the present cohort, and need to be carefully managed.

The rate of postoperative hematoma following risk-adapted cessation of oral anticoagulation in patients undergoing endoscopic endonasal surgery for pituitary adenomas

BACKGROUND

This study describes the management of patients on oral anticoagulation (OAC) undergoing endoscopic endonasal transsphenoidal surgery (EETS) and analyzes the risk of postoperative hematoma and epistaxis following treatment of pituitary adenoma (PA).

METHODS

Patients with OAC prior to EETS for PA were analyzed in a single center retrospective case series of consecutive patients with PA, who were treated between December 2008 and July 2022. Patient data (age, sex, clinical, endocrinology, tumor histology) were entered into a SPSS® database. The rate of postoperative hemorrhage (intracranial and epistaxis) and other perioperative complications were assessed.

RESULTS

Of 305 patients, 20 patients were on OAC prior to EETS for PA. Indications included non-valvular atrial fibrillation (AF) in 10 patients and previous venous thromboembolic event (VTE) in 8 patients, in 2 patients had overlapping indications. Twelve patients on direct oral anticoagulants (DOAC) paused medication 1-3 days (43.6 ± 23.6 h) before surgery, while phenprocoumon was paused 234 ± 123.55 h (min 6, max 22 days) before surgery. Baseline characteristics such as age, sex, tumor growth direction, tumor volume, and largest diameter showed no significant differences. No significant increase in postoperative hemorrhage was observed in patients with OAC compared to those without. One patient on apixaban paused 48 h before surgery experienced postoperative epistaxis. Among patients without OAC, one experienced intracranial hemorrhage and seven experienced epistaxis.

CONCLUSION

Patients with OAC prior to EETS for PA have no increased risk for postoperative hematoma when OAC is paused based on individual risk assessment and recent general recommendations.

Bleeding, stroke, and mortality risk of patients with septic shock receiving anticoagulation for atrial fibrillation

BACKGROUND

There are limited data on the effects of therapeutic anticoagulation (AC) on stroke and bleeding risk in patients with sepsis-induced atrial fibrillation (AF).

OBJECTIVE

This study aimed to determine the effect of therapeutic AC on the development of inpatient strokes and significant bleeding in hospitalized patients with septic shock and AF.

METHODS

This single-center, retrospective study examined 604 patients with septic shock and AF. The total AF population was further subdivided into new-onset AF. Propensity score matching was used to match patients with similar comorbidities who received and did not receive AC. The risks of bleeding, in-hospital stroke, increased length of stay, and mortality were compared between propensity score-matched cohorts.

RESULTS

Bleeding Academic Research Consortium 2 and 3a bleeding events were the most common. After propensity score matching, the relative risk of bleeding on AC was not significantly higher in either group (AF, 1.33 [95% confidence interval, 0.81-2.17]; new-onset AF, 1.60 [95% confidence interval, 0.72-3.54]). AC also did not decrease the number of ischemic strokes (AF, 1.34% with AC vs 1.34% without AC [P = 1]; new-onset AF, 0.89% with AC vs 1.79% without AC [P = .56]). There was significantly reduced mortality of patients who received AC (AF, 52.35% with AC vs 66.44% without AC [P = .01]; new-onset AF, 46.43% with AC vs 66.07% without AC [P = .04]).

CONCLUSION

In patients with septic shock and AF, AC was not associated with a higher incidence of bleeding or lowering of in-hospital strokes but was associated with decreased mortality, potentially protecting against disseminated intravascular coagulopathy or other embolic phenomena.

[Cardiovascular management of patients undergoing noncardiac surgery]

The risk assessment of patients with cardiovascular diseases before noncardiac surgery (NCS) is particularly relevant in cardiology because of the frequency and the involvement of different disciplines. The risk is determined by the operation itself and the disease or risk profile, including the patient's age. Specialist preoperative consultation can therefore remain limited if the surgery-related risk is low. The subjective symptoms (exercise tolerance) and also the determination of the cardiac biomarkers N‑terminal pro-brain natriuretic peptide (NT-proBNP) and troponin are particularly relevant for assessing the indications for an instrumental or specialist examination. Cardiovascular drug treatment should predominantly be continued perioperatively but not initiated just for the operation. There are practical guidelines for pausing oral anticoagulation, whereby a general heparin bridging is no longer recommended.

Prosthetic valve dysfunction in patients with mechanical heart valves: Results from the Emergency Salam Centre cohort

INTRODUCTION

Mechanical heart valve (MHV) replacement requires long-life anticoagulation due to the risk of Prosthetic Valve Dysfunction (PVD) and cardioembolism.

METHODS

We report data from a prospective observational study conducted on MHV patients in the Khartoum Salam Centre for Cardiac Surgery built by 'Emergency,' an Italian Non-Governmental Organization, to evaluate the occurrence of PVD and associated risk factors.

RESULTS

We prospectively followed 3647 patients, and 38 patients (rate 1.04 × 100 pt-years) had PVD during follow-up. The time in therapeutic range (TTR) among patients without PVD was 53 % (IQR 37-67), and it was 43 % (IQR 19-58) among patients with PVD (p = 0.04). Twenty-three over 38 patients (60.5 %) were symptomatic, 18 (47.4 %) had obstructive valvular stenosis, 24 patients (63.2 %) had INR <2.0 at diagnosis, and 21 patients (55.3 %) had been off warfarin for a long time: 3 patients for 1 week, 1 patient for 2 weeks, and 17 patients for >4 weeks (6 patients were off warfarin from 3 to 12 months). Ten were uncompliant to treatment, and 8 were pregnant women. Ten patients (26.3 %) with PVD had had a previous episode of PVD, and 14 patients (36.8 %) had 2 or more associated risk factors. Only in 6 cases were no associate risk factors found.

CONCLUSIONS

Among MHV patients on warfarin treatment with a sub-optimal quality of anticoagulation, the rate of PVD is 1.04 % pt-years, and the most frequent associated risk factor for PVD occurrence is warfarin withdrawal lasting more than one week.

