Периоперационное ведение пациентов, получающих длительную антитромботическую терапию. Методические рекомендации Общероссийской общественной организации «Федерация анестезиологов и реаниматологов»
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Ключевые слова

антикоагулянтная терапия
антиагрегантная терапия
прерывание антитромботической терапии
экстренная реверсия
регионарная анестезия
тромбоэмболический риск
геморрагический риск
искусственные клапаны сердца
фибрилляция предсердий
ишемический инсульт
инфаркт миокарда
коронарное стентирование

Как цитировать

Заболотских И.Б., Киров М.Ю., Афончиков В.С., Буланов А.Ю., Григорьев Е.В., Григорьев С.В., Грицан А.И., Замятин М.Н., Курапеев И.С., Лебединский К.М., Ломиворотов В.В., Лубнин А.Ю., Овечкин А.М., Потиевская В.И., Ройтман Е.В., Синьков С.В., Субботин В.В., Шадрин Р.В., Шулутко Е.М. Периоперационное ведение пациентов, получающих длительную антитромботическую терапию. Методические рекомендации Общероссийской общественной организации «Федерация анестезиологов и реаниматологов». Вестник интенсивной терапии имени А.И. Салтанова. 2021;(3):7–26. doi:10.21320/1818-474X-2021-3-7-26.

Статистика

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Аннотация

В обзоре представлены методические рекомендации Федерации анестезиологов и реаниматологов по ведению пациентов, получающих длительную антитромботическую терапию, пересмотренные в 2021 г. Представлены классификации осложнений и степени риска кровотечений, стратификация периоперационного тромбоэмболического риска. С учетом современных представлений описаны принципы прерывания и возобновления антитромботической, антикоагулянтной и антиагрегантной терапии. Приведены подходы к экстренному прерыванию антитромботической терапии при неотложных оперативных вмешательствах, в т. ч. экстренной реверсии эффектов получаемых пациентом препаратов. Описаны особенности назначения и изменения тактики антитромботической терапии в зависимости от тромбоэмболического и геморрагического риска при таких сопутствующих заболеваниях и состояниях, как наличие искусственных клапанов сердца, фибрилляция предсердий, ишемический инсульт, инфаркт миокарда, коронарное стентирование. Отдельный раздел посвящен тромбогеморрагической безопасности при выполнении регионарных методов анестезии на фоне проводимой антитромботической терапии. Приведены показания, противопоказания и ограничения к проведению регионарной анестезии в условиях проведения антитромботической терапии, а также критерии качества оказываемой медицинской помощи.
https://doi.org/10.21320/1818-474X-2021-3-7-26
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Библиографические ссылки

  1. Ревишвили А.Ш., Шляхто Е.В., Замятин М.Н. и др. Особенности оказания экстренной и неотложной медицинской помощи пациентам, получающим прямые оральные антикоагулянты. Согласительный документ междисциплинарной группы экспертов. Вестник аритмологии. 2018; (92): 59–72. [Revishvili A.Sh., Shlyakhto E.V., Zamyatin M.V., et al. Peculiar features of urgent and emergency medical care of patients taking direct oral anticoagulants: consensus statement of multidisciplinary expert group. Journal of Arrhythmology. 2018; (92): 59–72. (In Russ)]
  2. Lip G.Y., Nieuwlaat R., Pisters R., et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137(2): 263–72. DOI: 10.1378/chest.09-1584
  3. Wijns W., Kolh Ph, Danchin N. et al. Guidelines on myocardial revascularization. Eur. J. Cardiothorac. Surg. 2010; 38 (Suppl.): 1–52.
  4. Douketis J.D. Perioperative anticoagulation management in patients who are receiving oral anticoagulant therapy: A practical guide for clinicians. Thromb Res. 2002; 108: 3–13. DOI: 10.1016/s0049-3848(02)00387-0
  5. Lecompte T., Hardy J. Antiplatelet agents and perioperative bleeding. Canadian Journal of Anaesthesia. 2006; 53: S103–S112. DOI: 10.1007/BF03022257
  6. Keeling D., Tait R.C., Watson H. Peri-operative management of anticoagulation and antiplatelet Therapy. British Committee for Standards in Haematology. British Journal of Haematology, 2016; 175: 602–13. DOI: 10.1111/bjh.14344
  7. ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal, 2018; 39: 213–60.
