Management of Antithrombotic Therapy in Patients with Coronary Artery Disease or Atrial Fibrillation who Underwent Abdominal Surgical Operations

Abstract

Background: Patients treated with antithrombotic therapy that require abdominal surgical procedures have progressively increased over time. The management of antithrombotics during both the peri- and postoperative period is of crucial importance.

Methods: The goal of this review is to present current data concerning the management of antiplatelets in patients with coronary artery disease and of anticoagulants in patients with atrial fibrillation who had to undergo abdominal surgical operations. For this purpose, the incidence of major adverse cardiovascular events (MACE) and risk of antithrombotic use during surgical procedures, as well as the recommendations based on recent guidelines were reported. A thorough search of PubMed, Scopus and the Cochrane Databases was conducted to identify randomized controlled trials, observational studies, novel current reviews, as well as ESC and ACC/AHA guidelines on the subject.

Results: Antithrombotic use in daily clinical practice leads to two different pathways: reduction of thromboembolic risk, but a simultaneous increase of bleeding risk. This may cause a therapeutic dilemma during the perioperative period. Nevertheless, careless cessation of antithrombotics can increase MACE and thromboembolic events. However, maintenance of antithrombotic therapy may increase bleeding complications. Studies and current guidelines can help clinicians in making decisions for the treatment of patients that undergo abdominal surgical operations while on antithrombotic therapy. Aspirin should not be stopped perioperatively in the majority of surgical operations. Determining whether to discontinue the use of anticoagulants before surgery depends on the surgical procedure. In surgical operations with a low risk for bleeding, oral anticoagulants should not be discontinued. Bridging therapy should only be considered in patients with a high risk of thromboembolism. Finally, in patients with an intermediate risk for thromboembolism, management should be individualized according to patient's thrombotic and bleeding risk.

Conclusion: Management of antithrombotics therapy during the perioperative period in patients undergoing abdominal surgery should follow a patient-centered approach according to a patient's medical history and thrombotic risk weighted for bleeding risk.

Keywords: Antithrombotics; anticoagulants; antiplatelets; atrial fibrillation; coronary artery disease; non-cardiac surgical operations..