When should anticoagulation (blood thinner) therapy be restarted after surgery?

From the Guidelines

Anticoagulation therapy should be restarted as early as 12 to 24 hours postoperatively, once hemostasis is achieved, to minimize the risk of thrombotic events while balancing the risk of postoperative bleeding. The timing of anticoagulation resumption depends on the specific procedure, bleeding risk, and the patient's thrombotic risk. For patients undergoing low or moderate bleeding risk procedures, anticoagulation can be restarted 12-24 hours after surgery, as suggested by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1.

• For prophylactic anticoagulation, such as enoxaparin 40mg daily or heparin 5000 units three times daily, resumption typically occurs 12-24 hours after surgery if hemostasis is adequate.
• For therapeutic anticoagulation with warfarin, resumption typically occurs 24-72 hours postoperatively, with a target INR of 2-3 for most indications, as supported by the 2012 American College of Chest Physicians evidence-based clinical practice guidelines 1.
• Direct oral anticoagulants (DOACs) like apixaban, rivaroxaban, or dabigatran are usually restarted 2-3 days after surgery with low bleeding risk, and 5-7 days after procedures with high bleeding risk, as recommended by the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1.
• For patients at high thrombotic risk, such as those with recent venous thromboembolism or mechanical heart valves, bridging with therapeutic low molecular weight heparin may be necessary until oral anticoagulation reaches therapeutic levels, as suggested by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1.

The decision to restart anticoagulation requires careful consideration of the patient's individual risk factors and the potential benefits and risks of anticoagulation therapy. Close monitoring for bleeding complications is essential during the initial days after anticoagulation resumption.

From the FDA Drug Label

Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.

Restarting Anticoagulation: Anticoagulation therapy with apixaban should be restarted after surgery as soon as adequate hemostasis has been established 2.

• The exact timing of restarting anticoagulation is not specified in the drug label, but it should be based on the individual patient's condition and the surgeon's assessment of adequate hemostasis.

From the Research

Perioperative Anticoagulation Management

The decision to restart anticoagulation after surgery depends on various factors, including the type of surgery, the patient's risk of thromboembolism, and the risk of bleeding.

• For patients undergoing minimal bleeding risk procedures, anticoagulation may be continued or discontinued on the day of the procedure 3.
• For patients undergoing low to moderate bleeding risk procedures, anticoagulation should typically be discontinued 1 day before the operation and restarted 1 day after 3.
• For patients undergoing high bleeding risk procedures, anticoagulation should be stopped 2 days prior to the operation and restarted 2 days after 3.

Timing of Anticoagulation Restart

The timing of anticoagulation restart also depends on the individual patient's risk factors and the type of anticoagulant being used.

• For patients taking warfarin, anticoagulation should be stopped 5 days before major surgery and restarted 12 to 24 hours postoperatively 4.
• For patients with a prosthetic valve who suffer an intracranial bleed, anticoagulation can safely be withheld for a short period, up to 7-14 days, and restarted as early as 3 days with heparin and switched to oral anticoagulation at 7 days 5.

Bleeding and Thromboembolic Risks

The risk of bleeding and thromboembolism should be carefully considered when deciding when to restart anticoagulation after surgery.

• The rates of thromboembolism and major bleeding are low when a standardized approach to perioperative anticoagulation management is used 3.
• The risk of thromboembolic events is higher in patients with a history of arterial or venous thromboembolism, and these patients may require more aggressive anticoagulation management 6.
• The risk of bleeding is higher in patients undergoing high bleeding risk procedures, and these patients may require closer monitoring and more cautious anticoagulation management 3.