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Antithrombotic and Antiplatelet Therapy

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Abstract

Managing antithrombotic and antiplatelet therapy is one of the common issues while performing interventional techniques to balance the bleeding risk and perioperative risk of thrombosis. There are myriad procedural guidelines on managing anticoagulant and antithrombotic therapy, even though most are not based on appropriate evidence.

The risks of withholding antiplatelet therapy include cardiovascular, cerebrovascular, and peripheral vascular thrombosis which may result in catastrophic consequences including stroke and death. The risks of continuing antiplatelet therapy include bleeding and fatalities related to bleeding.

Based on an extensive review of the literature, there is good evidence for the risk of a thromboembolic phenomenon in patients who stop antithrombotic therapy. There is also good evidence for the lack of necessity of stopping nonsteroidal anti-inflammatory drugs (NSAIDs), including low-dose aspirin, prior to performing interventional techniques. There is fair evidence that excessive bleeding, including epidural hematoma formation, may occur with interventional techniques when antithrombotic therapy is continued. There is fair evidence that the risk of a thromboembolic phenomenon is higher than the risk of epidural hematomas when antiplatelet therapy is stopped prior to interventional techniques.

Keywords

  • Perioperative bleeding
  • Bleeding risk
  • Practice patterns
  • Anticoagulant therapy
  • Antithrombotic therapy
  • Interventional techniques
  • Safety precautions

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References

  1. Manchikanti L, Benyamin RM, Swicegood JR, et al. Assessment of practice patterns of perioperative management of antiplatelet and anticoagulant therapy in interventional pain management. Pain Physician. 2012;15:E955–68.

    PubMed  Google Scholar 

  2. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: part II: guidance and recommendations. Pain Physician. 2013;16:S49–S283.

    PubMed  Google Scholar 

  3. World Health Organization. Cardiovascular disease (CVDs) fact sheet. 2012. www.who.int/mediacentre/factsheets/fs317/en/index.html

  4. Schiller JS, Lucas JW, Ward BW, et al. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. Vital Health Stat. 2012;252:1–207.

    Google Scholar 

  5. Institute of Medicine (IOM). Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press; 2011.

    Google Scholar 

  6. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169:251–8.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  7. Hoy DG, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64:2028–37.

    CrossRef  PubMed  Google Scholar 

  8. Hoy DG, Protani M, De R, et al. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24:783–92.

    CAS  CrossRef  PubMed  Google Scholar 

  9. Martin BI, Turner JA, Mirza SK, et al. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997-2006. Spine (Phila Pa 1976). 2009;34:2077–84.

    CrossRef  Google Scholar 

  10. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13:715–24.

    CrossRef  PubMed  Google Scholar 

  11. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27:2667–74.

    CrossRef  PubMed  Google Scholar 

  12. Price MJ, Berger PB, Teirstein PS, et al; GRAVITAS Investigators. Standard- vs high dose clopidogrel based on platelet function testing after percutaneous coronary intervention: the GRAVITAS randomized trial. JAMA. 2011;305:1097–105.

    Google Scholar 

  13. Ho PM, Peterson ED, Wang L, et al. Incidence of death and acute myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA. 2008;299:532–9. Erratum in: JAMA 2008; 299:2390

    CAS  CrossRef  PubMed  Google Scholar 

  14. Johnson SG, Rogers K, Delate T, et al. Outcomes associated with combined antiplatelet and anticoagulant therapy. Chest. 2008;133:948–54.

    CAS  CrossRef  PubMed  Google Scholar 

  15. Marso SP, Amin AP, House JA, et al; National Cardiovascular Data Registry. Association between use of bleeding avoidance strategies and risk of periprocedural bleeding among patients undergoing percutaneous coronary intervention. JAMA. 2010;303:2156–64.

    Google Scholar 

  16. Chan AT, Giovannucci EL, Meyerhardt JA, et al. Long-term use of aspirin and nonsteroidal anti-inflammatory drugs and risk of colorectal cancer. JAMA. 2005;294:914–23.

