Periprocedural Management of Antithrombotic Therapy - Adult - Inpatient/Ambulatory Consensus Care Guideline Table of Contents Population/Problem: ...................................................................................................................... 2 Definitions: .................................................................................................................................... 2 Recommendations: ....................................................................................................................... 3 Step 1. Identify the bleeding risk category of the procedure ..................................................... 3 Step 2. Identify the usual recommendation for stopping the antithrombotic prior to the procedure .................................................................................................................................. 4 Step 3. Identify the usual recommendation for restarting the antithrombotic after the procedure .................................................................................................................................. 7 Step 4. Determine if bridging therapy is usually recommended .............................................. 10 Step 5. Individualize Recommendations ................................................................................. 12 Step 6. Communicate and Document Plan ............................................................................. 12 Step 7. Revisit the plan after the procedure and revise as necessary .................................... 12 Collateral Tools & Resources ..................................................................................................... 16 Appendix A. Examples of Warfarin Bridging with Enoxaparin .................................................... 17 Appendix B. Considerations for Antiplatelet Bridging With Cangrelor ........................................ 19 Appendix C. Holding Antithrombotics for Outpatient Endoscopy Procedures ............................ 20 References .................................................................................................................................. 22 Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Population/Problem: Patients receiving long term antithrombotic therapy who require surgery or an invasive procedure present a difficult therapeutic dilemma for clinicians. Efforts are made to minimize the patient’s risk of both thromboembolism and bleeding in the periprocedural setting. When a long- acting antithrombotic (e.g., warfarin) is interrupted, some patients may temporarily receive a short-acting antithrombotic (e.g., enoxaparin) before and after the procedure. This practice is referred to as bridging therapy and is intended to reduce a patient’s risk of periprocedural thromboembolism.1 Emerging evidence suggests bridging therapy may significantly increase a patient’s periprocedural bleeding risk and has not been shown to reduce the risk of thromboembolism.2,3 As such, bridging therapy is not recommended for most patients, but may be considered in select high-risk patients, as outlined in this guideline. Despite recent evidence, uncertainly remains regarding best practices for the majority of periprocedural antithrombotic management questions.4 This guideline is intended to serve as a framework for helping clinicians arrive at evidence- based decisions regarding periprocedural management of antithrombotics. It is understood that plans may need to be individualized to address unique patient- and procedure-specific risks and should involve shared decision making between various health care providers and the patient (or patient’s representative). Definitions: • Antithrombotic – includes any anticoagulant or antiplatelet medication • ASA – acetylsalicylic acid or aspirin • ASRA – American Society of Regional Anesthesia and Pain Medicine • ATE – arterial thromboembolism • Bridging therapy – use of a short-acting antithrombotic during the periprocedural interruption of a long-acting antithrombotic, often administered for a 10 to 12-day period • CABG – coronary artery bypass graft • CHA2DS2-VASc – congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease history, age 65 to 74 years, female sex • CHEST – American College of Chest Physicians • CrCl – creatinine clearance • DAPT – dual antiplatelet therapy • DOAC – direct oral anticoagulant (i.e., apixaban, dabigatran, edoxaban, rivaroxaban) • ICD – internal cardiac defibrillator • INR – international normalized ratio • ISTH – International Society on Thrombosis and Haemostasis • IV - intravenous • LMWH – low molecular weight heparin • Periprocedural – the period of time prior to, during, and following an invasive procedure • PLT – platelet count • TE – thromboembolic • TXA – tranexamic acid • UFH – unfractionated heparin • VTE – venous thromboembolism Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Recommendations: Table 1. Surgical Procedure Bleeding Risk Categories4,5 For procedures with minimal bleed risk, may continue antithrombotic therapy uninterrupted; See Step #2 for more details 1. Procedures not listed in Table 1 should be categorized based on estimated 30-day rates of major bleeding defined as: 1.1. Minimal bleed risk if the 30-day risk of major bleeding approximates 0%4,5 (UW Health GRADE very low quality of evidence, conditional recommendation) 1.2. Low/moderate bleed risk if the 30-day risk of major bleeding is 0-2%4,5 (UW Health GRADE very low quality of evidence, conditional recommendation) 1.3. High bleed risk if the 30-day risk of major bleeding exceeds 2%4,5 (UW Health GRADE very low quality of evidence, conditional recommendation) 1.4. Procedures involving neuraxial anesthesia 1.4.1. For procedures involving neuraxial anesthesia, including both spinal and epidural anesthesia or any neuraxial intervention (e.g., epidural pain management), consider both the bleed risk of the procedure