Nick Malden1. 1. Department of Oral Surgery, University of Edinburgh, Edinburgh Dental Institute, Edinburgh, UK.
Abstract
DATA SOURCES: Medline provided the primary data source with references from identified articles being reviewed for additional studies. The Cochrane Collaboration database was also searched and a search performed of cited references. STUDY SELECTION: Clinical studies, in English, examining perioperative management of patients receiving long-term oral anticoagulant (OAC) therapy were selected. DATA EXTRACTION AND SYNTHESIS: Data were extracted regarding management strategy, thrombo-embolic events and bleeding complications, and type of surgical or invasive procedure. Event rates were reported as number of patients experiencing the event divided by number of patients at risk. Binomial and Poisson distributions were used to calculate 95% confidence intervals (CI). RESULTS: A total of 31 reports were identified and concluded to be of generally poor quality. For studies reporting thrombo-embolic events, 29 events occurred in 1868 patients (1.6%; 95% CI, 1.0-2.1) of which seven were strokes (0.4%; 95% CI, 0.0-0.7). Major bleeding while receiving OAC was reported to be rare for dental procedures (occurring in four out of 2014 individuals), arthrocentesis (in none out of 32), cataract surgery (none out of 203), and upper endoscopy or colonoscopy with or without biopsy (no occurrences in 111 patients). For the other invasive and surgical procedures reviewed, OAC needs to be withheld and a suitable personalised perioperative management strategy instigated. A guideline, based on the limited evidence available, for the perioperative management of anticoagulation for procedures requiring discontinuation of OAC is presented. CONCLUSIONS: Certain surgical or invasive procedures can be undertaken in patients who are taking OAC therapy without alteration of their regimen. For procedures requiring discontinuation of OAC, personalised management strategies are required. More rigorous studies are needed to better inform this debate.
DATA SOURCES: Medline provided the primary data source with references from identified articles being reviewed for additional studies. The Cochrane Collaboration database was also searched and a search performed of cited references. STUDY SELECTION: Clinical studies, in English, examining perioperative management of patients receiving long-term oral anticoagulant (OAC) therapy were selected. DATA EXTRACTION AND SYNTHESIS: Data were extracted regarding management strategy, thrombo-embolic events and bleeding complications, and type of surgical or invasive procedure. Event rates were reported as number of patients experiencing the event divided by number of patients at risk. Binomial and Poisson distributions were used to calculate 95% confidence intervals (CI). RESULTS: A total of 31 reports were identified and concluded to be of generally poor quality. For studies reporting thrombo-embolic events, 29 events occurred in 1868 patients (1.6%; 95% CI, 1.0-2.1) of which seven were strokes (0.4%; 95% CI, 0.0-0.7). Major bleeding while receiving OAC was reported to be rare for dental procedures (occurring in four out of 2014 individuals), arthrocentesis (in none out of 32), cataract surgery (none out of 203), and upper endoscopy or colonoscopy with or without biopsy (no occurrences in 111 patients). For the other invasive and surgical procedures reviewed, OAC needs to be withheld and a suitable personalised perioperative management strategy instigated. A guideline, based on the limited evidence available, for the perioperative management of anticoagulation for procedures requiring discontinuation of OAC is presented. CONCLUSIONS: Certain surgical or invasive procedures can be undertaken in patients who are taking OAC therapy without alteration of their regimen. For procedures requiring discontinuation of OAC, personalised management strategies are required. More rigorous studies are needed to better inform this debate.