    CAS  CrossRef  PubMed  PubMed Central  Google Scholar 

  17. Berger JS, Krantz MJ, Kittelson JM, et al. Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA. 2009;301:1909–19.

    CAS  CrossRef  PubMed  Google Scholar 

  18. Howard-Alpe GM, de Bono J, Hudsmith L, et al. Coronary artery stents and non-cardiac surgery. Br J Anaesth. 2007;98:560–74.

    CAS  CrossRef  PubMed  Google Scholar 

  19. Eisenstein EL, Anstrom KJ, Kong DF, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA. 2007;297:159–68.

    CAS  CrossRef  PubMed  Google Scholar 

  20. Ogawa H, Nakayama M, Morimoto T, et al; Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) Trial Investigators. Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial. JAMA. 2008;300:2134–41. Erratum in: JAMA 2009;301:1882.

    Google Scholar 

  21. Paikin JS, Wright DS, Eikelboom JW. Effectiveness and safety of combined antiplatelet and anticoagulant therapy: a critical review of the evidence from randomized controlled trials. Blood Rev. 2011;25:123–9.

    CAS  CrossRef  PubMed  Google Scholar 

  22. Sprigg N, Gray LJ, England T, et al. A randomised controlled trial of triple antiplatelet therapy (aspirin, clopidogrel and dipyridamole) in the secondary prevention of stroke: safety, tolerability and feasibility. PLoS One. 2008;3:e2852.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  23. Walker CW, Dawley CA, Fletcher SF. Aspirin combined with clopidogrel (Plavix) decreases cardiovascular events in patients with acute coronary syndrome. Am Fam Physician. 2007;76:1643–5.

    PubMed  Google Scholar 

  24. Manchikanti L, Malla Y, Wargo BW, et al. A prospective evaluation of bleeding risk of interventional techniques in chronic pain. Pain Physician. 2011;14:317–29.

    PubMed  Google Scholar 

  25. Manchikanti L, Falco FJE, Benyamin RM, et al. Assessment of bleeding risk of interventional techniques: a best evidence synthesis of practice patterns and perioperative management of anticoagulant and antithrombotic therapy. Pain Physician. 2013;16:SE261–318.

    PubMed  Google Scholar 

  26. Horlocker TT, Wedel DJ, Schroeder DR, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg. 1995;80:303–9.

    CAS  PubMed  Google Scholar 

  27. Horlocker TT, Wedel DJ, Offord KP. Does preoperative antiplatelet therapy increase the risk of hemorrhagic complications associated with regional anesthesia? Anesth Analg. 1990;70:631-634.

    CrossRef  Google Scholar 

  28. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (third edition). Reg Anesth Pain Med. 2010;35:64–101.

    CAS  CrossRef  PubMed  Google Scholar 

  29. Raj PP, Shah RV, Kaye AD, et al. Bleeding risk in interventional pain practice: assessment, management, and review of the literature. Pain Physician. 2004;7:3–51.

    PubMed  Google Scholar 

  30. Ahmed SU, Tonidandel W, Trella J, et al. Peri-procedural protocols for interventional pain management techniques: a survey of US pain centers. Pain Physician. 2005;8:181–5.

    PubMed  Google Scholar 

  31. Gogarten W, Van Aken H, Buttner J, et al. Neuraxial blockade and thromboembolism prophylaxis/antithrombotic therapy: revised recommendations of the German Society of Anaesthesiology and Intensive Care. Anaesthesiol Intensivmed. 2003;44:218–30.

    Google Scholar 

  32. Bugada D, Massimo A, Nicola Z, et al. Regional anesthesia and anticoagulant drugs: a survey of current Italian practice. Eur J Pain Suppl. 2011;5:335–43.

    CAS  CrossRef  Google Scholar 

  33. Llau Pitarch JV, De Andrés Ibáñez J, Gomar Sancho C, et al. Hemostasis-altering drugs and techniques for regional anesthesia and analgesia: safety recommendations. Rev Esp Anestesiol Reanim. 2005;52:248–50.