  8. Burger W., Chemnitius J.M., Kneissl G.D., Rücker G. Low-dose aspirin for secondary cardiovascular prevention — cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation — review and meta-analysis. J Intern Med. 2005; 257(5): 399–414. DOI: 10.1111/j.1365-2796.2005.01477.x
  9. Devereaux P.J., Mrkobrada M., Sessler D.I., et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014; 370(16): 1494–503. DOI: 10.1056/NEJMoa1401105
  10. Biondi-Zoccai G.G., Lotrionte M., Agostoni P., et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006; 27(22): 2667–74. DOI: 10.1093/eurheartj/ehl334
  11. Myles P.S., Smith J.A., Forbes A., et al. Stopping vs. Continuing Aspirin before Coronary Artery Surgery. N Engl J Med. 2016; 374(8): 728–37. DOI: 10.1056/NEJMoa1507688
  12. Singla S., Sachdeva R., Uretsky B.F. The risk of adverse cardiac and bleeding events following noncardiac surgery relative to antiplatelet therapy in patients with prior percutaneous coronary intervention. J Am Coll Cardiol. 2012; 60(20): 2005–16. DOI: 10.1016/j.jacc.2012.04.062
  13. Mehran R., Baber U., Steg P.G., et al. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet. 2013; 382(9906): 1714–22. DOI: 10.1016/S0140-6736(13)61720-1
  14. Rossini R., Musumeci G., Capodanno D., et al. Perioperative management of oral antiplatelet therapy and clinical outcomes in coronary stent patients undergoing surgery: results of a multicentre registry. Thrombosis and Haemostasis. 2015; 113: 272–82.
  15. Hansson E.C., Jideus L., Aberg B., et al. Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study. Eur Heart J. 2016; 37: 189–97. DOI: 10.1093/eurheartj/ehv381
  16. Tomšič A., Schotborgh M.A., Manshanden J.S., et al. Coronary artery bypass grafting-related bleeding complications in patients treated with dual antiplatelet treatment. Eur J Cardiothorac Surg. 2016; 50(5): 849–56. DOI: 10.1093/ejcts/ezw149
  17. Gherli R., Mariscalco G., Dalen M., et al. Safety of preoperative use of ticagrelor with or without aspirin compared with aspirin alone in patients with acute coronary syndromes undergoing coronary artery bypass grafting. JAMA Cardiol 2016; 1: 921–8. DOI: 10.1001/jamacardio.2016.3028
  18. Corredor C., Wasowicz M., Karkouti K., Sharma V. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia. 2015; 70(6): 715–31. DOI:1111/anae.13083
  19. КолесниковаИ.М., Ройтман Е.В. Новый метод определения гемостатической способности тромбоцитов на основе тромбоэластографии. Тромбоз, гемостаз и реология. 2016; 67(S3): 203–4. [Kolesnikova I.M., Roitman E.V. New thromboelastography-based assay of platelet hemostatic capacity. Tromboz, Gemostaz i Reologia. 2016; 67(S3): 203–4. (In Russ)]
  20. Kasivisvanathan R., Abbassi-Ghadi N., Kumar S., et al. Risk of bleeding and adverse outcomes predicted by thromboelastography platelet mapping in patients taking clopidogrel within 7 days of non-cardiac surgery. Br J Surg. 2014; 101(11): 1383–90. DOI: 10.1002/bjs.9592
  21. Chan A.W., Moliterno D.J., Berger P.B., et al. Triple antiplatelet therapy during percutaneous coronary intervention is associated with improved outcomes including one-year survival: results from the Do Tirofiban and ReoProGive Similar Efficacy Outcome Trial (TARGET). J Am Coll Cardiol. 2003; 42(7): 1188–95. DOI: 10.1016/s0735-1097(03)00944-6
  22. Sousa-Uva M., Storey R., Huber K., et al. Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery. Eur Heart J. 2014; 35(23): 1510–4. DOI: 10.1093/eurheartj/ehu158
  23. Dunn A.S., Spyropoulos A.C., Turpie A.G. Bridging therapy in patients on long-term oral anticoagulants who require surgery: the Prospective Peri-operative Enoxaparin Cohort Trial (PROSPECT). J Thromb Haemost. 2007; 5(11): 2211–8. DOI: 10.1111/j.1538-7836.2007.02729.x
  24. Dentali F., Pignatelli P., Malato A., et al. Incidence of thromboembolic complications in patients with atrial fibrillation or mechanical heart valves with a subtherapeutic international normalized ratio: a prospective multicenter cohort study. Am J Hematol. 2012; 87(4): 384–7. DOI: 10.1002/ajh.23119
  25. Siegal D., Yudin J., Kaatz S., et al. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation. 2012; 126(13): 1630–9. DOI: 10.1161/CIRCULATIONAHA.112.105221
  26. Eischer L., Gartner V., Schulman S., et al. 6 versus 30 months anticoagulation for recurrent venous thrombosis in patients with high factor VIII. Ann Hematol. 2009; 88(5): 485–90.
