Perioperative Anticoagulation Management in Atrial Fibrillation
Risk Stratification Approach
- The American College of Cardiology recommends that patients with nonvalvular atrial fibrillation at low to moderate thromboembolic risk (CHA₂DS₂-VASc score <7 or CHADS₂ score <5) should undergo perioperative management without bridging therapy 1, 2
- For patients with mechanical heart valves, recent stroke or TIA (<3 months), very high thromboembolic risk (CHA₂DS₂-VASc score ≥7 or CHADS₂ score of 5-6), or history of perioperative stroke, bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended 1, 2, 5, 6
Management Protocol for Warfarin Interruption
- The American College of Cardiology suggests stopping warfarin 5 days before elective procedure and resuming it within 24 hours after procedure when adequate hemostasis is achieved 1, 3, 4
- For patients requiring bridging, therapeutic-dose UFH or LMWH should be started 3 days before procedure and resumed 24-72 hours after procedure, depending on bleeding risk 2, 5
Special Considerations
- The American College of Chest Physicians recommends considering performing minor procedures with low bleeding risk without interruption of oral anticoagulation 6
- For patients on Direct Oral Anticoagulants (DOACs), generally no bridging is required when interrupting DOACs, and the timing of interruption depends on renal function and procedure bleeding risk 6