itself and the potential catastrophic consequences of Step 1. Identify the bleeding risk category of the procedure Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions bleeding in the neuraxial space (e.g., lower extremity paralysis resulting from epidural bleeding)4 1.4.2. There is a lack of consensus regarding how to manage antithrombotic therapy for procedures involving neuraxial anesthesia. Some organizations (e.g., CHEST, ISTH) categorize these procedures the same as other “high bleed risk” procedures, whereas the American Society of Regional Anesthesia and Pain Medicine (ASRA) have separate recommendations that may be more conservative (i.e., longer interruptions in therapy prior to procedure), based on data from pharmacokinetic studies4-6 1.4.3. ASRA recommendations are presented in Table 2 and Table 3, alongside recommendations for high bleed risk procedures, so that it is apparent to clinicians when recommendations differ, and to prompt discussion and shared decision-making amongst various members of the healthcare team6 Table 2. Stopping Antithrombotics Prior to Surgical Procedures4-6 Oral Anticoagulant Patient-Specific Criteria Low/ Moderate Bleed Risk Procedure High Bleed Risk Procedure Neuraxial Anesthesia6 Warfarin4 INR 2.0-3.5 Stop 5 days prior Stop 5 or more days prior; check INR 1-2 days prior; if INR > 1.5, consider 1 to 2 mg oral vitamin K INR > 3.5 Stop 6 or more days prior Apixaban (Eliquis)4 Stop 1 day prior Stop 2 days prior Stop 72 hours prior Dabigatran (Pradaxa)4 CrCl ≥ 80 ml/min Stop 1 day prior Stop 2 days prior Stop 72 hours prior* CrCl 50-79 ml/min Stop 96 hours prior* CrCl < 50 ml/min Stop 2 days prior Stop 4 days prior Stop 120 hours prior Edoxaban (Savaysa)4 Stop 1 day prior Stop 2 days prior Stop 72 hours prior Rivaroxaban (Xarelto)4 Stop 1 day prior Stop 2 days prior Stop 72 hours prior Parenteral Anticoagulant Patient-Specific Criteria Low/Moderate Bleed Risk Procedure High Bleed Risk Procedure Neuraxial Anesthesia6 Argatroban¥ Normal liver function Stop 3 hours prior Stop 5 hours prior Neuraxial anesthesia is not recommended Child-Pugh > 6 Stop 9 hours prior Stop 15 hours prior Bivalirudin¥ CrCl ≥ 30 ml/min Stop 1.5 hours prior Stop 2.5 hours prior CrCl < 30 ml/min Stop 3 hours prior Stop 5 hours prior Enoxaparin (Lovenox)4 Prophylactic Dose Stop 12 hours prior¥ Stop ≥ 12 hours prior Therapeutic Dose Stop 24 hours prior Stop ≥ 24 hours prior Fondaparinux (Arixtra)¥ CrCl ≥ 50 ml/min Stop 3 days prior Stop 4 days prior See ASRA Guidelines for details CrCl < 50 ml/min Stop 5 days prior Stop 6 days prior Unfractionated heparin (UFH)4 5000 units BID/TID Stop at least 4 hours prior¥ Stop 4 to 6 hours prior UFH infusion Stop at least 4 hours prior Stop 4 to 6 hours prior Antiplatelet Agent Patient-Specific Criteria Low/Moderate Bleed Risk Procedure High Bleed Risk Procedure Neuraxial Anesthesia6 Aspirin (ASA)4 Continue ASA uninterrupted (If ASA interruption is required, stop ASA 7 days prior**) ASA may be continued Cangrelor¥ Stop 1 to 3 hours prior Stop 3 hours prior Cilostazol (Pletal)¥ Stop 1 to 2 days prior Stop 2 days prior Clopidogrel (Plavix)4 Stop 5 days prior** Stop 5 to 7 days prior Prasugrel4 Stop 7 days prior** Stop 7 to 10 days prior Ticagrelor4 Stop 3 to 5 days prior** Stop 5 to 7 days prior Step 2. Identify the usual recommendation for stopping the antithrombotic prior to the procedure 1 day = all doses on the calendar day prior to the procedure 24 hours = any dose within 24 hours from the time of the procedure Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions * For patients with additional risk factors for bleeding (e.g., age > 65 years, hypertension, concurrent antiplatelet medication), consider holding dabigatran 120 hours prior to procedure **For patients taking dual antiplatelet therapy (DAPT) with stents in place, ANY interruption in antiplatelets should be coordinated with surgeon, anesthesiologist, the prescribing provider (e.g., cardiologist, neurosurgeon, vascular surgeon); elective noncardiac surgery should be delayed at least 30 days after bare metal stent and at least 6 months after drug-eluting stent ¥ UW Health-specific recommendation based on institutional standards and/or opinion of guideline workgroup members Stopping Warfarin Prior to Procedures 2. For procedures with minimal bleed risk, warfarin may be continued uninterrupted4,5 (CHEST GRADE low certainty of evidence, conditional recommendation) 2.1. For dental procedures, recommend using a pro-hemostatic agent (e.g., tranexamic acid (TXA) mouthwash 2 to 3 times daily, extra sutures, gauze soaked in TXA)4 (CHEST GRADE low certainty of evidence, conditional recommendation) 2.2. For patients having pacemaker or ICD placement procedures, the recommendation to continue warfarin therapy is based on the premise that the INR is < 3.04 (CHEST GRADE moderate certainty of evidence, strong recommendation) 3. For procedures with low/moderate bleed risk, recommend stopping warfarin 5 days prior to the procedure to achieve normal or near-normal INR results4 (CHEST GRADE low certainty of evidence, conditional recommendation) 3.1. Consider holding warfarin for less than 5 days if the procedure can be performed with some residual anticoagulation or if the patient’s INR is below 2.0 prior to stopping warfarin5 4. For procedures with high bleed risk, recommend stopping warfarin 5 days prior to the procedure to achieve normal or near-normal INR results4 (CHEST GRADE low certainty of evidence, conditional recommendation) 4.1. Warfarin may need to be stopped 6 or more days prior to the procedure in select patients in which normalization of INR results is expected to be delayed (e.g., patients with INR > 3.5, elderly patients, patients with genetic polymorphisms expected to delay warfarin metabolism)4 5. For procedures involving neuraxial anesthesia, recommend stopping warfarin 5 or more days prior to the procedure and allowing INR results to normalize6 (ASRA grade 