Use of Prophylactic or Therapeutic Anticoagulation in Critically Ill Patients With Pre-existing Atrial Fibrillation

Purpose: The optimal anticoagulation regimen for atrial fibrillation (AF) in critically ill patients is challenging as these patients may be at an increased risk for bleeding and clotting despite an absence or presence of anticoagulation. The purpose of this study was to compare bleeding and thrombotic rates in critically-ill adults with pre-existing AF receiving therapeutic anticoagulation versus chemical or mechanical venous thromboembolism prophylaxis. Methods: A retrospective, observational study was conducted. The primary outcome identified rate of International Society of Thrombosis and Hemostasis bleeding, and secondarily assessed all venous or arterial thromboembolic events. To determine risk-factors associated with bleeding and to account for differences in baseline characteristics, a multivariable logistic regression model was used. Results: A total of 199 patients were included, 100 receiving therapeutic anticoagulation and 99 receiving venous thromboembolism prophylaxis. Patients receiving therapeutic anticoagulation compared to chemical or mechanical prophylaxis had a median (IQR) CHA2DS2VASc score of 4 (3-5) versus 4 (2-5) (P = .5499) and HAS-BLED score of 3 (3-4) versus 3 (2-4) (P = .0013); respectively. There was almost a threefold adjusted increased risk of bleeding in patients receiving therapeutic anticoagulation compared to venous thromboembolism prophylaxis (adjusted odds ratio [aOR] 2.7 [95% CI 1.1-9.9]; P = .0349). One stroke occurred in a patient receiving therapeutic anticoagulation, and none occurred in patients in the prophylaxis group (P = 1.000). Conclusion: Use of therapeutic anticoagulation in critically ill patients with pre-existing AF may increase bleed rates without protecting against stroke development.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Perioperative Care of Heart Failure, Arrhythmias, and Valvular Heart Disease

Frequently, the question of whether or not a patient is stable for surgery boils down to the question, "Does this patient need a preoperative stress test?" However, coronary artery disease and ischemic heart disease are only some of the many cardiac conditions that patients present with preoperatively-and that can negatively impact their intraoperative management and postoperative outcomes. This article will explore the evidence based, patient centered best practices surrounding the perioperative evaluation and management of heart failure, arrhythmias, and valvular heart disease.

Medical Clinics of North America-Periprocedural Antithrombotics: Prophylaxis and Interruption

Anticoagulation management in the surgical patient requires clinical expertise and careful attention. For patients already receiving anticoagulation for a defined indication (ie, stroke prevention for atrial fibrillation, treatment of venous thromboembolism (VTE), or presence of a mechanical heart valve), understanding how to manage these agents by weighing the risks of thromboembolic events and bleeding is paramount. Additionally, prevention of VTE in the surgical patient involves the identification of patient-specific and procedure-specific risk factors for both VTE and bleeding. With this information, as well as familiarity with the several antithrombotic options available, an appropriate prophylaxis strategy can be employed.

The Patient with Hip Fracture

Hip fractures are a frequent cause of hospitalization in the elderly population and can lead to significant morbidity and mortality. As the population continues to age, the incidence of hip fractures is expected to increase. The internist/hospitalist plays a critical role in the care of this population as many patients have multiple medical comorbidities. Management of the fragility hip fracture patient requires knowledge of several perioperative topics including preoperative risk assessment, risk reduction strategies, the optimal timing of surgical repair, venous thromboembolism prevention, and postoperative care considerations such as early mobilization with physical therapy, and osteoporosis treatment.

Management of antithrombotic therapy in patients undergoing dental procedures

A growing number of patients receiving antithrombotic therapy require dental procedures. Dental interventions in these patients can be challenging, as the risk of bleeding from the continuation of antithrombotic therapy needs to be weighed against the thromboembolic risk associated with drug interruption or de-escalation. Most minor dental procedures, including simple dental cleaning and filling, pose minimal bleeding risk, and antiplatelet or anticoagulation therapy can be continued without interruption. Local hemostatic measures, such as tranexamic mouthwash, can be used, as needed, to reduce bleeding events following these interventions. Managing antithrombotic therapy during more invasive dental interventions and oral surgeries with a higher risk of perioperative bleeding necessitates the consideration of specific factors influencing the bleeding risk and thromboembolism. In patients receiving antithrombotic therapy for primary prevention, temporary interruption is reasonable. In others, the decisions may be more complex and more nuanced. In this article, we review the current evidence for managing patients receiving oral antiplatelet or anticoagulant drugs scheduled for various dental procedures and present a practical approach for the periprocedural management of antithrombotic treatments.

Optimizing anticoagulation therapy for in-hospital patients on direct oral anticoagulants: a single-centre modified Delphi study

AIMS

The management of patients treated with direct oral anticoagulants (DOACs) during hospitalization is a common challenge in clinical practice. Although bridging is generally not recommended, too often DOACs are switched to parenteral therapy with low molecular weight heparins. Our objectives were to update a local guideline for perioperative DOAC management and to develop a guideline for the anticoagulation management in non-surgical patients regarding temporary DOAC discontinuation.

METHODS

We executed a two-step modified Delphi study in a 1000-bed university hospital in Belgium. The Delphi questionnaires were developed based on a literature review and a telephone survey of prescribers. Two expert panels were established: one dedicated to perioperative DOAC management and the other to DOAC management in non-surgical patients. Both panels completed two rounds, commencing with an individual and online round, followed by a face-to-face group session.

RESULTS

After the two-round Delphi process, the updated perioperative guideline on DOAC management included reasons for delaying the resumption of DOACs following surgery, such as oral intake not possible, the probability of re-intervention within 3 days, and insufficient haemostasis (e.g. active clinically significant haematoma, haemorrhagic drains or wounds). Furthermore, a guideline for non-surgical hospitalized patients was developed, outlining possible reasons for interrupting DOAC therapy. Both guidelines offer clear anticoagulation therapy strategies corresponding to the identified scenarios.

