Anticoagulation likely OK for stroke patients undergoing dental procedures

Stroke patients on blood thinners who undergo dental procedures can routinely continue aspirin or warfarin, according to level A recommendations issued by the American Academy of Neurology.

In patients being treated with antithrombotic therapy for ischemic cerebrovascular disease, individual decisions regarding periprocedural management of these medications need to weigh bleeding risks from drug continuation against thromboembolic risk from discontinuation. The American Academy of Neurology has issued a new evidence-based clinical practice guideline to provide assistance to clinicians in managing antithrombotic therapy in this group of patients undergoing procedures.

The available evidence on when to stop blood thinners or resort to bridging medications varies from medication to medication and procedure to procedure, the Academy noted in its recommendations. For certain minor procedures, particularly dental ones, the evidence shows that antithrombotics should not be stopped in most stroke patients.

Recommendations appeared in the May 28 Neurology.

Specifically, the Academy's statement states that patients taking aspirin or warfarin should be counseled that they are highly unlikely to increase clinically important bleeding complications with dental procedures (Level A) and it is reasonable to routinely continue the drugs in stroke patients undergoing dental procedures (Level A).

In addition, doctors can tell patients that aspirin probably does not increase clinically important bleeding complications with invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound-guided prostate biopsy, spinal/epidural procedures and carpal tunnel surgery (Level B), the recommendations stated. It is reasonable that stroke patients undergoing these procedures can continue aspirin (Level B). Patients taking aspirin should be counseled that it probably increases bleeding risks during orthopedic hip procedures (Level B, not supportive).

Aspirin might not increase clinically important bleeding in vitreoretinal surgery, electromyography (EMG), transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy with biopsy, sphincterotomy and abdominal ultrasound-guided biopsies, the statement continued. Because of the weaker data, the recommendations stated that it is reasonable that some stroke patients undergoing these procedures should possibly continue aspirin (Level C). Studies of transurethral resection of the prostate could not exclude clinically important bleeding risks with aspirin (Level U).

Physicians can counsel patients that continuing warfarin is probably associated with a 1.2% increased risk for bleeding during dermatologic procedures, based on a meta-analysis of heterogeneous and conflicting studies (Level B), so patients undergoing dermatologic procedures should probably continue it (Level B).

Warfarin might be associated with no increase in clinically important bleeding with EMG, prostate procedures, inguinal herniorrhaphy and endothermal ablation of the great saphenous vein. Patients undergoing these procedures should possibly continue warfarin (Level C). Patients should be counseled that continuing it might increase bleeding with colonoscopic polypectomy (Level C, not supportive) so they should possibly temporarily stop it (Level C).

Although warfarin is probably not associated with an increased risk of clinically important bleeding with ocular anesthesia (Level B), anticoagulant practices during ophthalmologic procedures may be driven by the postanesthesia procedure, so there was insufficient evidence to make practice recommendations about stopping it (Level U).