1B) Stopping DOACs Prior to Surgical Procedures 6. For procedures with minimal bleed risk, DOACs may be continued uninterrupted 6.1. May consider withholding DOAC on the day of the procedure to avoid peak anticoagulation effects4,5 7. For procedures with low/moderate bleed risk, recommend stopping DOAC therapy 1 day prior to the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 7.1. For patients taking dabigatran who have CrCl < 50 mL/min, recommend stopping dabigatran 2 days prior to high bleed risk procedures4 8. For procedures with high bleed risk, recommend stopping DOAC therapy 2 days prior to the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 8.1. For patients taking dabigatran who have CrCl < 50 mL/min, recommend stopping dabigatran 4 days prior to high bleed risk procedures4 9. For procedures involving neuraxial anesthesia, consider stopping (non-dabigatran) DOAC therapy 72 hours prior to the procedure6 (ASRA grade 2C) 9.1. For patients taking dabigatran who have CrCl 80 mL/min or greater and no additional risk factors for bleeding (e.g., age > 65 years, hypertension, concomitant antiplatelet medications), consider stopping dabigatran 72 hours prior to procedures involving neuraxial anesthesia (ASRA grade 2C) 9.2. For patients taking dabigatran who have CrCl 50 to 79 mL/min. and no additional risk factors for bleeding, consider stopping dabigatran 96 hours prior to procedures involving neuraxial anesthesia6 (ASRA grade 2C) 9.3. For patients taking dabigatran who have CrCl < 50 mL/min and/or have additional risk factors for bleeding, consider stopping dabigatran 120 hours prior to procedures involving neuraxial anesthesia6 (ASRA grade 2C) Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Stopping Parenteral Anticoagulants Prior to Surgical Procedures 10. For patients receiving therapeutic dose low molecular weight heparin (LMWH), recommend administering the last pre-procedure LMWH dose no less than 24 hours prior to the procedure (CHEST GRADE very low certainty of evidence, conditional recommendation) 10.1. Recommend that the final pre-procedure LMWH dose is half the total daily dose of LMWH, particularly for patients having high bleed risk procedures or procedures involving neuraxial anesthesia4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 11. For patients receiving therapeutic dose IV unfractionated heparin (UFH), recommend stopping UFH at least 4 hours before the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 12. For all other parenteral anticoagulants listed in Table 2 (argatroban, bivalirudin, fondaparinux), recommendations for stopping therapy prior to procedure are approximations of 2 to 3 drug half-lives (for low/moderate bleed risk procedures) or 4 to 5 drug half-lives (for high bleed risk procedures), based on 2019 ISTH recommendations by Spyropoulous et al.5 13. Recommendations listed in Table 2 for stopping parenteral anticoagulants prior to procedures involving neuraxial anesthesia are derived from ASRA 2018 guidelines6 Stopping Antiplatelet Medications Prior to Surgical Procedures Patients taking single antiplatelet therapy 14. For elective non-cardiac procedures with minimal bleed risk, single antiplatelet therapy may be continued uninterrupted4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 15. For elective non-cardiac procedures with low/moderate or high bleed risk 15.1. Recommend continuing ASA therapy uninterrupted4 (CHEST GRADE moderate certainty of evidence, conditional recommendation) 15.1.1. If ASA interruption is required for an elective non-cardiac surgery, recommend stopping ASA 7 days prior to the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 15.2. Recommend stopping clopidogrel 5 days prior to the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 15.3. Recommend stopping ticagrelor 3 to 5 days prior to the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 15.4. Recommend stopping prasugrel 7 days prior to the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) Patients with coronary stents taking dual antiplatelet therapy (DAPT) 16. Elective non-cardiac surgical procedures should be delayed 30 days after bare metal stent (BMS) implantation and optimally 6 months after drug-eluting stent (DES) implantation7 (ACC/AHA Class I, Level B-NR Recommendation) 17. If surgical procedure cannot be delayed or if elective non-cardiac procedure is being considered within first 12 months following DES implantation, recommend communication with Cardiology or Interventional Cardiology for interdisciplinary shared decision making. (UW Health GRADE very low quality of evidence, conditional recommendation) 18. For elective non-cardiac surgical procedures occurring more than 30 days after BMS implantation and more than 6 months after DES implantation, recommend continuing ASA therapy uninterrupted and stopping the P2Y12 inhibitor4,7 (UW Health GRADE very low quality of evidence, conditional recommendation) Patients with non-coronary peripheral stents on DAPT 19. For patients with non-coronary peripheral stents who require continued DAPT (both ASA and a P2Y12 inhibitor), recommend communication with provider managing the stents to determine if safe to interrupt one antiplatelet agent (decision dependent on timing and nature of stents) (UW Health GRADE very low quality of evidence, conditional recommendation) Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions If unable to reach the provider managing the stents, see recommendations above pertaining to coronary stents; similar considerations should apply to most peripheral stents Table 3. Restarting Antithrombotics After Surgical Procedures4,6 Oral Anticoagulant Patient-Specific Criteria Low or Moderate Bleed Risk Procedure High Bleed Risk Procedure Neuraxial Anesthesia6 Warfarin4 Restart within 24 hours post-op Remove neuraxial catheter when INR < 1.5 Apixaban (Eliquis)4 Restart at least 24 hours post-op Restart 48 to 72 hours post-op Restart at least 6 hours after