Perioperative Management of Anticoagulants and Antiplatelet Agents in Oculoplastic Surgery

Elizabeth S. Esparaz; Rachel K. Sobel

Curr Opin Ophthalmol. 2015;26(5):422-428.

Abstract and Introduction

Abstract

Purpose of review The decision to stop or continue anticoagulants or antiplatelet therapy for oculoplastic procedures has long been a complicated and serious discussion for surgeons and their patients. Although other specialties have developed evidenced-based algorithms to guide their decision-making our subspecialty remains driven largely by anecdotal information. This article aims to get closer to an evidenced-based approach to perioperative anticoagulant and antiplatelet management.

Recent findings Over the last few years, new antiplatelet and anticoagulant therapies are on the market with different characteristics in terms of half-life and mechanism of action. It is imperative the contemporary surgeon be well versed in these new medications. Also, new studies have emerged from the vascular literature with specific evidenced-based recommendations for heart and stroke patients. These guidelines need to be weighed with a patient's cardiologist or neurologist.

Summary The article will review the old and new anticoagulant and antiplatelet therapies as well as the recent literature for stroke and cardiac patients to guide the oculoplastic surgeon in this nuanced decision. It will also discuss current practice patterns in light of these new therapies and medical guidelines.

Introduction

Oculoplastic surgeons are faced daily with the dilemma of whether to ask their patients to consult with their primary care physician, cardiologist, or neurologist to discontinue blood thinners perioperatively. The risk of bleeding and subsequent sight-threatening complications must be weighed against the risk of systemic ischemic and embolic events. Over the last few years, new blood thinners have come into practice. These drugs have different pharmacologic profiles than their predecessors. In addition to recent therapeutic advances, new studies have come from the vascular literature with specific evidenced-based recommendations for heart and stroke patients.^[1–3] These guidelines need to be weighed in perioperative decision-making.

In the first section of this article, we review the documented risks of stopping antiplatelet and anticoagulant medications in ophthalmic and nonophthalmic perioperative patients with regard to myocardial infarctions (MIs), strokes, and systemic thromboembolic events. We then examine the risk of hemorrhage if these agents are continued during surgery, specifically for oculoplastics patients. We also describe the new oral anticoagulants and the current perioperative management in other fields. Lastly we highlight data from a recent survey we administered to oculoplastic surgeons from the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) regarding perioperative management of blood thinners.

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Table 1. Comparison of antiplatelet and anticoagulant agent properties
Antiplatelets [4]
	Mechanism of action	Half-life	Platelet function recovery time
Aspirin	COX-1 inhibition	15–20min	30% at 48 h
Clopidogrel	P2Y12 receptor inhibition	7–9 h	40% at 72 h
Prasugrel	P2Y12 receptor inhibition	7 h	48–72 h
Ticagrelor	P2Y12 receptor inhibition	7–9 h	57% at 24 h
Anticoagulants [5,6]
	Mechanism of action	Half-life	Time to peak effect
Warfarin	Vitamin K antagonist	20–60h	72–96 h
Dabigatran	Thrombin inhibitor	12–17h	2–3 h
Rivaroxaban	Factor Xa inhibitor	9–13h	0.5–3 h
Apixaban	Factor Xa inhibitor	9–14h	3 h

COX 1, cyclooxygenase 1.

Table 2. Perioperative management of antithrombotics
	Indication for antithrombotic agent	Risk of hemorrhage during surgery
		Low risk	High risk
		Chalazion, eyelid cyst removal, eyelid lesion removal	Deep orbital surgery, postseptal eyelid surgery (ptosis repair, blepharoplasty), dacryocystorhinostomy
Anticoagulant	Low risk of thromboembolism [9]	Continue all agents perioperatively	Warfarin
	Mechanical heart valve: aortic valve prosthesis without atrial fibrillation or other risk factors for stroke		Check INR 7 days prior to surgeryþone day prior to surgery [9]
	Atrial fibrillation: CHADS2 score of 0 to 2 (assuming no prior stroke or transient ischemic attack)		Stop 5 days preop [9]
	VTE: VTE >12 months previously		Goal INR <1.5 [33]
			Restart 12–24 h postoperatively [9]
			Dabigatran: [34,35]
			Assess renal function 7 days prior to surgery
			CrCl>80, hold 48 h preop
			CrCl 50–80, hold 72 h preop
			CrCl<50, hold 96 h preop
			Rivaroxaban and Apixaban: [34,35]
			Hold 48 h preop
			Restart NOACs within 24 h, but can delay for 48–72 h if high risk for continued bleeding postoperatively [34,35]
	Moderate – high risk of thromboembolism [9]	Continue all agents perioperatively	Warfarin: Discuss with cardiologist regarding safety of disruption. We do not recommend bridge therapy
	Mechanical heart valve: any mitral valve, recent stroke, or TIA (within 6 months), aortic valve with atrial fibrillation or risk factors for stroke		NOAC: Consult cardiologist to verify length of anticoagulation disruption pre and post operatively
	Atrial fibrillation: CHADS2 score of >3
	VTE: VTE within last 3–12 months or recurrent VTE, thrombophilia, active cancer
Antiplatelet	Primary prevention w/single agent (aspirin or clopidogrel)	Continue all agents perioperatively	Aspirin: stop 7 days preop [9]
			Clopidogrel: stop 5 days preop [36,37]
			Restart all agents as soon as possible once surgeon has determined there is adequate hemostasis
	Secondary prevention w/single agent (aspirin or clopidogrel)	Continue all agents perioperatively	Continue perioperatively [9]
	DAPT within 6 months of BMS or 12 months of DES placement	Continue all agents perioperatively	Continue perioperatively [9]
	DAPT beyond critical period	Continue all agents perioperatively	Aspirin: continue perioperatively [36,37]
			Clopidogrel, Ticagrelor: stop 5 days preop [36,37]
			Prasugrel: stop 7 days preop [36,37]
			Restart all agents as soon as possible once surgeon has determined there is adequate hemostasis

BMS, bare-metal stent; CHADS2, congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack; CrCl, creatinine clearance; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; LMWH, low-molecular weight heparin; UFH, unfractionated heparin; VTE, venous thromboembolism.

Table 3. Perioperative practice patterns
Warfarin
Hold prior to procedure?	Minor eyelid procedures N=218	Blepharoplasty or ptosis repair N=219	Deep orbital surgery or dacryocystorhinostomy N=210
Yes	24% (53)	93% (203)	98% (204)
No	76% (165)	7% (16)	2% (4)
Novel oral anticoagulants
Hold prior to procedure?	Minor eyelid procedures N=220	Blepharoplasty or ptosis repair N=215	Deep orbital surgery or dacryocystorhinostomy N=209
Yes	25% (54)	93% (200)	97% (203)
No	75% (166)	7% (15)	3% (6)
Antiplatelet
Hold prior to procedure?	Minor eyelid procedures N=217	Blepharoplasty or ptosis repair N=219	Deep orbital surgery or dacryocystorhinostomy N=214
Yes	22% (48)	94% (206)	99% (211)
No	78% (169)	6% (13)	1% (3)

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Perioperative Management of Anticoagulants and Antiplatelet Agents in Oculoplastic Surgery

Abstract and Introduction

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