New antithrombotic guidelines
A new guideline from the American Academy of Neurology gives primary care doctors guidance on periprocedural management of antithrombotic medications in patients with a history of stroke. Among the recommendations is that stroke patients undergoing dental procedures should routinely continue aspirin. Aspirin should also be considered for continuation in stroke patients undergoing invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound-guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery. Aspirin should possibly be continued during other procedures such as virtroretinal surgery, EMG, transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy and biopsy/sphincterotomy, and abdominal ultrasound-guided biopsies. For stroke patients on warfarin, the guideline recommends continuation of the drug during dental procedures and probably during most dermatologic procedures. Other more invasive procedures should warrant discussion. The guideline states there is insufficient evidence to support or refute periprocedural heparin-bridging therapy to reduce thromboembolic events in chronically anticoagulated patients. Bridging therapy is probably associated with increased bleeding risk as compared with warfarin cessation, but the risk difference compared with continuing warfarin is unknown (Neurology 2013;22:2065-2069).