    CAS  PubMed  Google Scholar 

  34. Kozek-Langenecker SA, Fries D, Gütl M, et al; Task force on Perioperative Coagulation of the Austrian Society for Anesthesiology and Intensive Care Medicine. Locoregional anesthesia and coagulation inhibitors. Recommendations of the task force on perioperative coagulation of the Austrian Society for anesthesiology and intensive care medicine. Anaesthesist. 2005;54:476–84.

    Google Scholar 

  35. Vandermeulen E, Singelyn F, Vercauteren M, et al; Belgian Association for Regional Anesthesia Working Party on Anticoagulants and Central Nerve Blocks. Belgian guidelines concerning central neural blockade in patients with drug-induced alteration of coagulation: an update. Acta Anaesthesiol Belg. 2005;56:139–46.

    Google Scholar 

  36. Horlocker TT, Bajwa ZH, Ashraf Z, et al. Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection. Anesth Analg. 2002;95:1691–7.

    CAS  CrossRef  PubMed  Google Scholar 

  37. Horlocker TT, Wedel DJ. Anticoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management. Reg Anesth Pain Med. 1998;23:129–34.

    CAS  PubMed  Google Scholar 

  38. Cameron CM, Scott DA, McDonald WM, et al. A review of neuraxial epidural morbidity: experience of more than 8,000 cases at a single teaching hospital. Anesthesiology. 2007;106:997–1002.

    CrossRef  PubMed  Google Scholar 

  39. Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth. 2007;99:316–28.

    CAS  CrossRef  PubMed  Google Scholar 

  40. Giroud D, Li JM, Urban P, et al. Relation of the site of acute myocardial infarction to the most severe coronary arterial stenosis at prior angiography. Am J Cardiol. 1992;69:729–32.

    CAS  CrossRef  PubMed  Google Scholar 

  41. Yusuf S, Zhao F, Mehta SR, et al; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators, CURE Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494–502.

    Google Scholar 

  42. Dawood MM, Gutpa DK, Southern J, et al. Pathology of fatal perioperative myocardial infarction: implications regarding physiopathology and prevention. Int J Cardiol. 1996;57:37–44.

    CAS  CrossRef  PubMed  Google Scholar 

  43. Landesberg G. The pathophysiology of perioperative myocardial infarction: facts and perspectives. J Cardiothorac Vasc Anesth. 2003;17:90–100.

    CrossRef  PubMed  Google Scholar 

  44. Priebe HJ. Perioperative myocardial infarction—aetiology and prevention. Br J Anaesth. 2005;95:3–19.

    CrossRef  PubMed  Google Scholar 

  45. Hoffmeister HM, Heller W, Seipel L. Activation markers of coagulation and fibrinolysis: alterations and predictive value in acute coronary syndrome. Thromb Haemost. 1999;82:76–9.

    PubMed  Google Scholar 

  46. Blake GJ, Ridker PM. Inflammatory biomarkers and cardiovascular risk prediction. J Intern Med. 2002;252:283–94.

    CAS  CrossRef  PubMed  Google Scholar 

  47. Laffey JG, Boylan JF, Cheng DC. The systemic inflammatory response to cardiac surgery. Anesthesiology. 2002;97:215–52.

    CAS  CrossRef  PubMed  Google Scholar 

  48. Savonitto S, D’Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of “bridging” antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth. 2010;104:285–91.

    CAS  CrossRef  PubMed  Google Scholar 

  49. Mariscalco G, Bruno VD, Cottini M, et al. Optimal timing of discontinuation of clopidogrel and risk of blood transfusion after coronary surgery. Propensity score analysis. Circ J. 2011;75:2805–12.

    CAS  CrossRef  PubMed  Google Scholar 

  50. Di Minno MN, Prisco D, Ruocco AL, et al. Perioperative handling of patients on antiplatelet therapy with need for surgery. Intern Emerg Med. 2009;4:279–88.

