Perioperative Anticoagulation Management

Introduction to Anticoagulant Management

The American Society of Anesthesiologists recommends stopping direct oral anticoagulants (DOACs) like apixaban and rivaroxaban 48 hours before high bleeding risk surgery and 24 hours before low bleeding risk procedures 1
For warfarin, the American College of Cardiology recommends discontinuing it 5 days preoperatively to allow INR to normalize below 1.5 2, 3

The American College of Cardiology recommends stopping warfarin 5 days before surgery to allow INR to normalize below 1.5 2, 3
The American Society of Anesthesiologists recommends checking INR prior to the procedure to confirm it is <1.5 3
The American College of Cardiology recommends restarting warfarin the evening of the procedure at the usual daily dose 2
Bridging with low molecular weight heparin (LMWH) is not routinely recommended for most patients, including those with atrial fibrillation, according to the American Heart Association 2, 1

The European Society of Cardiology recommends stopping DOACs the night before the procedure (approximately 24 hours) for low bleeding risk procedures 1, 4
The American College of Cardiology recommends resuming therapy 6 hours or more after the procedure if hemostasis is adequate 1, 5
For high bleeding risk procedures, the French guidelines recommend stopping rivaroxaban and apixaban 3 days (72 hours) before surgery when creatinine clearance is >30 mL/min 1, 6

The American College of Cardiology recommends that renal function determines timing due to predominant renal elimination 1, 6
For CrCl >50 mL/min, the European Society of Cardiology recommends stopping dabigatran 4 days before high-risk surgery 1, 6
For CrCl 30-50 mL/min, the American Heart Association recommends stopping dabigatran 5 days before high-risk surgery 1, 6

The American Society of Anesthesiologists recommends not using bridging anticoagulation with heparin products when stopping DOACs, as this increases bleeding risk without reducing thrombotic risk 1, 6, 4
The American College of Cardiology recommends not performing neuraxial anesthesia if there is any possibility of residual DOAC levels, especially in elderly patients (>80 years) or those with renal impairment 6

The European Society of Cardiology recommends resuming DOACs 6-48 hours after surgery depending on bleeding risk and adequacy of hemostasis 1, 5
For low bleeding risk, the American College of Cardiology recommends resuming as early as 6 hours post-procedure 1
For high bleeding risk, the American Heart Association recommends delaying 24-48 hours until hemostasis is secure 5

The American College of Cardiology recommends considering reversal agents, such as prothrombin complex concentrate (PCC) 50 IU/kg for warfarin, in cases of emergent surgery (<6 hours) 2