Gestion des anticoagulants pour une procédure invasive programmée

Objectif : To update the previous guidelines on the management of oral anticoagulants in patients undergoing elective invasive procedures.

Conception : A consensus committee of 100 experts from the French Working Group on Perioperative Haemostasis (GIHP), the French Society of Anaesthesia and Intensive Care (SFAR) and 30 surgical and procedural specialty societies was convened. A formal conflict-of-interest policy was developed at the outset and enforced throughout the process, which was conducted independently of any industrial funding. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to guide assessment of the quality of evidence.

Méthodes : The experts studied questions within 2 fields and 11 domains. Each question was formulated according to the PICO (Patients, Intervention, Comparison, Outcome) model, and evidence profiles were produced. An extensive literature review and the formulation of recommendations were carried out according to the GRADE methodology, while surgical and procedural specialty societies classified invasive procedures according to their bleeding risk. Each recommendation was graded as strong (GRADE 1) or optional (GRADE 2) based on the overall level of evidence, or formulated as expert opinion when evidence was lacking. Recommendations were validated by a vote of 36 experts; strong agreement required ≥70% approval with <20% opposition.

Résultats : 62 recommendations addressing 11 clinical questions were formulated, covering the determinants of perioperative anticoagulant management, interruption and resumption of vitamin K antagonists and direct oral anticoagulants according to bleeding risk, heparin bridging in atrial fibrillation, mechanical heart valves and venous thromboembolism, left ventricular assist devices, perioperative stroke, chronic kidney disease, and extremes of body weight. Of these, 9 were graded strong (GRADE 1), 43 optional (GRADE 2), and 10 as expert opinion.

Conclusion : Strong agreement was reached among experts for all recommendations aimed at improving the management of oral anticoagulants in patients undergoing elective invasive procedures.