• 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 it should be discontinued?
    • is bridging therapy necessary, and at what dose?
    • when the anticoagulant therapy should 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)
    • take into account the features of the prescribed anticoagulant agent (warfarin x DOAC)
    • renal function
  • 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 was < 2 (if bridging is indicated)
  • DOACs simplify the situation due to 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always a matter of better or worse estimate because the ratio of the thromboembolism risk (TE) when anticoagulation is withdrawn and bleeding when it is retained is often unclear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%)
  • 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 mo
  • 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

Bleeding risk assessment

  • consider combination of individual patient risks and the risk of the procedure itself
  • the localization and invasiveness of the procedure amust bee taken into account
  • 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

Warfarin
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DOAC

Discontinuation of DOAC before neuroaxial 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 ≥r 24 hours
  • 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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