Dr. Daniela Poli, Azienda Ospedaliera Universitaria Careggi, Firenze and Dr. Alessandro Squizzato, Universita degli Studi dell'Insubria, Como, Italy
Thrombosis and Haemostasis
Author Interview
Position Paper
Squizzato et al.
CC BY-NC-ND 4.0 · Thromb Haemost 2022; 122(03): 329-335 / DOI: 10.1055/a-1715-5960
T&H
Why did you (and your colleagues) write this paper? What was its main purpose?
ALESSANDRO SQUIZZATO and DANIELA POLI
Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. About a quarter of the anticoagulated patients require temporary cessation of direct oral anticoagulants (DOACs) or vitamin K antagonists for a planned intervention – invasive procedure or surgery - within 2 years from anticoagulation inception. As several clinical issues about DOAC interruption remain unanswered, the Italian Federation of Centers for the diagnosis of thrombotic disorders and the Surveillance of the Antithrombotic therapies (FCSA) decided to write a position paper to help physicians in frequent and complex decision on how to manage perioperatively/periprocedurally anticoagulated patients.
T&H
What are the main conclusions?
ALESSANDRO SQUIZZATO and DANIELA POLI
FCSA proposes (see main paper for details) to clinical physicians to:
1) perform a multiparametric assessment of bleeding (high and low) and thrombotic (high and non-high) risk based on patients’ individual and surgical risk factors;
2) test for prothrombin time, activated partial thromboplastin time and DOAC plasma levels before surgery or invasive procedure, in particular in patients at high risk of bleeding or of severe complications in case of bleeding ;
3) restarting of full-dose of DOAC after high-risk of bleeding surgery when local haemostasis is safe;
4) implement non-pharmacological strategies to manage patients pre- and post-operatively.
T&H
What are the paper's implications? - to the public? -to medical professionals?
ALESSANDRO SQUIZZATO and DANIELA POLI
As the evidence is sparse, many questions about the optimal individual DOAC interruption for planned invasive procedures or surgery are tentatively addressed daily by thousands of physicians worldwide. FCSA has a decades experience on the perioperatively/periprocedurally management of anticoagulated patients. Therefore, our paper may really help physicians in their daily clinical practice and allow to reduce the risk of bleeding and thrombotic complications for patients.
'FCSA believes that every hospital should introduce an ‘Anticoagulation Team’
T&H
Are the findings clinically significant? Should the findings change practice?
ALESSANDRO SQUIZZATO and DANIELA POLI
Among possible valuable answers about perioperatively/periprocedurally management of anticoagulated patients with DOAC and waiting for the results of ongoing and future studies, FCSA really believes that every hospital should introduce an ‘Anticoagulation Team’ with the aim to define the optimal perioperative management of anticoagulation and implement management strategy based on a pre- and post-operatively multiparametric assessment, testing of DOAC plasma levels and practical non-pharmacological strategies. Medicine is moving to an integrated care approach to management: as it happened for other thrombotic disorders - such as atrial fibrillation and pulmonary embolism (PE) (i.e. PERT: PE Response Team) – our proposal may really improve clinically relevant outcomes. Thrombosis and hemostasis experts, lab experts, anesthesiologists, intensivists, endoscopy experts, and surgeons of different specializations should work dynamically together.