CONCLUSIONS

We have updated and developed guidelines for DOAC management in surgical and non-surgical patients during hospitalization, which aim to support prescribers and to enhance targeted prescription review by hospital pharmacists.

Perioperative Management of Antiplatelet and Anticoagulation in Brain Tumor Surgery: A Survey of International Practices

BACKGROUND

Perioperative management of antithrombotic therapy is a necessary preprocedural consideration for patients prescribed direct oral anticoagulants (DOACs), vitamin K antagonists, or antiplatelet medications. There is a lack of evidence-based guidelines to help inform decision-making in managing antiplatelet and anticoagulation medications in the perioperative period around brain tumor resection. The objective of this study was to provide an example of the heterogeneity in practice and raise awareness for the need to create standardized guidelines for managing these medications.

METHODS

A survey was sent to a list of over 800 international neurosurgeons who are members of the Neurosurgery Research Listserv. The survey comprised 70 questions assessing individual practices for managing thromboprophylaxis, antiplatelet medications, and anticoagulation in the perioperative period. The survey was sent via e-mail invitation between March 2021 and June 2021.

RESULTS

A total of 72 surgeons responded to the survey. There was no difference in medication management preoperatively or postoperatively when comparing intra- and extra-axial tumor resections. Cessation of antiplatelet medications varied between 3 and 11 days while restart varied between 1 and 14 days. Preoperative management of vitamin K antagonists varied between indication for use (P < 0.001) while DOAC management did not. In our group of respondents, 90% started heparin products within 5 days of surgery, while the same fraction restarted DOAC within 14 days.

CONCLUSIONS

Respondents demonstrated significant heterogeneity in their perioperative management of antiplatelet and anticoagulation medication in brain tumor resection. This may lead to an unacceptable level of heterogeneity in practice that has the potential to cause patient harm due to errors in medication management.

An Evaluation of the Safety of Half-Dose Direct Oral Anticoagulants Following Total Joint Arthroplasty: A Pilot Study

Background Total joint arthroplasty (TJA) patients on preoperative anticoagulation therapy present a challenge for adult reconstruction surgeons. The goal in managing such patients is to limit bleeding complications associated with administering the medications while preventing medical complications from withholding them. At our institution, we began a protocol in 2017 that utilizes a half-dose direct oral anticoagulant (DOAC) regimen for one week followed by resuming of the full-dose regimen in select patients who underwent TJA. This study investigated the 90-day safety profile associated with this protocol compared to previous literature. Methodology A retrospective review of 898 patients from a single institution was conducted including all patients receiving a half-dose DOAC protocol for one week followed by resuming of the full-dose regimen after total knee and total hip arthroplasty between 2017 and 2022. Data were collected on patient demographics, type of surgery, and DOAC dosage. Ninety-day complications were collected and separated into reduced dose complications of DOAC (such as cerebrovascular accidents (CVAs) or venothrombotic events (VTEe)) and DOAC therapy-related complications (including wound and bleeding complications). Results In the total hip arthroplasty (THA) subgroup (n = 396, 44.10%), there were four major VTE occurrences, aligning with the range seen in historical protocols. Deep vein thrombosis (DVT) and pulmonary embolism (PE) incidents were three and one, respectively, both within the historical range. In the total knee arthroplasty (TKA) subgroup of 502 (55.90%) patients, there were seven major VTE events, with five DVTs and two PEs, also aligning with historical ranges. Medical complications in the THA group included no CVA events and one myocardial infarction, with the latter slightly higher than the historical range. In the TKA group, there were two medical complications, both being CVAs. Regarding bleeding complications, THA patients showed four major bleeding incidents, two blood transfusions, and two hemorrhages, with these numbers comparable to or lower than historical ranges. There were seven minor bleeding events. For TKA, there were two major bleeding events, two blood transfusions, no hemorrhages, and five minor bleeding events. Wound complications in THA included five surgery-related complications, two cases of wound dehiscence, and three infections. TKA patients experienced 17 surgery-related complications, six cases of wound dehiscence, and 11 infections. Conclusions This study suggests that the half-dose DOAC protocol in patients undergoing TJA is non-inferior to historical full-dose DOAC protocols warranting further investigation to generalize across broader populations.

Risk factors for MACE and bleeding in atrial fibrillation patients undergoing surgery: Insights from the bridge trial

INTRODUCTION

Patients with atrial fibrillation (AF) undergoing elective procedures are at risk for Major Adverse Cardiovascular Events (MACE) and symptomatic bleeding. We aimed to identify risk factors to guide perioperative risk stratification.

METHODS

We conducted a post-hoc analysis of the "Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery" randomized trial. The primary outcomes were MACE and symptomatic bleeding. Our statistical approach encompassed standard univariate analysis, logistic stepwise regression, and Cox regression models. Additional interaction analyses evaluated the interplay between low-molecular-weight heparin bridge therapy and other identified risk factors.

RESULTS

Among a total of 1,813 participants (mean age 71.6 ± 8.8, 73.3 % male), MACE occurred in 25 (1.4 %) individuals, with pre-procedure clopidogrel use (adjusted hazard ratio [aHR] 7.73, 95 % CI 2.63-22.72, p < 0.001) and CHA2DS2-VASc score ≥ 5 (aHR 2.89, 95 % CI 1.26-6.63, p = 0.012) identified as risk factors. Symptomatic bleeding occurred in 57 (3.1 %) individuals, with bridge therapy (aHR 1.84, 95 % CI 1.07-3.19, p = 0.029), renal disease (aHR 2.50, 95 % CI 1.34-4.67, p = 0.004), post-procedure aspirin use (aHR 2.86, 95 % CI 1.66-4.91, p < 0.001), post-procedure nonsteroidal anti-inflammatory drug use excluding aspirin (aHR 3.40, 95 % CI 1.22-9.43, p = 0.019), and major surgery (aHR 3.94, 95 % CI 2.26-6.85, p < 0.001) identified as risk factors. The interactions between risk factors and bridging therapy on MACE and symptomatic bleeding outcomes were not significant (p > 0.05).