catheter removal Dabigatran (Pradaxa)4 Edoxaban (Savaysa)4 Rivaroxaban (Xarelto)4 Parenteral Anticoagulant Patient-Specific Criteria Low or Moderate Bleed Risk Procedure High Bleed Risk Procedure Neuraxial Anesthesia6 Argatroban¥ Restart at least 24 hours post-op Restart 48 to 72 hours post-op Neuraxial anesthesia not recommended Bivalirudin¥ Restart at least 24 hours post-op Restart 48 to 72 hours post-op Enoxaparin (Lovenox)4 Prophylactic Dose (once daily) Restart at least 12 hours post-op¥ Restart at least 24 hours post-op¥ Restart once-daily prophylactic LMWH at least 12 hours after neuraxial catheter placement and at least 4 hours after catheter removal¥ Prophylactic Dose (twice daily) Restart at least 12 hours post-op¥ Restart at least 24 hours post-op¥ Restart twice-daily prophylactic LMWH no sooner than the day after the procedure, at least 4 hours after catheter was removed Therapeutic Dose Restart at least 24 hours post-op Restart 48 to 72 hours post-op Restart at least 4 hours after neuraxial catheter was removed, and at least 24 hours after catheter was placed Fondaparinux (Arixtra)¥ Restart at least 24 hours post-op Restart 48 to 72 hours post-op Restart at least 6 hours after catheter removal Unfractionated heparin (UFH)4 5000 units BID/TID Restart at least 12 hours post-op¥ Restart at least 24 hours post-op¥ OK to use with indwelling neuraxial catheter; remove indwelling neuraxial catheters 4 to 6 hours after last heparin dose; restart at least 1 hour after catheter removal UFH infusion Restart at least 24 hours post-op; when therapeutic dose UFH is used for bridging therapy, omit bolus dose and start with a lower intensity infusion4 Delay restarting UFH at least 1 hour after needle placement; remove indwelling neuraxial catheters 4 to 6 hours after last UFH dose; restart at least 1 hour after catheter removal Step 3. Identify the usual recommendation for restarting the antithrombotic after the procedure Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Antiplatelet Medication Patient-Specific Criteria Low or Moderate Bleed Risk Procedure High Bleed Risk Procedure Neuraxial Anesthesia6 Aspirin4 Restart within 24 hours post-op Restart 24 hours post-op; neuraxial catheter may be maintained and removed without regard to ASA Cangrelor4 Restart within 4 to 6 hours post-op, continue for a minimum of 48 hours and maximum of 7 days total Restart at least 8 hours after catheter removal Cilostazol (Pletal)¥ Restart within 24 hours post-op Restart at least 6 hours after catheter removal Clopidogrel (Plavix)4 Restart within 24 hours post-op Restart 24 hours post-op, neuraxial catheter may be maintained for 1 to 2 days provided no loading dose is given; if loading dose is planned, wait at least 6 hours after catheter removal Prasugrel4 Restart within 24 hours post-op Restart 24 hours post-op, after neuraxial catheter has been removed (if a loading dose is planned, wait at least 6 hours after catheter removal) Ticagrelor4 Restart within 24 hours post-op Restart 24 hours post-op, after neuraxial catheter has been removed (if a loading dose is planned, wait at least 6 hours after catheter removal) ¥ UW Health-specific recommendation, based on institutional standards and/or expert opinion of guideline workgroup members Restarting Warfarin After Surgical Procedures 20. When warfarin is interrupted for a surgical procedure, recommend resuming warfarin within 24 hours after the procedure4 (CHEST GRADE low certainty of evidence, conditional recommendation) 20.1. Warfarin resumption may need to be delayed in select clinical scenarios (e.g., inadequate procedure-site hemostasis, anticipated need for additional intervention, patient unable to take oral medications)4 20.2. Following a procedure involving neuraxial anesthesia, the neuraxial catheter should be removed when the patient’s INR is < 1.56 21. When warfarin is interrupted for a surgical procedure, recommend resuming warfarin at the patient’s usual dose4 (CHEST GRADE very low certainty of evidence, conditional recommendation) Restarting DOACs After Surgical Procedures 22. Following a procedure with low/moderate bleed risk, recommend resuming DOAC therapy at least 24 hours after the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 23. Following a procedure with high bleed risk, recommend resuming DOAC therapy 48 to 72 hours after the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 24. Following a procedure involving neuraxial anesthesia, restart DOAC therapy at least 6 hours after the neuraxial catheter has been removed6 (ASRA grade 2C) Restarting Parenteral Anticoagulants After Surgical Procedures 25. Following a procedure with low/moderate bleed risk, when therapeutic dose LMWH is being used, recommend administering the first post-procedure LMWH dose at least 24 hours after the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions 26. Following a procedure with high bleed risk, when therapeutic dose LMWH is being used, recommend administering the first post-procedure LMWH dose 48 to 72 hours after the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 26.1. Patients considered high risk for postoperative VTE may receive low-dose LMWH until therapeutic dose LMWH is resumed4 27. When therapeutic dose IV UFH is used for bridging therapy, recommend resuming IV UFH at least 24 hours after the procedure, omitting bolus dosing, and starting with a lower intensity infusion4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 28. For all other parenteral anticoagulants listed in Table 3 (argatroban, bivalirudin, fondaparinux), recommendations for restarting therapy after a procedure are extrapolated from CHEST 2022 guidelines for restarting therapeutic enoxaparin and UFH (waiting at least 24 hours after low/moderate bleed risk procedures and 48 to 72 hours after high bleed risk procedures) 29. Recommendations listed in Table 3 for restarting parenteral anticoagulants following procedures involving neuraxial anesthesia