  27. Ortel T.L., Neumann I., Ageno W., et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020; 4(19): 4693–738. DOI: 10.1182/bloodadvances.2020001830
  28. Schulman S., Hwang H.G., Eikelboom J.W., et al. Loading dose vs. maintenance dose of warfarin for reinitiation after invasive procedures: a randomized trial. J Thromb Haemost. 2014; 12(8): 1254–9. DOI: 10.1111/jth.12613
  29. Dunn A.S., Turpie A.G. Perioperative management of patients receiving oral anticoagulants: a systematic review. Archives of Internal Medicine. 2003; 163: 901–8. DOI: 10.1001/archinte.163.8.901
  30. Douketis J.D., Spyropoulos A.C., Spencer F.A., 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 Suppl): e326S-e350S. DOI: 10.1378/chest.11-2298
  31. Spyropoulos A.C., Douketis J.D. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood. 2012; 120: 2954–62. DOI: 10.1182/blood-2012-06-415943
  32. Sherwood M.W., Douketis J.D., Patel M.R., et al. Outcomes of temporary interruption of rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: results from the rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET AF). Circulation. 2014 May 6; 129(18): 1850–9. DOI: 10.1161/CIRCULATIONAHA.113.005754
  33. Schulman S., Carrier M., Lee A.Y., Shivakumar S., et al. Perioperative Management of Dabigatran: A Prospective Cohort Study. Circulation. 2015; 132: 167–73. DOI: 10.1161/CIRCULATIONAHA.115.015688
  34. Garcia D., Alexander J.H., Wallentin L., et al. Management and clinical outcomes in patients treated with apixaban vs warfarin undergoing procedures. Blood. 2014; 124: 3692–8. DOI: 10.1182/blood-2014-08-595496
  35. Vonk A.B., Veerhoek D., van den Brom C.E., et al. Individualized heparin and protamine management improves rotational thromboelastometric parameters and postoperative hemostasis in valve surgery. J Cardiothorac Vasc Anesth. 2014; 28: 235–41. DOI: 10.1053/j.jvca.2013.09.007
  36. Guo Y., Tang J., Du L., et al. Protamine dosage based on two titrations reduces blood loss after valve replacement surgery: a prospective, double-blinded, randomized study. Can J Cardiol. 2012; 28: 547–52. DOI: 10.1016/j.cjca.2012.03.012
  37. Kakkos S.K., Gohel M., Baekgaard N., et al. Editorʼs Choice — European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg. 2021; 61(1): 9–82. DOI: 10.1016/j.ejvs.2020.09.023
  38. Makris M., Van Veen J.J., Tait C.R., et al. Guideline on the management of bleeding in patients on antithrombotic agents. Br J Haematol. 2013; 160(1): 35–46. DOI: 10.1111/bjh.12107
  39. Refaai M.A., Goldstein J.N., Milling T.J.Jr, et al. Randomized phase IIIb study of rapid vitamin K antagonist reversal in patients requiring an urgent surgical procedure: Four-factor prothrombin complex concentrate is superior to plasma. Blood (ASH Annual Meeting Abstracts), 2013; 122: 3588. DOI: 10.1182/blood.V122.21.3588.3588
  40. Goldstein J.N., Refaai M.A., Milling T.J.Jr, et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet. 2015; 385: 2077–87. DOI: 10.1016/S0140-6736(14)61685-8