CONCLUSION

We identified predictors for MACE and symptomatic bleeding in AF patients undergoing elective procedures. These insights may help guide perioperative decisions to reduce the risk of adverse outcomes.

Assessment of Temporary Warfarin Reversal in Patients With Left Ventricular Assist Devices: the KVAD Study

BACKGROUND

Patients with left ventricular assist devices (LVADs) require interruption of warfarin for invasive procedures, but parenteral bridging is associated with many complications. Four-factor prothrombin complex concentrate (4F-PCC) can temporarily restore hemostasis in patients undergoing anticoagulation with warfarin.

OBJECTIVES

This pilot study evaluated the strategy of using variable-dose 4F-PCC to immediately and temporarily reverse warfarin before invasive procedures without holding warfarin in patients with LVADs. The duration of effect of 4F-PCC on factor levels and time to reestablish therapeutic anticoagulation post procedure were assessed.

METHODS

Adult patients with LVADs and planned invasive procedures were enrolled from a single center. Warfarin was continued uninterrupted. The 4F-PCC dose administered immediately pre-procedure was based on study protocol. International normalized ratio (INR)- and vitamin K-dependent factor levels were collected before and during the 48 hours after 4F-PCC administration. The use of parenteral bridging, International Society for Thrombosis and Haemostasis major and clinically relevant nonmajor bleeding (CRNMB) and thromboembolic events at 7 and 30 days were collected.

RESULTS

In 21 episodes of 4F-PCC reversal, median baseline INR was 2.7 (IQR 2.2-3.2). The median dosage of 4F-PCC administered was 1794 units (IQR 1536-2130). At 24 and 48 hours post 4F-PCC administration, median INRs were 1.8 (IQR 1.7-2.0) and 2.0 (IQR 1.9-2.4). Two patients required postoperative bridging. One patient experienced major bleeding within 72 hours, and 2 experienced CRNMB within 30 days. There were no thromboembolic events. Baseline and post 4F-PCC vitamin K-dependent factor levels corresponded with changes in INR values. The median time to achieve therapeutic INR post-procedure was 2.5 days (IQR, 1-4).

CONCLUSION

Administration of 4F-PCC for temporary reversal of warfarin for invasive procedures in patients with LVADs allowed for continued warfarin dosing with minimal use of post-intervention bridging, limited bleeding and no thromboembolic events.

Comparison of societal guidance on perioperative management of glucagon-like peptide-1 receptor agonists: implications for clinical practice and future investigations

PURPOSE

The use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) by patients undergoing surgery and procedures requiring anesthesia has become a topic of significant concern for perioperative providers because of the potential increased risk of aspiration resulting from the medication's effect of delaying gastric emptying. There is currently a lack of high-quality data regarding the safety of GLP-1 RAs in patients undergoing surgery, which has led to variations in practice.

SOURCE

We performed an internet search of society-endorsed statements and guidelines related to perioperative management of GLP-1 RAs, focusing on the top 20 countries with the largest anesthesiology societies determined by membership data from the World Federation of Societies of Anesthesiologists. We excluded articles and websites that were not in English.

PRINCIPAL FINDINGS

Our search revealed endorsed statements from fourteen major anesthesiology, endocrinology, and gastroenterology societies. There was considerable variation between societies in the recommendations and guidance for withholding these medications before surgery, the duration of withholding, assessment of the need for avoiding deep sedation or general anesthesia, use of rapid sequence intubation, need for prolonged fasting periods and clear fluid before a nil per os period, recognition of signs and symptoms for aspiration risk, the management of glucose in the perioperative period, and the use of point-of-care ultrasound for risk assessment.

CONCLUSION

Society-endorsed statements and guidelines provide varying recommendations on the perioperative management of GLP-1 RAs. The insights gained from this comparative analysis may help guide clinical practice, develop institutional practice guidelines, and direct future research efforts.

Postoperative Atrial Fibrillation: A Review

Atrial fibrillation (AF) in the postoperative phase is a manifestation of numerous factors, including surgical stress, anesthetic effects, and underlying cardiovascular conditions. The resultant cardiac hyperactivity can induce new onset or exacerbate existing AF. A common phenomenon, postoperative atrial fibrillation (POAF) affects nearly 40% of patients and is associated with longer hospitalization stays, and increased mortality, heart failure, stroke, and healthcare costs. Areas of controversy in POAF include whether to anticoagulate patients who have short-lived POAF, especially given their higher bleeding risk in the postoperative period, and the identification of patients who would benefit the most from preventive drug therapy for POAF. This review discusses the pathophysiology and management of POAF, and strategies to reduce its occurrence.

Perioperative Management of Antithrombotic Therapy

This JAMA Clinical Guidelines Synopsis summarizes the American College of Chest Physicians’ 2022 guideline on perioperative management of patients taking oral anticoagulation or antiplatelet therapy who are undergoing an elective surgery or procedure.

Perioperative management and outcomes in patients receiving low-dose rivaroxaban and/or aspirin: a subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial

BACKGROUND

No study has investigated the perioperative management and clinical outcomes in patients who are receiving rivaroxaban 2.5 mg twice a day and acetylsalicylic acid (ASA) 81 to 100 mg daily.

OBJECTIVE

To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily.

METHODS

Subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial was performed to assess perioperative management and clinical outcomes in patients with stable coronary or peripheral artery disease who were randomized to receive rivaroxaban 2.5 mg twice a day plus ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA 100 mg daily. Patients studied required a surgery/procedure during the trial. The study outcomes, which included myocardial infarction, angina, stroke, acute limb ischemia, bleeding, and death, were assessed according to treatment allocation.