are derived from ASRA 2018 guidelines6, except where noted to be UW Health-specific recommendations based on institutional standards and/or expert opinion of guideline workgroup members Restarting Antiplatelet Medications After Surgical Procedures 30. When antiplatelet therapy is interrupted for an elective surgical procedure, recommend resuming antiplatelet medications within 24 hours after the procedure4 (CHEST GRADE very low certainty of evidence, conditional recommendation) 31. When ASA or P2Y12 inhibitor therapy is interrupted for CABG surgery, recommend resuming the ASA or P2Y12 inhibitor within 24 hours after the procedure4 (CHEST GRADE low certainty of evidence, conditional recommendation) 31.1. Antiplatelet therapy resumption may need to be delayed in patients who develop post-CABG thrombocytopenia (PLT < 50,000 x 109/L)4 32. Recommendations listed in Table 3 for restarting antiplatelet medications following procedures involving neuraxial anesthesia are derived from ASRA 2018 guidelines6 Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Figure 1. Is Bridging Therapy Usually Recommended?4,8 Warfarin DOAC • Apixaban • Dabigatran • Edoxaban • Rivaroxaban Parenteral Anticoagulant • Argatroban • Bivalirudin • Enoxaparin • Fondaparinux • Unfractionated heparin Antiplatelet Medication • Aspirin • Clopidogrel • Dipyridamole • Prasugrel • Ticagrelor Bridging is NOT recommended What is the TE risk of the patient s indication? Which type of antithrombotic is the patient taking? Bridging is NOT recommended, but may be considered on a case-by-case basis for select high-risk individuals with coronary stents in a critical location, placed within the past 3 months when surgical procedure cannot be delayed See Appendix B Bridging is NOT recommended for low and moderate TE risk indications Bridging therapy is recommended for high TE risk indications See Appendix A Step 4. Determine if bridging therapy is usually recommended Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Bridging Therapy for Patients Taking Warfarin 33. For patients taking warfarin for atrial fibrillation, recommend against bridging therapy, except in select individuals at high risk for TE included in Figure 14 (CHEST GRADE moderate certainty of evidence, strong recommendation) 34. For patients taking warfarin for venous thromboembolism (VTE), recommend against bridging therapy, except in select individuals at high risk for TE included in Figure 14 (CHEST GRADE very low certainty of evidence, conditional recommendation) 35. For patients taking warfarin for a mechanical heart valve, recommend against bridging therapy, except in select individuals at high risk for TE included in Figure 14 (CHEST GRADE very low certainty of evidence, conditional recommendation) 36. For patients identified in Figure 1 as high risk for TE who require warfarin interruption for an elective procedure, recommend bridging therapy4 (CHEST GRADE very low certainty of evidence, conditional recommendation) How to bridge a warfarin patient 37. If bridging therapy is indicated, select the bridging therapy medication and identify the appropriate dose 37.1. Enoxaparin is frequently the drug of choice for bridging warfarin patients, because it has similar efficacy to unfractionated heparin and subcutaneous (SQ) injections may be self- administered in the ambulatory setting (UW Health GRADE very low quality of evidence, conditional recommendation) 37.1.1. The preferred dose of enoxaparin when used as bridging therapy is 1 mg/kg SQ every 12 hours, dose rounded to the nearest prefilled syringe strength 37.1.2. Patients with a CrCl < 30 mL/min should receive enoxaparin 1 mg/kg SQ every 24 hours, or may be admitted for unfractionated heparin (UFH) bridging 37.1.2.1. For patients on dialysis who require bridging anticoagulation, consider hospital admission for UFH bridging 37.1.3. Once daily enoxaparin (1.5 mg/kg SQ every 24 hours) is not preferred due to less desirable pharmacokinetics (i.e., higher peaks, lower troughs) and less clinical data, but may be considered in patients who are unable to receive twice daily SQ injections 37.1.4. Prophylactic dose enoxaparin (e.g., 40 mg SQ once daily, etc.) is not dosed to prevent ATE complications, but may be used to help prevent VTE following high VTE risk procedures4 37.2. UFH may be used for patients with severe renal impairment/dialysis or those requiring more rapid onset/offset of anticoagulant activity. Therapeutic dose UFH requires continuous infusion and is not suitable for most non-hospitalized patients. See UW Health Guidelines for Therapeutic Dosing of Unfractionated Heparin. (UW Health GRADE very low quality of evidence, conditional recommendation) 37.3. Fondaparinux may be an option for patients with an allergy/intolerance to heparin products but has not been well studied as bridging therapy. Its long half-life requires that it be stopped 3 or more days prior to procedure (see Table 2), making its use as a pre-procedure bridging therapy impractical but might be considered for post-procedure bridging therapy. (UW Health GRADE very low quality of evidence, conditional recommendation) 37.4. DOACs may affect INR results and have not been studied as bridging therapy for patients taking warfarin; recommend against using DOACs as bridging therapy (UW Health GRADE very low quality of evidence, conditional recommendation) 38. Start the bridging therapy medication when the INR is either known or expected to be subtherapeutic, typically following two held doses of warfarin (UW Health GRADE very low quality of evidence, conditional recommendation) 39. Stop the bridging therapy medication prior to the procedure based on information in Table 2 40. Restart the bridging therapy medication after the procedure when adequate hemostasis is achieved and based on information in Table 3 41. Continue the bridging therapy medication concomitantly with warfarin until the patient’s INR is known or expected to be 2.0 or