Perioperative Anticoagulation and Antiplatelet Management

Anticoagulants

The American College of Cardiology recommends stopping warfarin 4-5 days before surgery to allow INR to normalize (target INR ≤1.5) 1, 2
For patients with mechanical heart valves or venous thromboembolism within 3 months, bridging with low molecular weight heparin (LMWH) is recommended 2, 3
The American College of Cardiology suggests that for patients with atrial fibrillation without additional risk factors, routine bridging is not recommended 4, 5
Warfarin should be resumed 12-24 hours after surgery when adequate hemostasis is achieved 1, 3
For low-to-moderate bleeding risk procedures, dabigatran should be stopped 1 day before if CrCl ≥50 mL/min; 2 days before if CrCl <50 mL/min 6, 7
For high bleeding risk procedures, dabigatran should be stopped 2 days before if CrCl ≥50 mL/min; 4 days before if CrCl <50 mL/min 6, 7
Rivaroxaban and apixaban should be stopped 1 day before surgery for low-to-moderate bleeding risk procedures 6, 8
Rivaroxaban and apixaban should be stopped 2-3 days before surgery for high bleeding risk procedures 6, 8
DOACs should be resumed at least 24 hours after low-to-moderate bleeding risk procedures and 48-72 hours after high bleeding risk procedures 6
Bridging anticoagulation is not required with DOACs except in patients with recent (<3 months) venous thromboembolism 8, 6

Aspirin should be continued until the day before surgery for most procedures 2, 8
Aspirin should be stopped 5 days before high bleeding risk procedures (intracranial, spinal surgery) 2
For patients with coronary stents, management should be coordinated with cardiology 2, 8
Clopidogrel and other thienopyridines should be stopped 7 days before surgery unless point-of-care testing is used to check platelet function 2
For patients with recent coronary stent placement, elective surgery should be postponed (4-6 weeks for bare metal stents, 6 months for drug-eluting stents) 2, 8

High bleeding risk procedures, such as neurosurgery, spinal surgery, cardiac surgery, and major vascular procedures, require more conservative management with longer discontinuation periods for anticoagulants and antiplatelets 6, 2
Low bleeding risk procedures, such as dental procedures, cataract extraction, and minor dermatologic procedures, can often be performed without interrupting anticoagulation, especially warfarin 6

Failure to consider renal function can significantly affect medication clearance, especially for DOACs 8, 7
Overlooking thrombotic risk can lead to thromboembolic events, and abrupt discontinuation without appropriate bridging in high-risk patients is not recommended 3
Premature resumption of anticoagulants increases bleeding risk, especially with DOACs due to their rapid onset of action 6, 7
Inadequate communication between surgery, anesthesia, and cardiology teams can lead to poor management of patients with coronary stents 2, 8