RESULTS

There were 2632 patients studied (mean age, 68 years; 80% male) who had a surgery/procedure, comprising percutaneous coronary interventions (∼43%), carotid or other arterial angioplasty (∼15%), pacemaker or internal cardiac defibrillator implantation (∼9%), and coronary artery bypass graft surgery (∼7%). Perioperative study drug management varied, with about one-third of patients not interrupting study drug and the remainder interrupting it between 1 and ≥10 days preprocedure. The incidences of adverse outcomes across treatment groups were 12.7% to 15.3% for myocardial ischemia, 0.8% to 1.2% for stroke, 0.1% to 0.2% for venous thromboembolism, and 3.1% to 4.2% for any bleeding. There was no statistically significant difference in outcome rates across treatment groups.

CONCLUSION

In patients in the COMPASS trial who required a surgery/procedure, there was no significant difference in perioperative adverse outcomes whether patients were receiving rivaroxaban 2.5 mg twice a day and ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA alone.

Temporary omission of oral anticoagulation in atrial fibrillation patients undergoing percutaneous coronary intervention: rationale and design of the WOEST-3 randomised trial

The optimal antithrombotic management of atrial fibrillation (AF) patients who require oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) remains unclear. Current guidelines recommend dual antithrombotic therapy (DAT; OAC plus P2Y12 inhibitor - preferably clopidogrel) after a short course of triple antithrombotic therapy (TAT; DAT plus aspirin). Although DAT reduces bleeding risk compared to TAT, this is counterbalanced by an increase in ischaemic events. Aspirin provides early ischaemic benefit, but TAT is associated with an increased haemorrhagic burden; therefore, we propose a 30-day dual antiplatelet therapy (DAPT; aspirin plus P2Y12 inhibitor) strategy post-PCI, temporarily omitting OAC. The study aims to compare bleeding and ischaemic risk between a 30-day DAPT strategy following PCI and a guideline-directed therapy in AF patients requiring OAC. WOEST-3 (ClinicalTrials.gov: NCT04436978) is an investigator-initiated, international, open-label, randomised controlled trial (RCT). AF patients requiring OAC who have undergone successful PCI will be randomised within 72 hours after PCI to guideline-directed therapy (edoxaban plus P2Y12 inhibitor plus limited duration of aspirin) or a 30-day DAPT strategy (P2Y12 inhibitor plus aspirin, immediately discontinuing OAC) followed by DAT (edoxaban plus P2Y12 inhibitor). With a sample size of 2,000 patients, this trial is powered to assess both superiority for major or clinically relevant non-major bleeding and non-inferiority for a composite of all-cause death, myocardial infarction, stroke, systemic embolism or stent thrombosis. In summary, the WOEST-3 trial is the first RCT temporarily omitting OAC in AF patients, comparing a 30-day DAPT strategy with guideline-directed therapy post-PCI to reduce bleeding events without hampering efficacy.

Postoperative bleeding after complex abdominal wall reconstruction: A post hoc analysis of a randomized clinical trial

BACKGROUND

Abdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction.

METHODS

All patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion.

RESULTS

In 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75-43.8], P < .01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34-8.53], P < .01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention.

CONCLUSION

Patients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk.

Chinese guidelines for the diagnosis and management of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Preoperative Risk Assessment Before Elective Craniotomy: Are Aspirin, Arrhythmias, Deep Venous Thromboses, and Hyperglycemia Contraindications to Surgery?

OBJECTIVE

Perioperative risk assessment and stratification before craniotomy is necessary to identify and optimize modifiable risk factors. Due to the high costs of diagnostic testing and concerns for delaying surgery, some have questioned whether and when surgery delays are warranted and supported by the current body of literature. The objective of this scoping review was to evaluate the available evidence on the prognostic value of preoperative risk assessment before anesthesia for elective craniotomy.

METHODS

In this scoping review, we reviewed 156 papers that assess preoperative risk assessment before elective craniotomy, of which 27 papers were included in the final analysis.

RESULTS

There is little high-quality evidence to suggest significant risk reduction when 4 common preexisting abnormalities are present: preoperative chronic aspirin therapy, cardiac arrhythmias, deep vein thrombosis, or hyperglycemia.

CONCLUSIONS

The risk of delaying craniotomy should ultimately be weighed against the perceived risks associated the patient's comorbid conditions and should be considered on an individualized basis.

Early chest tube removal within 6 hours after thoracic surgery results in improved postoperative prognosis and no adverse effects

Background

Advances in minimally invasive surgery and drainage systems have caused earlier chest-tube-removal. This retrospective study aimed to assess the safety of early chest tube removal using the institution's new criteria 6 hours after thoracic surgery.

Methods

Elective thoracic surgery patients from 2017 to 2023 were reviewed for meeting or not meeting the newer institutional requirement for early chest tube removal; (I) no air leak detected under the digital drainage device observation; (II) no fluid drainage of ≥100 mL/h; (III) no ≥3 combined risks [male, chronic obstructive pulmonary disease (COPD), body mass index (BMI) of <18.5 kg/m2, severe pleural adhesion, upper lobe lobectomy, or left upper division segmentectomy]. The incidence of adverse events, including chest tube replacement, subcutaneous tube placement, and postoperative thoracentesis, were investigated for 1 month postoperatively. Perioperative outcomes and factors involved in conventional chest tube removal were also assessed.

Results

Of the 942 patient charts reviewed, 244 (25.9%) met the criteria for chest tube removal within 6 hours postoperatively. This patient group did not experience adverse events. They also demonstrated shorter postoperative hospital stay (4 vs. 6 days, P<0.001), and lesser postoperative complications (7.4% vs. 25.6%, P<0.001) compared to those for whom early chest tube removal was not done. A correlation with thoracotomy, COPD, and steroid and/or immunosuppressant use was observed for patients in the conventional chest tube removal group.

Conclusions

Early chest tube removal after 6 postoperative hours was deemed safe for a selected group of patients who met the criteria for early chest tube removal. This study would support the potential expansion of our early removal criteria.

