Perioperative and Periprocedural Management of the Anticoagulant Therapy

Created 09/02/2022, last revision 21/01/2023

long-term anticoagulation therapy often has to be interrupted for various reasons (most often due to planned diagnostic or surgical procedures); for the interruption in emergencies, see the chapter on neutralizing the anticoagulant effect
the decision to discontinue anticoagulation periprocedurally represents a complex balancing act between the estimated risk of thromboembolism and bleeding
4 questions need to be addressed:
- is it necessary to discontinue anticoagulation?
- if so, how long before the procedure should it be discontinued?
- is bridging therapy necessary? at what dose?
- when should the anticoagulant therapy be restarted after the procedure?
to answer these questions, we need to evaluate:
- individual risk of thromboembolism
- the risk of bleeding (taking into account the characteristics of the patient and the planned procedure)
  - type of procedure and its risk of bleeding
  - features of the prescribed anticoagulant agent (warfarin x DOAC)
  - renal functions

warfarin requires a rather complex procedure – timely discontinuation (at least 3-5 days before the procedure), then monitoring of INR decline and starting LMWH once INR gets below 2 (if bridging is indicated)
DOACs simplify the situation because of their rapid onset of action and predictable, relatively short-lasting normalization of coagulation parameters (LMWH bridging is therefore not necessary in most cases)

Is it really necessary to stop anticoagulant therapy?

it is always a matter of better or worse estimate because the ratio of the thromboembolism risk (TE) when anticoagulation is withdrawn and bleeding when it is retained is often unclear
- TE is relatively rare but can be fatal
- bleeding with continued anticoagulation is more common but often less clinically relevant, usually without permanent sequelae

use the CHA₂DS₂-VASc score in patients with Afib
in patients with venous thrombosis (VTE), the time since the diagnosis of VTE and the presence/absence of thrombophilia (a prothrombotic state) are taken into account
in patients with a mechanical valve, the risk depends on the type and location of the valve and the presence of contributing risk factors (AFib, heart failure, hypertension, diabetes, age >75y, previous stroke)

	Clinical Indication for Anticoagulant Therapy
Thromboembolic Risk Category	Atrial Fibrillation	Mechanical Heart Valve	VTE
High risk (annual risk >10%)	CHADS₂ score 5-6 recent (< 3 months) stroke/TIA rheumatic valvular heart disease	any mechanical mitral valve older aortic mechanical valve (caged ball, tilting disk) recent (< 3 months) stroke or TIA	recent (< 3 months) VTE high-risk thrombophilia (deficiency of protein C, protein S, or antithrombin; antiphospholipid syndrome; homozygous factor V Leiden or prothrombin gene mutation)
Moderate risk (annual risk 5% to 10%)	CHADS₂ score 3-4	bileaflet aortic valve prosthesis with ≥1 risk factor	VTE within 3–12 months moderate-risk thrombophilia (heterozygous factor V Leiden or prothrombin gene mutation) recurrent VTE active cancer (metastatic or treated within the past 6 months)
Low risk (annual risk <5%)	CHADS₂ score 0–2 (no prior stroke or TIA)	bileaflet aortic valve prosthesis without any risk factors	VTE >12 months ago

consider a combination of individual patient risks and the risk of the procedure itself
take into account the localization and invasiveness of the procedure
many procedures can be safely performed without interrupting anticoagulation (either warfarin or DOACs) – dermatological, ophthalmological, and dental procedures

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Warfarin

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DOAC

higher perioperative hemorrhagic risk is assumed; therefore, a longer interval is recommended
- for dabigatran 4-5 days before surgery
- for Xa inhibitors 3-5 days before surgery
restart DOAC ≥ 24 hours after the procedure
consider LMWH bridging in high-risk patients
separate guidelines for spinal and analgesic procedures are here a here

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