  41. Holbrook A., Schulman S., Witt D.M., et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141: e152Se84S.
  42. Fazavana J., Bianchini E.P., Saller F., et al. A chemically-modified inactive antithrombin as a potent antagonist of fondaparinux and heparin anticoagulant activity. J Thromb Haemost. 2013; 11: 1128–36. DOI: 10.1111/jth.12249
  43. Eikelboom J.W., Kozek-Langenecker S., Exadaktylos A., et al. Emergency care of patients receiving non-vitamin K antagonist oral anticoagulants. Br J Anaesth. 2018; 120(4): 645–56. DOI: 10.1016/j.bja.2017.11.082
  44. Eerenberg E.S., Kamphuisen P.W., Sijpkens M.K., et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation. 2011; 124: 1573–79. DOI: 10.1161/CIRCULATIONAHA.111.029017
  45. Glund S., Stangier J., Schmohl M., et al. Safety, tolerability, and efficacy of idarucizumab for the reversal of the anticoagulant effect of dabigatran in healthy male volunteers: a randomised, placebo-controlled, double-blind phase 1 trial. Lancet. 2015; 386: 680–90. DOI: 10.1016/S0140-6736(15)60732-2
  46. Practice guidelines for perioperative blood management. An updated report by the American Society of Anesthesiologists. Task force on perioperative blood management. Anesthesiology. 2015; 122: 241–75. DOI: 10.1097/ALN.0000000000000463
  47. Chang D.N., Dager W.E., Chin A.I. Removal of dabigatran by hemodialysis. Am J Kidney Dis. 2013; 61(3): 487–9. DOI: 10.1053/j.ajkd.2012.08.047
  48. Chai-Adisaksopha C., Hillis C., Lim W., et al. Hemodialysis for the treatment of dabigatran-associated bleeding: a case report and systematic review. J Thromb Haemost. 2015; 13(10): 1790–8. DOI: 10.1111/jth.13117.
  49. Thiele T., Sümnig A., Hron G., et al. Platelet transfusion for reversal of dual antiplatelet therapy in patients requiring urgent surgery: a pilot study. J Thromb Haemost. 2012; 10(5): 968–71. DOI: 10.1111/j.1538-7836.2012.04699.x
  50. Price M.J., Walder J.S., Baker B.A., et al. Recovery of platelet function after discontinuation of prasugrel or clopidogrel maintenance dosing in aspirintreated patients with stable coronary disease: the recovery trial. J Am Coll Cardiol. 2012; 59: 2338–43. DOI: 10.1016/j.jacc.2012.02.042
  51. Vilahur G., Choi B.G., Zafar M.U., et al. Normalization of platelet reactivity in clopidogrel-treated subjects. J Thromb Haemost. 2007; 5(1): 82–90. DOI: 10.1111/j.1538-7836.2006.02245.x
  52. Li C., Hirsh J., Xie C., et al. Reversal of the anti-platelet effects of aspirin and clopidogrel. J Thromb Haemost. 2012; 10(4): 521–8. DOI: 10.1111/j.1538-7836.2012.04641.x
  53. Horlocker T.T., Vandermeuelen E., Kopp S.L., et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med. 2018; 43(3): 263–309. DOI: 10.1097/AAP.0000000000000763
  54. Gogarten W., Vandermeulen E., Aken H.V., et al. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol. 2010; 27: 999–1015. DOI: 10.1097/EJA.0b013e32833f6f6f
  55. Llau J.V., De Andres J., Gomar C. et al. Anticlotting drugs and regional anaesthetic and analgesis technigues: comparative update of the safety recommendatios. European Journal of Anaesthesiology. 2007; 24: 387–98. DOI: 10.1017/S0265021506001918
  56. Cooke E.D., Lloyd M.J., Bowcock S.A., Pilcher M.F. Letter: monitoring during low-dose heparin prophylaxis. N Engl JMed. 1976; 294: 1066–7.
