20 Sep Surgery in Patients on Anticoagulants
It’s sometimes difficult to decide whether to stop drug treatment when patients on anti-platelet agents or oral anticoagulants require a procedure or operation. Surgeon’s views vary widely and are often slanted towards stopping therapy to avoid bleeding complications. GP’s know more about the overall health status of the patient and should be an advocate for advising the patient on the safest course . The following are some guidelines to help.
- High-risk patients require bridging anticoagulation with clexane – high risk includes those who have had a thrombotic episode before (embolic stroke, unprovoked DVT or PE), or where thrombus is likely to occur because of either a mechanical heart valve or drug eluting stent in the past few months.
- Most other patients can have their anticoagulants stopped – this includes individuals with AF who have not had a stroke, patients with a bioprosthetic heart valve and patients on aspirin for primary prevention.
- Patients with coronary stents should generally not have interventions while on dual anti-platelet therapy. If they do require a procedure, its reasonably safe after 3 months, to temporarily cease clopidogrel or ticagrelor 5 days prior to the procedure then restart it when the risk of bleeding is low.
- Patients with coronary stents who are on aspirin should not cease taking it unless they are having an operation where the risk of bleeding is extremely high and the consequence disastrous – neurosurgery is the commonest example. In almost all other cases aspirin should be continued.
Often the best decision is reached after a discussion between GP surgeon and cardiologist or physician.