Exploring the Perioperative Use of DOACs, off the Beaten Track

A notable increase in direct oral anticoagulant (DOAC) use has been observed in the last decade. This trend has surpassed the prescription of vitamin K antagonists (VKAs) due to the absence of the need for regular laboratory monitoring and the more favorable characteristics in terms of efficacy and safety. However, it is very common that patients on DOACs need an interventional or surgical procedure, requiring a careful evaluation and a challenging approach. Therefore, perioperative anticoagulation management of patients on DOACs represents a growing concern for clinicians. Indeed, while several surgical interventions require temporary discontinuation of DOACs, other procedures that involve a lower risk of bleeding can be conducted, maintaining a minimal or uninterrupted DOAC strategy. Therefore, a comprehensive evaluation of patient characteristics, including age, susceptibility to stroke, previous bleeding complications, concurrent medications, renal and hepatic function, and other factors, in addition to surgical considerations, is mandatory to establish the optimal discontinuation and resumption timing of DOACs. A multidisciplinary approach is required for managing perioperative anticoagulation in order to establish how to face these circumstances. This narrative review aims to provide physicians with a practical guide for DOAC perioperative management, addressing the most controversial issues.

[Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]

The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.

Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial

BACKGROUND

Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy.

METHODS

Patients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding.

RESULTS

Among 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 109/L were independent predictors of minor bleeding events.

CONCLUSIONS

This study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH.

TRIAL REGISTRATION

ISRCTN65203415.

A decade of experience in over 300 surgically treated spine patients with long-term oral anticoagulation: a propensity score matched cohort study

PURPOSE

The aim of this study was to investigate the risks and outcomes of patients with long-term oral anticoagulation (OAC) undergoing spine surgery.

METHODS

All patients on long-term OAC who underwent spine surgery between 01/2005 and 06/2015 were included. Data were prospectively collected within our in-house Spine Surgery registry and retrospectively supplemented with patient chart and administrative database information. A 1:1 propensity score-matched group of patients without OAC from the same time interval served as control. Primary outcomes were post-operative bleeding, wound complications and thromboembolic events up to 90 days post-surgery. Secondary outcomes included intraoperative blood loss, length of hospital stay, death and 3-month post-operative patient-rated outcomes.

RESULTS

In comparison with the control group, patients with OAC (n = 332) had a 3.4-fold (95%CI 1.3-9.0) higher risk for post-operative bleeding, whereas the risks for wound complications and thromboembolic events were comparable between groups. The higher bleeding risk was driven by a higher rate of extraspinal haematomas (3.3% vs. 0.6%; p = 0.001), while there was no difference in epidural haematomas and haematoma evacuations. Risk factors for adverse events among patients with OAC were mechanical heart valves, posterior neck surgery, blood loss > 1000 mL, age, female sex, BMI > 30 kg/m2 and post-operative PTT levels. At 3-month follow-up, most patients reported favourable outcomes with no difference between groups.

CONCLUSION

Although OAC patients have a higher risk for complications after spine surgery, the risk for major events is low and patients benefit similarly from surgery.

Management of Anticoagulant and Antiplatelet Agents in Acute Gastrointestinal Bleeding and Prevention of Gastrointestinal Bleeding

Managing gastrointestinal bleeding in patients using antithrombotic agents remains challenging in clinical practice. This review article provides a comprehensive and evidence-based approach to managing acute antithrombotic-related gastrointestinal bleeding, focusing on the triage of patients, appropriate resuscitation, and timely endoscopy. The latest clinical practice guidelines are highlighted to guide decisions concerning the use of reversal agents, temporary interruption, and resumption of antithrombotic drugs. Additionally, preventive measures are discussed to lower the risk of future bleeding and minimize complications among patients prescribed antithrombotic drugs.

Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Periprocedural management of direct oral anticoagulants in patients with atrial fibrillation and active cancer

BACKGROUND

Cancer and atrial fibrillation (AF) are common concurrent disorders. Direct oral anticoagulants (DOACs) are prescribed to prevent stroke in patients with AF. Patients with cancer often undergo invasive procedures for diagnostic or therapeutic purposes, necessitating interruption of anticoagulation. There are limited data to guide best periprocedural anticoagulation management practices in the setting of active cancer.

OBJECTIVES

To describe patient characteristics, periprocedural management, and clinical outcomes in DOAC-treated patients with AF according to active cancer status.

METHODS

We conducted descriptive and comparative analyses using data from the PAUSE study. Multivariable logistic regression was used to determine whether active cancer status was an independent risk factor for bleeding outcomes. Covariates were selected a priori based on biological rationale and preexisting knowledge.

RESULTS

Patients with active cancer were older (P < .001), more likely to be thrombocytopenic (P = .026), have moderate renal dysfunction (P = .005), and more likely to receive low-dose DOAC therapy (P < .001). A greater proportion of patients with active cancer underwent a high-bleed-risk procedure (P < .001), with longer periprocedural DOAC-interruption intervals (P <.001) and lower preprocedural residual DOAC levels (P = .002). Active cancer was an independent predictor for surgical major bleeding (OR = 2.45; 95% CI, 1.08-5.14) after adjusting for study center, procedure category and bleed risk, thrombocytopenia, hypertension, and the use of a P2Y12 inhibitor.

CONCLUSIONS

Active cancer status is associated with an increased risk of surgical major bleeding among DOAC-treated patients with AF undergoing interruption of anticoagulation for elective invasive procedures.

Potential of Direct Oral Anticoagulant in Bleeding After Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

An increasing number of patients are undergoing gastric endoscopic submucosal dissection (ESD) with active prescriptions of direct oral anticoagulants (DOACs). Only a few reports have described the effects of DOAC intake on postoperative bleeding. We aimed to investigate the bleeding risk associated with DOACs after gastric ESD.

METHODS

Clinical studies published up to April 2022 showing bleeding rates after gastric ESD in patients taking DOACs were identified using electronic searches. The primary outcome was the rate of bleeding after gastric ESD in patients receiving DOACs compared to those not receiving antithrombotic therapy. In this meta-analysis, odds ratios (ORs) were calculated and pooled using a random effects model. The secondary outcome was the difference in the bleeding rate between patients treated with DOACs and those treated with warfarin and antiplatelet drugs.