  57. Davis J.J., Bankhead B.R., Eckman E.J., et al. Three-times-daily subcutaneous unfractionated heparin and neuraxial anesthesia: a retrospective review of 928 cases. Reg Anesth Pain Med. 2012; 37: 623–6. DOI: 10.1097/AAP.0b013e31826a8d10
  58. Pace M., Koury K., Gulur P. Epidurals in Patients Receiving Thromboprophylaxis With Unfractionated Heparin Three Times a Day: The Value of Activated Partial Thromboplastin Time Testing. Anesth Analg. 2014; 119(5): 1215–8. DOI: 10.1213/ANE.0000000000000437
  59. Dickman C.A., Shedd S.A., Spetzler R.F., et al. Spinal epidural hematoma associated with epidural anesthesia: complications of systemic heparinization in patients receiving peripheral vascular thrombolytic therapy. Anesthesiology. 1990; 72: 947–50. DOI: 10.1097/00000542-199005000-00028
  60. Gallus A.S., Hirsh J., Tutle R.J., et al. Small subcutaneous doses of heparin in prevention of venous thrombosis. N Engl J Med. 1973; 288: 545–51. DOI: 10.1056/NEJM197303152881103
  61. Sanderink G.-J.C.M., Guimart C.G., Ozoux M.-L., et al. Pharmacokinetics and pharmacodynamics of the prophylactic dose of enoxaparin once daily over 4 days in patients with renal impairment. Thromb Res. 2002; 105: 225–31. DOI: 10.1016/s0049-3848(02)00031-2
  62. Horlocker T.T., Wedel D.J. Neuraxial block and low-molecular-weight heparin: balancing perioperative analgesia and thromboprophylaxis. Reg Anesth Pain Med. 1998; 23: 164–77. DOI: 10.1016/s1098-7339(98)90143-2
  63. Weitz J.I. Low-molecular-weight heparins. N Engl J Med. 1997; 337: 688–98.
  64. Bergqvist D., Lindblad B., Matzsch T. Risk of combining low molecular weight heparin for thromboprophylaxis and epidural or spinal anesthesia. Semin Thromb Hemost. 1993; 19(Suppl 1): 147–51.
  65. Douketis J.D., Kinnon K., Crowther M.A. Anticoagulant effect at the time of epidural catheter removal in patients receiving twice-daily or once-daily low-molecular-weight heparin and continuous epidural analgesia after orthopedic surgery. Thromb Haemost. 2002; 88: 37–40.
  66. Singelyn F.J., Verheyen C.C., Piovella F, et al. EXPERT Study Investigators. The safety and efficacy of extended thromboprophylaxis with fondaparinux after major orthopedic surgery of the lower limb with or without a neuraxial or deep peripheral nerve catheter: the expert study. Anesth Analg. 2007; 105: 1540–7. DOI: 10.1213/01.ane.0000287677.95626.60
  67. Xu Q. Xarelto (Rivaroxaban). Cardiovascular and Renal Drugs Advisory Committee Meeting; 19 March 2009. FDA Cardiovascular and Renal Drugs 2009.
  68. Liu S.S., Buvanendran A., Viscusi E.R., et al. Uncomplicated removal of epidural catheters in 4365 patients with international normalized ratio greater than 1.4 during initiation of warfarin therapy. Reg Anesth Pain Med. 2011; 36: 231–5. DOI: 10.1097/AAP.0b013e31820d4376
  69. Benzon H.T., Avram M.J., Green D., Bonow R.O. New oral anticoagulants and regional anaesthesia. Br J Anaesth. 2013; 111(Suppl 1): i96–i113. DOI: 10.1093/bja/aet401
  70. Lassen M.R., Raskob G.E., Gallus A., et al. Apixaban or enoxaparin for thromboprophylaxis after knee replacement. N Engl J Med. 2009; 361: 594–604. DOI: 10.1056/NEJMoa0810773
  71. Stangier J. Clinical pharmacokinetics and pharmacodynamics of the oral direct thrombin inhibitor dabigatran etexilate. Clin Pharmacokinetics. 2008; 47: 285–95. DOI: 10.2165/00003088-200847050-00001
  72. Leese P.T., Hubbard R.C., Karim A., et al. Effects of celecoxib, a novel cyclooxygenase-2 inhibitor, on platelet function in healthy adults: a randomized, controlled trial. J ClinPharmacol. 2000; 40: 124–32. DOI: 10.1177/00912700022008766
  73. Angiolillo D.J., Firstenberg M.S., Price M.J., et al. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA. 2012; 307: 265–74. DOI: 10.1001/jama.2011.2002
  74. Gogarten W. The influence of new antithrombotic drugs on regional anesthesia. Curr Opin Anaesthesiol. 2006; 19: 545–50. DOI: 10.1097/01.aco.0000245282.45529.b0
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