higher, then stop the bridging therapy medication (UW Health GRADE very low quality of evidence, conditional recommendation) Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions 41.1. It may take 5 to 10 days after resuming warfarin for most patients to achieve an INR result of 2.0 or higher 42. See Appendix A for examples of typical bridge therapy plans for warfarin patients Bridging Therapy for Patients Taking DOACs 43. The rapid onset and offset of DOAC activity negate the need for bridging therapy in a periprocedural setting4 (CHEST GRADE very low certainty of evidence, conditional recommendation) Bridging Therapy for Patients Taking Antiplatelet Medications 44. When antiplatelet therapy is interrupted for a surgical procedure in patients with coronary stents, recommend against routine bridging therapy with a glycoprotein IIb-IIIa inhibitor, cangrelor, or LMWH (CHEST GRADE low certainty of evidence, conditional recommendation) 44.1. Bridging therapy may be considered in select high-risk patients (e.g., patients with a coronary stent in a critical location placed within the past 3 months)4 45. See Appendix B for additional considerations regarding use of cangrelor as bridging therapy 46. Consider the patient’s unique bleeding risk factors and the patient’s history of bleeding and thromboembolic (TE) complications with previous invasive procedures; individualize recommendations as appropriate4 (UW Health GRADE very low quality of evidence, conditional recommendation) 47. Consider the unique bleeding and TE risks of the procedure; revise recommendations as appropriate4 (UW Health GRADE very low quality of evidence, conditional recommendation) 48. Review recommendations with other members of the patient’s healthcare team and the patient (or patient’s representative)4 (UW Health GRADE very low quality of evidence, conditional recommendation) 48.1. Other members of the healthcare team include, but are not limited to the proceduralist and the provider or anticoagulation clinic managing the patient’s antithrombotic therapy 49. Utilize shared decision-making, including the patient’s values and preferences, cost, and feasibility to arrive at a final recommendation (UW Health GRADE very low quality of evidence, conditional recommendation) 50. Provide clear written (paper or electronic) instructions to the patient (or patient’s representative)4 (UW Health GRADE very low quality of evidence, conditional recommendation) 51. Document the plan in the patient’s electronic medical record (UW Health GRADE very low quality of evidence, strong recommendation) 52. After the procedure, assess for the occurrence of bleeding or TE complications and revise the post- procedure antithrombotic therapy plan if necessary (UW Health GRADE very low quality of evidence, conditional recommendation) 53. Contact the patient (or patient’s representative) to clarify whether/how to modify the post-procedure antithrombotic therapy plan and confirm understanding of instructions (UW Health GRADE very low quality of evidence, conditional recommendation) Step 5. Individualize Recommendations Step 6. Communicate and Document Plan Step 7. Revisit the plan after the procedure and revise as necessary Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Disclaimer Consensus care models assist clinicians by providing a framework for the evaluation and treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem. Content Expert(s): Name: Anne Rose, PharmD – Pharmacy Email Address: arose@uwhealth.org Contact for Changes: Drug Policy Program Email Address: DrugPolicyProgram@uwhealth.org Guideline Author(s): Name: Anne Rose, PharmD – Pharmacy Email Address: arose@uwhealth.org Name: Erin Robinson, PharmD – Drug Policy Program Email Address: erobinson@uwhealth.org Reviewer(s): Deepak Gopal, MD – Department of Medicine, Gastroenterology Vanessa Grapsas, PharmD – Pharmacy Lisa Klesius, MD – Anesthesiology Jennifer Lai, PharmD - Pharmacy Anne O’Connor, MD – Department of Medicine, Cardiology Kevin Patel, MD – Department of Medicine, Gastroenterology Gregory Tester, MD – Department of Medicine, Cardiology Philip Trapskin, PharmD – Drug Policy Program Committee Approval(s): Ambulatory Anticoagulation Committee: Jan 2023 Inpatient Anticoagulation Committee: Jan 2023 Pharmacy & Therapeutics Committee: • Original: 2011 • Revisions: 2013, 2015, 2019, 2023 Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Methodology Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations: Recommendations developed by external organizations maintained the evidence grade assigned within the original source document and were adopted for use at UW Health. Internally developed recommendations, or those adopted from external sources without an assigned evidence grade, were evaluated by the guideline workgroup using an algorithm adapted from the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology (see Figure 2). Figure 2. GRADE Methodology Adapted by UW Health GRADE Ranking of Evidence (used by UW Health and CHEST) High We are confident that the effect in the study reflects the actual effect. Moderate We are quite confident that the effect in the study is close to the true effect, but it is also possible it is substantially different. Low The true effect may differ significantly from the estimate. Very Low The true effect is likely to be substantially different from the estimated effect. GRADE Ratings for Recommendations for or Against Practice (used by UW Health and CHEST) Strong (S) Generally, should be performed (i.e., the net benefit of the treatment is clear, patient values and circumstances are unlikely to affect the decision.) Conditional (C) May be reasonable to perform (i.e., may be conditional upon patient values and preferences, the resources available, or the setting in which the intervention will be implemented.) American Society of Regional Anesthesia and Pain Level of Evidence Grading: Strength of Recommendation (used by ASRA) Grade 