RESULTS

Seven studies were included in this meta-analysis. The pooled analysis showed that DOACs had a higher bleeding rate than non-thrombotic therapy (17.0% vs. 3.4%; OR 5.72; 95% confidence interval [CI], 4.33-7.54; I2 = 0%). The bleeding risk associated with DOAC administration was similar to that associated with warfarin (17.0% vs. 20.0%; OR 0.83; 95% CI 0.59-1.18; I2 = 0%), whereas it was higher than that associated with antiplatelet administration (16.9% vs. 11.0%; OR 1.63; 95% CI 1.14-2.34; I2 = 8%).

CONCLUSIONS

This meta-analysis reveals that the bleeding risk of DOACs is higher than that of non-antithrombotics and antiplatelets, whereas it is comparable to that of warfarin. Gastric ESD in patients on anticoagulants requires careful postoperative management.

Anticoagulation for Atrial Fibrillation: A Review of Current Literature and Views

Atrial fibrillation is a common supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction. This leads to an increased risk of atrial thrombi, most commonly in the left atrial appendage, and increased risks of embolic strokes and/or peripheral thromboembolism. It is associated with significant morbidity and mortality. To meet the concerns of thrombi and stroke, anticoagulation has been the mainstay for prevention and treatment thereof. Historically, anticoagulation involved the use of aspirin or vitamin K antagonists, mainly warfarin. Since early 2010s, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have been introduced and approved for anticoagulation of atrial fibrillation. DOACs demonstrated a dramatic reduction in the rate of intracranial hemorrhage as compared to warfarin, and offer the advantages of absolution of monitoring therefore avoid the risk of hemorrhages in the context of narrow therapeutic window and under-treatment characteristic of warfarin, particularly in high-risk patients. One major concern and disadvantage for DOACs was lack of reversal agents, which have largely been ameliorated by the approval of Idarucizumab for dabigatran and Andexanet alfa for both apixaban and rivaroxaban, with Ciraparantag as a universal reversal agent for all DOACs undergoing Fast-Track Review from FDA. In this article, we will be providing a broad review of anticoagulation for atrial fibrillation with a focus on risk stratification schemes and anticoagulation agents (warfarin, aspirin, DOACs) including special clinical considerations.

Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications

PURPOSE

The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists.

METHODS

The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control.

RESULTS

The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period.

CONCLUSION

Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.

Prospective insights into spinal surgery outcomes and adverse events: A comparative study between patients 65-79 years vs. ≥80 years from a German tertiary center

Introduction

In light of an aging global population, understanding adverse events (AEs) in surgeries for older adults is crucial for optimal outcomes and patient safety.

Research question

Our study compares surgical outcomes and AEs in patients aged 65-79 with those aged ≥80, focusing on clinical outcomes, morbidity and mortality rates, and age-related risk factors for AEs.

Material and methods

Our study, from January 2019 to December 2022, involved patients aged 65-79 and ≥ 80 undergoing spinal surgery. Each patient was evaluated for AEs post-discharge, defined as negative clinical outcomes within 30 days post-surgery. Patients were categorized based on primary spinal diagnoses: degenerative, oncological, traumatic, and infectious.

Results

We enrolled 546 patients aged 65-79 and 184 octogenarians. Degenerative diseases were most common in both groups, with higher infection and tumor rates in the younger cohort. Octogenarians had a higher Charlson Comorbidity Index and longer ICU/hospital stays. Surgery-related AE rates were 8.1% for 65-79-year-olds and 15.8% for octogenarians, with mortality around 2% in both groups.

Discussion and conclusion

Our prospective analysis shows octogenarians are more susceptible to surgical AEs, linked to greater health complexities. Despite higher AEs in older patients, low mortality rates across both age groups highlight the safety of spinal surgery. Tracking AEs is crucial for patient communication and impacts healthcare accreditation and funding.

An Analysis of Delayed Bleeding in Cases of Colorectal Endoscopic Submucosal Dissection Due to Types of Direct Oral Anticoagulants in Japan

BACKGROUND & AIMS

Reported rates of delayed bleeding (DB) after endoscopic resection using direct oral anticoagulants (DOACs) are high and heterogeneous. This large-scale multicenter study analyzed cases of DB after colorectal endoscopic submucosal dissection related to various types of DOACs in Japan (the ABCD-J study) with those associated with warfarin.

METHODS

We retrospectively reviewed 1019 lesions in patients treated with DOACs and 459 lesions in patients treated with warfarin among 34,455 endoscopic submucosal dissection cases from 47 Japanese institutions between 2012 and 2021. The DB rate (DBR) with each DOAC was compared with that with warfarin. Risk factors for DB in patients treated with DOACs or warfarin were also investigated.

RESULTS

The mean tumor sizes in the DOAC and warfarin groups were 29.6 ± 14.0 and 30.3 ± 16.4 mm, respectively. In the DOAC group, the DBR with dabigatran (18.26%) was significantly higher than that with apixaban (10.08%, P = .029), edoxaban (7.73%, P = .001), and rivaroxaban (7.21%, P < .001). Only rivaroxaban showed a significantly lower DBR than warfarin (11.76%, P = .033). In the multivariate analysis, heparin bridging therapy (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.27-3.73, P = .005), rectal location (2.01, 1.28-3.16, P = .002), and procedure time ≥55 minutes (2.43, 1.49-3.95, P < .001) were significant risk factors for DB in the DOAC group. The DB risk in the DOAC group (OR, (95% CI)) was 2.13 (1.30-3.50) and 4.53 (2.52-8.15) for 1 and 2 significant risk factors, respectively.

CONCLUSIONS

Dabigatran was associated with a higher DBR than other DOACs, and only rivaroxaban was associated with a significantly lower DBR than warfarin.

