ADD-ONS / MEDICATION
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
- type of procedure and its risk of bleeding
- 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always a matter of better or worse estimate because the ratio of the thromboembolism risk (TE) when anticoagulation is withdrawn and bleeding when it is retained is often unclear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
Thromboembolism risk assessment
- 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%) |
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Moderate risk (annual risk 5% to 10%) |
CHADS2 score 3-4 | bileaflet aortic valve prosthesis with ≥1 risk factor |
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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 |
Bleeding risk assessment
- 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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Timing of anticoagulant therapy discontinuation
Discontinuation of DOAC before neuraxial anesthesia
- 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
Is bridging required?
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Restart of the anticoagulant therapy
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