1 General agreement on the efficacy Grade 2 Conflicting evidence or opinion on the usefulness Grade 3 May not be useful (and possibly harmful) Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Quality of Evidence (used by ASRA) A Level Randomized clinical trials, meta-analyses, or observational/epidemiologic series yielding very large risk reduction B Level Observational or epidemiologic series C Level Case reports or expert opinion American College of Cardiology (ACC)/American Heart Association (AHA) Level of Evidence Grading: Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Collateral Tools & Resources Metrics • % patients appropriately selected to receive bridge therapy • Incidence of thromboembolic events up to 30 days after procedure • Incidence of bleeding events up to 30 days after procedure • % patients with appropriate hold time of antithrombotic in relation to procedure or neuraxial catheter placement or removal • Incidence of inappropriate administration of antithrombotic medications during neuraxial catheter placement Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Appendix A. Examples of Warfarin Bridging with Enoxaparin Assumptions: • Warfarin is being taken in the evening and is being held x 5 days prior to an outpatient procedure • The patient has been deemed high risk for TE complications • The patient’s CrCl > 30 mL/min • Enoxaparin dose = 1 mg/kg SQ every 12 hours, rounded to nearest commercially available strength Low/Moderate Bleed Risk Procedure Example Bridge Plan Date Enoxaparin AM Enoxaparin PM Warfarin Notes Pre-Procedure Day -5 Hold Hold Hold Pre-Procedure Day -4 Hold Hold Hold Pre-Procedure Day -3 *** mg *** mg Hold Pre-Procedure *** mg *** mg Hold Day - 2 Pre-Procedure Day -1 *** mg Hold Hold Procedure Day Hold Hold *** mg (*** tablets) After your procedure, ask your proceduralist if it is safe to restart warfarin and enoxaparin at the times listed Post Procedure Day 1 Hold *** mg *** mg (*** tablets) Post Procedure Day 2 *** mg *** mg *** mg (*** tablets) Post Procedure Day 3 *** mg *** mg *** mg (*** tablets) Post Procedure Day 4 *** mg *** mg *** mg (*** tablets) Post Procedure Day 5 *** mg To Be Determined To Be Determined Check INR KEY Dark gray shaded cells: no doses administered Unshaded cells: doses administered Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions High Bleed Risk Procedure Example Bridge Plan Date Enoxaparin AM Enoxaparin PM Warfarin Notes Pre-Procedure Day -5 Hold Hold Hold Pre-Procedure Day -4 Hold Hold Hold Pre-Procedure Day -3 *** mg *** mg Hold Pre-Procedure *** mg *** mg Hold Day - 2 Pre-Procedure Day -1 *** mg Hold Hold Procedure Day Hold Hold *** mg (*** tablets) After your procedure, ask your proceduralist if it is safe to restart warfarin and enoxaparin at the times listed Post Procedure Day 1 Hold Hold *** mg (*** tablets) Post Procedure Day 2 Hold Hold vs *** mg *** mg (*** tablets) Post Procedure Day 3 Hold vs *** mg *** mg *** mg (*** tablets) Post Procedure Day 4 *** mg *** mg *** mg (*** tablets) Post Procedure Day 5 *** mg To Be Determined To Be Determined Check INR KEY Dark gray shaded cells: no doses administered Diagonal line shaded cells: determine whether to administer doses based on bleeding risk Unshaded cells: doses administered Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Appendix B. Considerations for Antiplatelet Bridging With Cangrelor National Guidelines4 CHEST Guidelines 2022: Perioperative Management of Antithrombotic Therapy Guidance Statement 39: “In patients with coronary stents who require interruption of antiplatelet drugs for an elective surgery/procedure, we suggest against routine bridging therapy with a glycoprotein IIb-IIIa inhibitor, cangrelor, or LMWH over routine use of bridging therapy (Conditional recommendation, low certainty of evidence) Guideline implementation considerations: • A bridging approach may be considered in selected high-risk patients, for example in those with a recent (within 3 months) coronary stent in a critical location.” Cangrelor Drug Information Mechanism of Action Cangrelor is a reversible ultra-shorting-acting direct P2Y12 inhibitor Time to Peak Within 2 minutes Half-Life of Elimination ~ 3 to 6 minutes Bridging Therapy Dose (Off-Label Use)4,9,10 • Routine use not suggested • Consult UW Health Interventional Cardiology prior to initiating cangrelor as bridging therapy • UW Health restricts cangrelor use to high-risk patients with cardiac stents placed in the previous 6 to 12 months who require surgical intervention with interruption in thienopyridine therapy • Continue low dose ASA throughout • Prior to the procedure: o Start cangrelor 48 to 72 hours after oral P2Y12 inhibitor discontinuation¥ o Dose = 0.75 mg/kg/minute IV continuous infusion o STOP cangrelor 1 to 3 hours prior to the procedure¥ • 1 to 6 hours after the procedure, when adequate hemostasis is achieved: o Can the patient take oral medications? ▪ If Yes → restart oral P2Y12 inhibitor including an oral loading dose • Clopidogrel preferred over prasugrel or ticagrelor due to lower bleeding risk ▪ If No → restart cangrelor infusion and continue for a minimum of 48 hours and maximum of 7 days total • When able to tolerate oral medications, STOP cangrelor immediately prior to restarting oral P2Y12 inhibitor including an oral loading dose o Clopidogrel preferred over prasugrel or ticagrelor due to lower bleeding risk ¥ UW Health-specific recommendation, based on institutional standards and/or expert opinion of guideline workgroup members Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions Appendix C. Holding Antithrombotics for Outpatient Endoscopy Procedures How to Use this Appendix This appendix provides additional details regarding how UW Digestive Health Center (DHC) providers categorize the bleeding risk of specific outpatient endoscopic procedures, and their corresponding recommendations for stopping oral antithrombotics prior to the procedure. This appendix