Anticoagulation Management

Introduction to Anticoagulants

The American Heart Association recommends anticoagulants for prevention of thromboembolic events in non-valvular atrial fibrillation, treatment of venous thromboembolism, and postoperative prevention 3
The European Society of Cardiology states that anticoagulants act on different points of the coagulation cascade, from inhibition of factor synthesis to direct blockade of specific enzymes 1

The American College of Cardiology notes that vitamin K antagonists (warfarin) inhibit hepatic synthesis of vitamin K-dependent coagulation factors (II, VII, IX, X) and require frequent monitoring with INR due to their narrow therapeutic window 1
Aspirin (acetylsalicylic acid) irreversibly inhibits platelet cyclooxygenase, blocking thromboxane A2 synthesis, according to the American Academy of Otolaryngology-Head and Neck Surgery 2
Clopidogrel (Plavix) is a P2Y12 receptor antagonist, blocking ADP-mediated platelet activation, as stated by the Journal of the American College of Cardiology 3

Dabigatran (Pradaxa) is a direct thrombin inhibitor with 80% renal elimination, according to the European Heart Journal 1
Rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa) are direct Factor Xa inhibitors, as noted by the European Heart Journal 1

For elective surgeries, the American Society of Anesthesiologists recommends suspending DOACs based on the bleeding risk of the procedure and the patient's renal function, without the need for bridging therapy in most cases 6
The European Heart Journal states that warfarin should be suspended 3-5 days before surgery, with INR monitoring daily until it reaches ≤1.5 on the day of the procedure 1

Idarucizumab (Praxbind) is a specific antagonist of dabigatran, allowing for complete reversal in minutes, according to the Journal of Anesthesia 6
Andexanet alfa reverses Factor Xa inhibitors (apixaban, rivaroxaban, edoxaban), as stated by the Journal of Anesthesia 6

The American College of Cardiology recommends adjusting the dose of DOACs and prolonging the preoperative suspension time in patients with impaired renal function 7
Apixaban is preferred in moderate renal insufficiency due to its lower renal elimination (27%), according to the European Heart Journal 7

The American Society of Anesthesiologists advises against routine use of bridging therapy with DOACs, as it increases bleeding without thrombotic benefit 6
The European Society of Cardiology recommends verifying renal function before each decision, especially for dabigatran 1