2022 Updated American College CHEST Guidelines Anticoagulation for Patients

The American College of Chest Physicians (CHEST) has announced the updated clinical guidelines for the management of perioperative antithrombotic therapy. According to chest guidelines anticoagulation shared on August 11, 44 recommendations were included which depended on evidence-based perioperative management therapy.

The CHEST guidelines anticoagulation was launched with the intent to replace the original organizational guidelines shared in 2012 for the same topic.

According to the guidelines;

“For perioperative antithrombotic management, it’s very important to have standardized approaches and protocols to limit variability in practice and, in turn, to minimize preventable bleeding and thrombotic events. Until now, guidance for clinicians was available only in a piecemeal approach—related to specific clinical areas—whereas the CHEST guidelines provide a ‘one-stop’ comprehensive and definitive compilation of evidence to inform best practices in perioperative anticoagulant and antiplatelet management,” said the leader of the guideline writing committee James D. Douketis, MD, a staff physician in Vascular Medicine and General Internal Medicine at St. Joseph’s Healthcare Hamilton, in a statement. “These guidelines are also practical, providing clinicians with ‘how to’ approaches for managing patients on warfarin, DOACs, and antiplatelet drugs who are undergoing a wide array of surgeries and procedures as well as those who may need heparin bridging.”

Connected 43 population, intervention, comparator, and outcome (PICO) questions by Douketis and other 13 multidisciplinary writing committees. These questions were compared with 11 PICO questions asked previously on the 2012 guideline.

In these guidelines, the CHEST panel discusses the questions regarding the issue of using new agents in the 2012 market that are used commonly in 2022. These agents include direct oral anticoagulants (DOACs), antiplatelet drugs, and vitamin K anticoagulants.

The guidelines are further divided into four categories that break down the patient management system into specified groups. These groups are defined by the use of agents like

  • Use of Perioperative heparin bridging
  • Use of Vitamin K antagonist
  • Use of DOACs
  • Use of the antiplatelet drug

According to the data focused on those 43 PICO questions mentioned above, CHEST recommended guidelines have been graded into different grades according to very low, low, and moderate evidence certainty for clinical guideline practice and methodology of GRADE – Grading of Recommendations, Assessments, Development, and Evaluation.

The newly announced guidelines from CHEST highlighted six guideline recommendations;

  • It is strongly recommended that in-patients that go through atrial fibrillation where it is required to receive VKA therapy with VKA interruption with the elective procedure, the guideline suggests it against heparin bridging.
  • Secondly, the in-patients receiving VKA therapy requiring ICD implantation or pacemaker, according to the guidelines, it is strongly recommended that they should continue using VKA therapy over heparin bridging and VKA interruption.
  • Thirdly, the guidelines conditionally recommend heparin bridging for those in-patients prescribed with VKA therapy for VTA or mechanical heart valve with the requirement of VKA interruption for an elective procedure.
  • The guidelines conditionally recommend against heparin bridging for in-patient treatment who receive VKA therapy and are required colonoscopy for VKA interruption with anticipated polypectomy.
  • In addition, the guidelines conditionally recommend stopping DOAC (apixaban, edoxaban, dabigatran, and rivaroxaban) before the elective procedure or surgery for one or two days (and one to four days dabigatran) over apixaban continuation.
  • Plus, postoperative guidelines measures suggest resuming DOAC within 24 hours when the in-patient has low or moderate bleeding risk after the procedure and take 48-72 hours when the in-patient has a high level of bleeding risk procedure or surgery.
  • Lastly, in-patients taking acetylsalicylic acid (ASA) are supposed to undergo noncardiac elective surgery, the guidelines conditionally suggest ASA continuation against ASA interruption.

These guidelines suggested by CHEST contain recommendations separately for the preoperative patient management who are or will be undergoing compromising dental, ophthalmological, ICD/pacemaker implantation, dermatological, gastrointestinal, or any other minor surgery or procedures.

For in-patients having absent proximal DVT or PE – subsegmental pulmonary embolism in their legs along with low risk for recurrent VTE, the guideline strongly suggests them to employ clinical surveillance over anticoagulation. Although, anticoagulation is also similar and suggested to use over clinical surveillance on patients with higher risks of VTE.

To conclude, the guidelines suggested by CHEST strongly recommend for in-patients with cerebral venous sinus thrombosis and anticoagulant provision for three months of the first treatment phase. In accordance with the guidelines writing committee, these recommendations are applied to in-patients associated with or without intracranial hemorrhage related to CVT.