is meant to facilitate communication of recommendations between DHC providers and providers managing the patient’s antithrombotic therapy. Outpatient Endoscopic Procedure Bleeding Risk Categories4,11 MINIMAL BLEED RISK 30 day bleed risk: ~0% LOW/MODERATE BLEED RISK 30 day bleed risk: 0-2% HIGH BLEED RISK 30 day bleed risk: > 2% • Video capsule endoscopy • Argon plasma coagulation (APC) • Balloon dilation of luminal stenoses • Colonoscopy +/- biopsy • Enteral stent deployment • Esophagogastroduodenoscopy (EGD) +/- biopsy • Flexible sigmoidoscopy +/- biopsy • Marking (including clipping, electrocoagulation, tattooing) • Push enteroscopy and diagnostic balloon-assisted enteroscopy • Ampullary resection • Colonic polyp resectiona • Cystogastrostomy • Endoscopic hemostasis (excluding argon plasma coagulation) • Endoscopic mucosal resection (EMR)/ endoscopic submucosal dissection (ESD) • Endoscopic retrograde cholangiopancreatography (ERCP)b • Endoscopic ultrasound (EUS) with fine needle aspiration (FNA)c • Laser ablation and coagulation • Percutaneous endoscopic gastrotomy (PEG) placement • Percutaneous endoscopic jejunostomy (PEJ) placement • Peroral endoscopic myotomy (POEM) • Pneumatic or bougie dilation for achalasia or esophageal strictures • Radiofrequency ablation • Therapeutic balloon-assisted enteroscopy • Treatment of varices (including variceal band ligation) • Tumor ablation aPolypectomy < 1 cm may be considered low/moderate bleed risk; polyp size may not be known prior to procedure bERCP without sphincterotomy may be considered low/moderate bleed risk cEUS without FNA may be considered low/moderate bleed risk Step 1. Identify the bleeding risk category of the patient’s procedure Step 2. Identify the recommendation for stopping the antithrombotic prior to the procedure Step 3. The provider managing the antithrombotic therapy should determine whether they agree with the DHC recommendations for stopping antithrombotics prior to the procedure, based on their knowledge of the patient’s thromboembolic risk and past medical history • If Yes → please confirm instructions with the patient or their caregiver • If No (or if further discussion is needed) → please contact DHC at 608-890-5000 or (for UW Health providers) via Health Link In Basket: DHC ENDOSCOPY CLINICAL ALL Step 4. Decisions about restarting antithrombotic therapy after the procedure should be made by the provider managing the antithrombotic therapy; DHC providers may provide updated post-procedure instructions, based on what occurred during the procedure Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions When to Stop Oral Antithrombotics Prior to Procedure4,5 • For minimal bleed risk procedures, antithrombotics may be continued uninterrupted • For low/moderate bleed risk and high bleed risk procedures, see recommendations below • This table is not all-inclusive; for more information, see Step 2 of the full guideline Antithrombotic Medication Patient-Specific Criteria Low/Moderate Bleed Risk Procedure High Bleed Risk Procedure Warfarin (Coumadin) INR 2.0-3.5 Stop 5 days prior INR > 3.5 Stop 6 or more days prior Apixaban (Eliquis) Stop 1 day prior Stop 2 days prior Dabigatran (Pradaxa) CrCl ≥ 50 ml/min Stop 1 day prior Stop 2 days prior CrCl < 50 ml/min Stop 2 days prior Stop 4 days prior Edoxaban (Savaysa) Stop 1 day prior Stop 2 days prior Rivaroxaban (Xarelto) Stop 1 day prior Stop 2 days prior Aspirin (ASA) Continue ASA uninterrupted Cilostazol (Pletal) Stop 1 to 2 days prior Clopidogrel (Plavix) Stop 5 days priord Prasugrel (Effient) Stop 7 days priord Ticagrelor (Brilinta) Stop 5 days priord d For patients taking dual antiplatelet therapy (DAPT) with stents in place, ANY interruption in antiplatelets should be coordinated between the proceduralist, anesthesiologist (if applicable), and the prescribing provider (e.g., cardiologist, neurosurgeon, vascular surgeon); elective procedures should be delayed at least 30 days after bare metal stent and at least 6 months after drug-eluting stent 1 day = all doses on the calendar day prior to the procedure Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions References 1. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2 Suppl):e326S-e350S. doi:10.1378/chest.11-2298 2. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. Aug 27 2015;373(9):823-33. doi:10.1056/NEJMoa1501035 3. Kovacs MJ, Wells PS, Anderson DR, et al. Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): double blind randomised controlled trial. BMJ. 2021:n1205. doi:10.1136/bmj.n1205 4. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;doi:10.1016/j.chest.2022.07.025 5. Spyropoulos AC, Brohi K, Caprini J, et al. Scientific and Standardization Committee Communication: Guidance document on the periprocedural management of patients on chronic oral anticoagulant therapy: Recommendations for standardized reporting of procedural/surgical bleed risk and patient‐specific. Journal of Thrombosis and Haemostasis. 2019;17(11):1966-1972. doi:10.1111/jth.14598 6. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med. Apr 2018;43(3):263-309. doi:10.1097/aap.0000000000000763 7. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. Sep 6 2016;68(10):1082-115. doi:10.1016/j.jacc.2016.03.513 8. Corrigendum to: CHEST. 2022;162(5):e207-e243. CHEST. 2023;164(1):267. doi:10.1016/j.chest.2023.05.019 9. Rossini R, Masiero G, Fruttero C, et al. Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience. TH Open. 2020;04(04):e437- e445. doi:10.1055/s-0040-1721504 10. Angiolillo DJ, Rollini F, Storey RF, et al. International Expert Consensus on Switching Platelet P2Y ₁₂ Receptor–Inhibiting Therapies. Circulation. 2017;136(20):1955-1975. doi:10.1161/circulationaha.117.031164 11. Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol. Apr 1 2022;117(4):542-558. doi:10.14309/ajg.0000000000001627 Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 08/2023 Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions