2017-18 HSC Section 3 Green Book

Otolaryngology–Head and Neck Surgery 153(4)

doses (81 mg), can be safely continued perioperatively. Guidelines for timing interruption of therapy are discussed in detail above. The management of perioperative antithrombotic agents in patients on long-term therapy must be individualized. The paucity of prospective data on the bleeding risk in otolaryn- gologic procedures has necessitated the use of nonspecialty specific bleeding risk thresholds, such as the 1.5% cutoff cited in this study. Although we present several recommenda- tions related to the management of perioperative antithrom- botic therapy in otolaryngology patients, these are not intended to act as clinical guidelines, and their use must be coupled with sound clinical judgment. In particular, the oto- laryngologist must consider the potential consequences of a perioperative hemorrhage—even if such hemorrhage is deemed unlikely—and balance this against the risk of throm- bosis in the individual patient. Because definitive guidelines cannot be established on the basis of presently available data, it is critical to involve patients in the decision-making process after discussing the risk-benefit balance. 119 Overall, the recommendations above cannot substitute for appropriate patient-centered clinical judgment about perioperative antithrombotic management but should instead be used to facilitate a critical discussion between surgical and medical care providers regarding the management of a patient’s antithrombotic regimen. In the future, the publica- tion of prospective studies quantifying bleeding risks and complications in specific otolaryngologic procedures may allow for the establishment of definitive clinical guidelines. Author Contributions Wayne D. Hsueh, review concept and design, drafting of manu- script; Peter H. Hwang, review concept and design, critical revi- sion; Waleed M. Abuzeid, review concept and design, drafting of manuscript, critical revision. Disclosures Competing interests: Peter H. Hwang, Medtronic (consultant), Sinuwave (consultant), Intersect (consultant), Xoran (consultant). Sponsorships: None. Funding source: None. 1. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest . 2008;133(6):299S-339S. 2. Gage BF, Waterman AD, Shannon W, et al. Validation of clin- ical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA . 2001;285: 2864-2870. 3. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboem- bolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest . 2010;137(2):263-272. References

4. Cannegieter SC, Rosendaal FR, Briet E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation . 1994;89:635-641. 5. Hering D, Piper C, Bergemann R, et al. Thromboembolic and bleeding complications following St Jude Medical valve replacement: results of the German Experience With Low- Intensity Anticoagulation Study. Chest . 2005;127:53-59. 6. 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 . 2012;141(2):e326S-e3250S. 7. Healey JS, Eikelboom J, Douketis J, et al. Periprocedural bleeding and thromboembolic events with dabigatran com- pared with warfarin: results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) randomized trial. Circulation . 2012;126:343-348. 8. Go AS, Hylek EM, Chang Y, et al. Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do rando- mized trials translate into clinical practice? JAMA . 2003;290: 2685-2692. 9. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery; Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J . 2010;31: 2369-2429. 10. Le Tourneau T, Lim V, Inamo J, et al. Achieved anticoagula- tion vs prosthesis selection for mitral mechanical valve replacement: a population-based outcome study. Chest . 2009; 136:1503-1513. 11. Heras M, Chesebro JH, Fuster V, et al. High risk of throm- boemboli early after bioprosthetic cardiac valve replacement. J Am Coll Cardiol . 1995;25(5):1111-1119. 12. Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic ther- apy and prevention of thrombosis, 9th ed. American College of Chest Physicians evidence-based clinical practice guide- lines. Chest . 2012;141(2):e576S-e600S. 13. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation . 2008;118:e523-e661. 14. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J . 2012;33:2451-2496. 15. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic ther- apy for VTE disease: antithrombotic therapy and prevention of

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