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Open Access

Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation

Louise Y Y Yeung, Babak Sarani, Jordan A Weinberg, Paul B McBeth, Addison K May
DOI: 10.1136/tsaco-2016-000022 Published 13 July 2016
Louise Y Y Yeung
1Kaiser Permanente Medical Center, Los Angeles, California, USA
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Babak Sarani
2Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia, USA
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Jordan A Weinberg
3Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Paul B McBeth
4Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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Addison K May
5Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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  • Figure 1
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    Figure 1

    Standard TEG tracing. R time is reflective of enzyme/coagulation factor deficiency. α Angle is reflective of the thrombin burst. Maximal amplitude (MA) consists of 80% of platelet activity and 20% of fibrinogen. TEG, thrombelastography-platelet mapping.

  • Figure 2
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    Figure 2

    TEG platelet map tracing. Note the insert which shows the degree of platelet inhibition both as a percentage of total as well as the actual MA associated with the pathway. This assay shows 75.5% inhibition in the ADP pathway. ADP, adenosine diphosphate; MA, maximal amplitude; TEG, thrombelastography-platelet mapping.

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    Figure 3

    Algorithm for perioperative bridging of warfarin. INR, International Normalized Ratio; LMWH, low-molecular-weight heparin; UFH, unfractionated heparin.

Tables

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  • Table 1

    Basic characteristics and interpretation of commonly used assays to assess platelet function

    TestMediumInterpretationComments
    Light transmission aggregometryPlasmaIncreased light transmission α increased platelet functionDoes not account for effect of blood cells on clotting
    Impedance aggregometryWhole bloodIncreased impedance α increased platelet function
    PFA-100Whole bloodDecreased closure time α increased platelet functionNot approved for detection of clopidogrel
    VerifyNowWhole bloodAkin to light transmission aggregometry
    TEG platelet mapWhole bloodDirectly reports the percentage of inhibition in maximal platelet functionVariable and high degree of inhibition noted due to illness and injury
    • TEG, thrombelastography-platelet mapping.

  • Table 2

    CHAD2 scoring system for assessing thromboembolic risk

    ConditionPoints
    CCongestive heart failure1
    HHypertension: blood pressure consistently above 140/90 mm Hg (or treated hypertension on medication)1
    AAge ≥75 years1
    DDiabetes mellitus1
    S2Prior Stroke or TIA or Thromboembolism2
    • TIA, transient ischemic attack.

  • Table 3

    CHA2DS2-VASc scoring system for assessing thromboembolic risk

    ConditionPoints
    CCongestive heart failure (or Left ventricular systolic dysfunction)1
    HHypertension: blood pressure consistently above 140/90 mm Hg (or treated hypertension on medication)1
    A2Age ≥75 years2
    DDiabetes Mellitus1
    S2Prior Stroke or TIA or thromboembolism2
    VVascular disease (eg, peripheral artery disease, myocardial infarction, aortic plaque)1
    AAge 65–74 years1
    ScSex category (ie, female sex)1
    • TIA, transient ischemic attack.

  • Table 4

    Stroke risk by CHADS2 score

    CHADS2 scoreStroke risk %95% CI
    01.91.2 to 3.0
    12.82.0 to 3.8
    24.03.1 to 5.1
    35.94.6 to 7.3
    48.56.3 to 11.1
    512.58.2 to 17.5
    618.210.5 to 27.4
  • Table 5

    Stroke risk by CHA2DS2-VASc score

    CHA2DS2-VASc scoreStroke Risk %95% CI
    00–
    11.3–
    22.2–
    33.2–
    44.0–
    56.7–
    69.8–
    79.6–
    812.5–
    915.2–
  • Table 6

    HAS-BLED score to assess bleeding risk

    HAS-BLED riskScore
    Hypertension1
    Abnormal
     Renal function1
     Liver function1
    Stroke1
    Bleeding1
    Labile INRs1
    Elderly: age >65 years1
    Drugs1
    Alcohol1
    • Hypertension: systolic blood pressure >160 mm Hg; Abnormal renal function: presence of chronic dialysis or renal transplantation or serum creatinine ≥200 μmol/L; abnormal hepatic function: chronic hepatic disease or biochemical evidence of significant hepatic derangement (eg, bilirubin >2× upper limit of normal, in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase >3× upper limit of normal, etc); ‘Bleeding’ refers to previous bleeding history and/or predisposition to bleeding (eg, bleeding diathesis, anemia); ‘Labile INRs’ refer to unstable/high INRs or poor time in therapeutic range (eg, <60%); Drugs/alcohol use refers to concomitant use of drugs, such as antiplatelet agents, nonsteroidal anti-inflammatory drugs, alcohol abuse, etc.

    • INR, International Normalized Ratio.

  • Table 7

    Risk of bleeding by HAS-BLED score

    ScoreBleeding risk classification (% bleeds/100 patient-years)
    0–1Low risk (1.1%)
    2Intermediate risk (1.9%)
    >3High risk (4.9%)
  • Table 8

    Recommendations for timing of discontinuation of anticoagulation for elective surgery

    DrugTiming of discontinuation
    Warfarin5 days
    Direct thrombin inhibitors (dabigatran)CrCl ≥50 mL/min: 1–2 days
    CrCl <50 mL/min: 3–5 days
    CrCl (mL/min)Bleed risk: lowBleed risk: high (days)
    ≥5024 hours2-3
    30–502 days2-3
    <302–4 days>5
    Factor Xa inhibitors
     Rivaroxaban (Xarelto)≥24 hours
    ROCKET AF: ≥3 days
     Apixaban (Eliquis)Low-bleed risk: ≥24 hours
    High-bleed risk: ≥48 hours
    Antiplatelet agents
     AspirinHigh-CV risk/minor: continue
    Low CV/high-bleed risk: 7–10 days
     Clopidogrel5 days
    • Stents: bare metal stents—delay surgery for 6 weeks; drug eluding stents delay surgery for 6–12 months due to risk of occlusion; otherwise, consider continuing agents.

    • CV, cardiovascular.

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Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation
Louise Y Y Yeung, Babak Sarani, Jordan A Weinberg, Paul B McBeth, Addison K May
Trauma Surg Acute Care Open Jul 2016, 1 (1) e000022; DOI: 10.1136/tsaco-2016-000022

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Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation
Louise Y Y Yeung, Babak Sarani, Jordan A Weinberg, Paul B McBeth, Addison K May
Trauma Surg Acute Care Open Jul 2016, 1 (1) e000022; DOI: 10.1136/tsaco-2016-000022
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Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation
Louise Y Y Yeung, Babak Sarani, Jordan A Weinberg, Paul B McBeth, Addison K May
Trauma Surgery & Acute Care Open Jul 2016, 1 (1) e000022; DOI: 10.1136/tsaco-2016-000022
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    • Abstract
    • Introduction
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    • Management of antiplatelet therapy in the perioperative period
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