    CrossRef  PubMed  Google Scholar 

  51. Chassot PG, Marcucci C, Delabays A, et al. Perioperative antiplatelet therapy. Am Fam Physician. 2010;82:1484–9.

    PubMed  Google Scholar 

  52. Chou S, Eshaghian S, Lamer A, et al. Bridging therapy in the perioperative management of patients with drug-eluting stents. Rev Cardiovasc Med. 2009;10:209–18.

    PubMed  Google Scholar 

  53. Korte W, Cattaneo M, Chassot PG, et al. Peri-operative management of antiplatelet therapy in patients with coronary artery disease: joint position paper by members of the working group on perioperative Haemostasis of the Society on thrombosis and Haemostasis research (GTH), the working group on perioperative coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC). Thromb Haemost. 2011;105:743–9.

    CAS  CrossRef  PubMed  Google Scholar 

  54. Savonitto S, Caracciolo M, Cattaneo M, et al. Management of patients with recently implanted coronary stents on dual antiplatelet therapy who need to undergo major surgery. J Thromb Haemost. 2011;9:2133–42.

    CAS  CrossRef  PubMed  Google Scholar 

  55. Bell B, Layland J, Poon K, et al. Focused clinical review: periprocedural management of antiplatelet therapy in patients with coronary stents. Heart Lung Circ. 2011;20:438–45.

    CrossRef  PubMed  Google Scholar 

  56. Douketis JD, Spyropoulos AC, Spencer FA, et al; American College of Chest Physicians. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:e326S–50S. Erratum in: Chest. 2012;141:1129.

    Google Scholar 

  57. Hall R, Mazer CD. Antiplatelet drugs: a review of their pharmacology and management in the perioperative period. Anesth Analg. 2011;112:292–318.

    CAS  CrossRef  PubMed  Google Scholar 

  58. Parodi G, Marcucci R, Valenti R, et al. High residual platelet reactivity after clopidogrel loading and long-term cardiovascular events among patients with acute coronary syndromes undergoing PCI. JAMA. 2011;306:1215–23.

    CAS  CrossRef  PubMed  Google Scholar 

  59. Lardizabal JA, Joshi BK, Ambrose JA. The balance between anti-ischemic efficacy and bleeding risk of antithrombotic therapy in percutaneous coronary intervention: a yin-yang paradigm. J Invasive Cardiol. 2010;22:284–92.

    PubMed  Google Scholar 

  60. Levy JH, Dutton RP, Hemphill JC 3rd, et al; Hemostasis Summit Participants. Multidisciplinary approach to the challenge of hemostasis. Anesth Analg. 2010;110:354–64.

    Google Scholar 

  61. Huczek Z, Filipiak KJ, Kochman J, et al. Baseline platelet size is increased in patients with acute coronary syndromes developing early stent thrombosis and predicts future residual platelet reactivity. A case-control study. Thromb Res. 2010;125:406–12.

    CAS  CrossRef  PubMed  Google Scholar 

  62. Ray JG, Deniz S, Olivieri A, et al. Increased blood product use among coronary artery bypass patients prescribed preoperative aspirin and clopidogrel. BMC Cardiovasc Disord. 2003;3:3.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  63. Chassot PG, Delabays A, Spahn DR. Perioperative use of anti-platelet drugs. Best Pract Res Clin Anaesthesiol. 2007;21:241–56.

    CAS  CrossRef  PubMed  Google Scholar 

  64. Ko WM, Ferrante FM. New onset lumbar radicular pain after implantation of an intrathecal drug delivery system: imaging catheter migration. Reg Anesth Pain Med. 2006;31:363–7.

    CAS  PubMed  Google Scholar 

  65. Randelli F, Biggi F, Della Rocca G, et al. Italian intersociety consensus statement on antithrombotic prophylaxis in hip and knee replacement and in femoral neck fracture surgery. J Orthop Traumatol. 2011;12:69–76.

