Systematic Review on Perioperative Management of Anticoagulation Therapy in Patients with Ischemic Heart Disease Undergoing Surgery
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Abstract
Background: Patients with ischemic heart disease undergoing surgery frequently receive long-term antiplatelet or anticoagulant therapy, creating a perioperative dilemma between thrombotic protection and bleeding safety. Premature interruption of antithrombotic therapy may increase myocardial infarction, stent thrombosis, or ischemic stroke risk, whereas continuation or bridging may increase surgical bleeding, transfusion requirement, and reoperation risk. Objective: This systematic review aimed to synthesize evidence on perioperative antithrombotic management strategies in adult patients with ischemic heart disease or clinically relevant cardiovascular comorbidity undergoing surgery, focusing on continuation, interruption without bridging, and heparin-based bridging. Methods: A structured search was conducted across PubMed, Scopus, the Cochrane Library, BMJ Heart, and major cardiology and perioperative medicine sources for studies published between 2001 and 2024. Eligible sources included randomized trials, systematic reviews, meta-analyses, clinical studies, and guideline documents evaluating perioperative antiplatelet or anticoagulant management. Eighteen sources were included from 312 identified records. Findings were synthesized narratively because of heterogeneity in populations, surgical settings, antithrombotic indications, and outcome definitions. Results: Interruption without bridging showed the most favorable descriptive balance between thromboembolic events and major bleeding, particularly for direct oral anticoagulant-based protocols. Aspirin continuation appeared cardioprotective in selected high-risk ischemic heart disease patients but increased bleeding risk. Bridging anticoagulation showed the highest major bleeding burden without clear thromboembolic reduction and was most defensible only in narrowly defined very high-risk thrombotic indications. Conclusion: Perioperative antithrombotic management in ischemic heart disease should be individualized according to cardiac risk, surgical bleeding risk, antithrombotic agent, renal function, and timing of postoperative hemostasis. Routine bridging should be avoided in most patients, while structured interruption and selective aspirin continuation offer more favorable risk–benefit profiles.
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