AAN Guidelines on Periprocedural Management of Antithrombotic Drugs

Guideline Watch |
June 24, 2013

AAN Guidelines on Periprocedural Management of Antithrombotic Drugs

  1. Hooman Kamel, MDAU1992

These useful guidelines are a good reminder that patients with cerebrovascular disease should be thoroughly counseled about periprocedural risks.

  1. Hooman Kamel, MDAU1992

Neurologists frequently are asked to make recommendations about whether to continue or stop antithrombotic drugs in patients with cerebrovascular disease who are about to undergo invasive procedures. Given the variety of antithrombotic drugs and widely varying levels of patient and procedural risk, such decisions can be difficult. Recently issued evidence-based guidelines from the American Academy of Neurology promise to make these decisions easier, or at least less arbitrary.

After surveying the literature through August 2011, the guideline authors found few high-quality studies to inform decisions about periprocedural antithrombotic drug management in patients with cerebrovascular disease. Their recommendations, based on the available evidence, can be summed as follows:

  • Aspirin and warfarin should be continued during dental procedures (Level A).

  • Continuing these drugs may be safe during several other types of relatively minor procedures (Levels B and C).

  • Little evidence exists for or against periprocedural heparin bridging in patients whose warfarin is being held (Level U).

  • Heparin bridging appears to increase bleeding risk compared with simply holding warfarin (Level B).

  • Patients should be counseled that stopping aspirin or warfarin, particularly for ≥7 days, is probably associated with an increased risk for stroke (Level B).


These guidelines highlight the lack of good evidence regarding optimal strategies for periprocedural antithrombotic medication use, especially in patients with existing cerebrovascular disease. Still, they include many useful recommendations, based on a synthesis of the available evidence that will help neurologists give consistent advice to patients. The guidelines also remind neurologists to ensure that their cerebrovascular patients are adequately counseled about the periprocedural risks for stroke and bleeding before giving informed consent for any invasive procedure. They do not address the importance of multidisciplinary discussions when determining the necessity of each procedure in this high-risk patient population.

Editor Disclosures at Time of Publication

  • Disclosures for Hooman Kamel, MD at time of publication Consultant / Advisory board Genentech Grant / research support American Heart Association


Reader Comments (2)

JULIO CUNHA, M.D. Physician, Neurology, OFFICE


Hooman Kamel, MD Physician, Neurology, Weill Cornell Medical College

This is a great question, and unfortunately I'm not sure that we know the answer precisely. Two conclusions from the AAN guideline committee are relevant to this question:

1. Continued aspirin use might not increase clinically important bleeding with colonoscopic polypectomy (one Class II study, three Class III studies), upper endoscopy and polypectomy (one Class II study), or sphincterotomy (one Class II study, one Class III study).
2. Variations in surgeries and methodologic approach and limited statistical precision prevent conclusions from being made regarding clopidogrel use in various invasive surgeries (four Class II studies with limited statistical precision).

* I am the author of this JW Summary.

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