    CAS  CrossRef  PubMed  PubMed Central  Google Scholar 

  66. Bell AD, Roussin A, Cartier R, et al; Canadian Cardiovascular Society. The use of antiplatelet therapy in the outpatient setting: Canadian Cardiovascular Society guidelines. Can J Cardiol. 2011;27:S1–59.

    Google Scholar 

  67. Chernoguz A, Telem DA, Chu E, et al. Cessation of clopidogrel before major abdominal procedures. Arch Surg. 2011;146:334–9.

    CAS  CrossRef  PubMed  Google Scholar 

  68. Ono S, Fujishiro M, Kanzaki H, et al. Conflicting clinical environment about the management of antithrombotic agents during the periendoscopic period in Japan. J Gastroenterol Hepatol. 2011;26:1434–40.

    CrossRef  PubMed  Google Scholar 

  69. Stone DH, Goodney PP, Schanzer A, et al; Vascular Study Group of New England. Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery. J Vasc Surg. 2011;54:779–84.

    Google Scholar 

  70. Abbate R, Cioni G, Marcucci R, et al. Antithrombotic drugs in women: should we worry more about bleeding? G Ital Cardiol (Rome). 2012;13:407–13.

    Google Scholar 

  71. Ono S, Fujishiro M, Kodashima S, et al. Evaluation of safety of endoscopic biopsy without cessation of antithrombotic agents in Japan. J Gastroenterol. 2012;47:770–4.

    CAS  CrossRef  PubMed  Google Scholar 

  72. Lip GY, Durrani OM, Roldan V, et al. Peri-operative management of ophthalmic patients taking antithrombotic therapy. Int J Clin Pract. 2011;65:361–71.

    CAS  CrossRef  PubMed  Google Scholar 

  73. Gerstein NS, Schulman PM, Gerstein WH, et al. Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome. Ann Surg. 2012;255:811–9.

    CrossRef  PubMed  Google Scholar 

  74. Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med. 2003;163:901–8.

    CrossRef  PubMed  Google Scholar 

  75. Horlocker TT. Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy. Br J Anaesth. 2011;107:i96–i106.

    CAS  CrossRef  PubMed  Google Scholar 

  76. Breivik H, Bang U, Jalonen J, et al. Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and intensive care medicine. Acta Anaesthesiol Scand. 2010;54:16–41.

    CAS  CrossRef  PubMed  Google Scholar 

  77. Gogarten W, Vandermeulen E, Van Aken H, et al; European Society of Anaesthesiology. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol. 2010;27:999–1015.

    Google Scholar 

  78. Vandermeulen E. Regional anaesthesia and anticoagulation. Best Pract Res Clin Anaesthesiol. 2010;24:121–31.

    CAS  CrossRef  PubMed  Google Scholar 

  79. www.brilinta.com

  80. Frishman WH, Nawarskas JJ, Clark SM. Brilinta® (Ticagrelor): chapter 18 antiplatelet and other antithrombotic drugs. Cardiovascular Pharmacotherapeutics. 2011. http://cardiovascularpharmacotherapeutics.com/2011/08/30/brilinta-ticagrelor-chapter-18-antiplatelet-and-other-antithrombotic-drugs/

  81. Fawole A, Daw HA, Crowther MA. Practical management of bleeding due to the anticoagulants dabigatran, rivaroxaban, and apixaban. Cleve Clin J Med. 2013;80:443–51.

    CrossRef  PubMed  Google Scholar 

  82. Rose A. Periprocedural Anticoagulation – Adult – Inpatient and Ambulatory– Clinical Practice Guideline. UW Health, Original October 2011, Revised February 2013. http://www.uwhealth.org/files/uwhealth/docs/anticoagulation/Periprocedural_Anticoagulation_Guideline.pdf

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Manchikanti, L., Kaye, A.D., Falco, F.J.E. (2018). Antithrombotic and Antiplatelet Therapy. In: Manchikanti, L., Kaye, A., Falco, F., Hirsch, J. (eds) Essentials of Interventional Techniques in Managing Chronic Pain. Springer, Cham. https://doi.org/10.1007/978-3-319-60361-2_6

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