2012 ACCP Periprocedure anticoagulation guidelines

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Bleeding risk and surgery type:
Yes
	Minor: dental including "tooth extractions and endodontic (root canal) procedures"(2012 Rec 4.4)?
	Minor: dermatologic including "excision of basal and squamous cell skin cancers, actinic keratoses, and premalignant or cancerous skin nevi"(2012 Rec 4.4)?
	Minor: cataract(2012 Rec 4.4)?
	High risk: urologic surgery; "pacemaker or implantable cardioverter-defibrillator device"; "colonic polyp resection, typically of large (ie, > 1-2 cm long) sessile polyps"; "Surgery and procedures in highly vascular organs, such as the kidney, liver, and spleen"; "Cardiac, intracranial, or spinal surgery, especially as small pericardial, intracerebral, or epidural bleeds can have serious clinical consequences" (2012 Rec 4.4)?
	None of the above

Indication for VKA Therapy:
	Mechanical Valve	A-fib	VTE
High	Any mitral valve prosthesis Any caged-ball or tilting disc aortic valve prosthesis Recent (within 6 mo) stroke or transient ischemic attack	CHADS2 score of 5 or 6 Recent (within 3 mo) stroke or transient ischemic attack Rheumatic valvular heart disease	VTE within 3 mo Severe thrombophilia (eg, deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)
Moderate	Bileaflet aortic valve prosthesis and one or more of the of following risk factors: atrial fibrillation, prior stroke or transient ischemic attack, hypertension, diabetes, congestive heart failure, age > 75 y	CHADS2 score of 3 or 4	VTE within the past 3-12 mo Nonsevere thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation) Recurrent VTE Active cancer (treated within 6 mo or palliative)
Low	Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke	CHADS2 score of 0 to 2 (assuming no prior stroke or transient ischemic attack)	VTE > 12 mo previous and no other risk factors
"High-risk patients may also include those with a prior stroke or transient ischemic attack occurring > 3 mo before the planned surgery and a CHADS2 score < 5, those with prior thromboembolism during temporary interruption of VKAs, or those undergoing certain types of surgery associated with an increased risk for stroke or other thromboembolism (eg, cardiac valve replacement, carotid endarterectomy, major vascular surgery)."

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Additional considerations for this patient

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References

American College of Chest Physicians

Douketis JD at 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 Feb;141(2 Suppl):e326S-e350S. doi: 10.1378/chest.11-2298. Erratum in: Chest. 2012 Apr;141(4):1129. PMID: 22315266 PMCID: PMC3278059.
Douketis JD 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. PMID: 22315266 PMCID: PMC3278059.
Douketis JD et al; American College of Chest Physicians. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):299S-339S. doi: 10.1378/chest.08-0675. PMID: 18574269.
Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):204S-233S. Erratum in: Chest. 2005 Jan;127(1):415-6. Dosage error in article text. PMID: 1538347

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