Patient blood management in major digestive surgery: Recommendations from the Italian multisociety (ACOI, SIAARTI, SIdEM, and SIMTI) modified Delphi consensus conference

Patient blood management (PBM) is defined as the timely application of evidence-based medical and surgical concepts designed to maintain a surgical patient’s hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve the outcomes. PBM is able to reduce mortality up to 68%, reoperation up to 43%, readmission up to 43%, composite morbidity up to 41%, infection rate up to 80%, average length of stay by 16%–33%, transfusion from 10% to 95%, and costs from 10% to 84% after major surgery. It should be noticed, however, that the process of PBM implementation is still in its infancy, and that its potential to improve perioperative outcomes could be strictly linked to the degree of adherence/compliance to the whole program, with decoupling and noncompliance being significant factors for failure. Therefore, the steering committees of four major Italian scientific societies, representing general surgeons, anesthesiologists and transfusion medicine specialists (Associazione Chirurghi Ospedalieri Italiani; Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva; Società Italiana di Emaferesi e Manipolazione Cellulare; Società Italiana di Medicina Trasfusionale e Immunoematologia), organized a joint modified Delphi consensus conference on PBM in the field of major digestive surgery (upper and lower gastrointestinal tract, and hepato-biliopancreatic resections), whose results and recommendations are herein presented.

Perioperative stroke

Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Periprocedural Edoxaban Management and Clinical Outcomes in Patients Undergoing Transcatheter Cardiovascular Procedures in the EMIT-AF/VTE Program

Clinical trial registration number: NCT02950168, NCT02951039.

Anticoagulation Stewardship to Bridge the Implementation Gap in Perioperative Anticoagulation Management

Lack of alignment of care protocols among providers in health care is a driver of increased costs and suboptimal patient outcomes. Perioperative anticoagulation management is a good example of a complex area where protocol creation is a clinical challenge that demands input from multiple experts. Questions regarding the need for anticoagulation interruptions are frequent. Yet, due to layers of complexity involving analysis of anticoagulation indication, surgical risk, and anesthesia-associated bleeding risk as well as institutional practices, there is heterogeneity in how these interruptions are approached. The recent perioperative anticoagulation guidelines from the American College of Chest Physicians summarize extensive evidence for the management of anticoagulant and antiplatelet medications in patients who undergo elective interventions. However, implementation of these guidelines by individual clinicians is highly varied and often does not follow the best available clinical evidence. Against this background, anticoagulation stewardship units, which exist to improve safety and quality monitoring for the anticoagulated patient, are of growing interest. These units provide a bridge for the implementation of value-based, high-quality guidelines for patients who need perioperative anticoagulation interruption. We use a case to pragmatically illustrate the problem and tactics for change management and implementation science that may facilitate the adoption of perioperative anticoagulation guidelines.

Update of Anticoagulation Use in Cardioembolic Stroke With a Special Reference to Endovascular Treatment

Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.

Living on Oral Anticoagulants: Duke Anticoagulation Satisfaction Scale Results

BACKGROUND

Direct oral anticoagulants (DOACs) are widely used in patients with atrial fibrillation and venous thromboembolism. The lack of the need for laboratory monitoring and a better safety than vitamin K antagonists (VKAs) has probably changed the quality of life of patients on these oral anticoagulants. This was a real-life prospective observational cohort study. The aim was to evaluate if a long-term treatment with DOACs could offer a better quality of life than VKAs. Moreover, age, gender, education level, time in therapeutic range for VKAs, taking medication once or twice a day for DOACs, the total daily number of medications and thrombotic and bleeding complications were considered as variables probably associated with the quality of life of these patients.

METHODS

Between January and December 2021, the Duke Anticoagulation Satisfaction Scale (DASS) 25-items was administered as an interview to patients on either VKAs or DOACs therapy. During the follow-up period, all of the patients were closely monitored to evaluate possible bleeding and thrombotic events.

RESULTS

The analysis included 300 outpatients treated with VKAs and 254 treated with DOACs. In general, the quality of life was better in patients taking DOACs (DASS total score: DOACs = 44.7, 42.9-46.5 vs. VKAs = 51, 49.2-52.8, p < 0.0001) as the daily-life limitations, hassles and burdens and the psychological impact were less important than in patients on VKAs therapy.

CONCLUSIONS

VKAs negatively influence the daily-life of the patients in terms of both less satisfaction and time-consuming tasks. DOACs confer a better quality of life even if some concerns emerge from not knowing how their therapy is working.

Anticoagulation in acute ischemic stroke patients with mechanical heart valves: To bridge or not with heparin. The ESTREM study

INTRODUCTION

The best therapeutic strategy for patients with mechanical heart valves (MHVs) having acute ischemic stroke during treatment with vitamin K antagonists (VKAs) remain unclear. Being so, we compared the outcomes for: (i) full dose heparin along with VKA (bridging therapy group) and (ii) restarting VKA without heparin (nonbridging group).

PATIENTS AND METHODS

For this multicenter observational cohort study, data on consecutive acute ischemic stroke patients with MHV was retrospectively collected from prospective registries. Propensity score matching (PSM) was adopted to adjust for any treatment allocation confounders. The primary outcome was the composite of stroke, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding at 90 days.

RESULTS

Overall, 255 out of 603 patients (41.3%) received bridging therapy: 36 (14.1%) had combined outcome, compared with 28 (8.0%) in the nonbridging group (adjusted OR 1.83; 95% CI 1.05-3.18; p = 0.03). Within the bridging group, 13 patients (5.1%) compared to 12 (3.4%) in the nonbridging group had an ischemic outcome (adjusted OR 1.71; 95% CI 0.84-3.47; p = 0.2); major bleedings were recorded in 23 (9.0%) in the bridging group and 16 (4.6%) in the nonbridging group (adjusted OR 1.88; 95% CI 0.95-3.73; p = 0.07). After PSM, 36 (14.2%) of the 254 bridging patients had combined outcome, compared with 23 (9.1%) of 254 patients in the nonbridging group (OR 1.66; 95% CI 0.95-2.85; p = 0.07).

CONCLUSION

Acute ischemic stroke patients with MHV undergoing bridging therapy had a marginally higher risk of ischemic or hemorrhagic events, compared to nonbridging patients.