From the Guidelines
The resumption of anticoagulation postoperatively should be guided by the bleeding risk associated with the surgery, with anticoagulants resumed at least 24 hours after low-to-moderate-bleed-risk procedures and 48-72 hours after high-bleed-risk procedures. When considering the resumption of anticoagulation, it's crucial to balance the risk of bleeding against the risk of thromboembolism. The decision to restart anticoagulation should be individualized based on the patient's specific clinical scenario, including the type of surgery, the patient's underlying condition requiring anticoagulation, and their overall risk profile 1.
Key Considerations for Resuming Anticoagulation
- For patients undergoing low-to-moderate-bleed-risk procedures, anticoagulation can typically be resumed 24 hours postoperatively 1.
- For high-bleed-risk procedures, it is recommended to delay the resumption of anticoagulation until 48-72 hours postoperatively 1.
- Direct Oral Anticoagulants (DOACs) have a rapid onset of action, reaching peak effect within 1 to 3 hours after intake, which necessitates cautious administration postoperatively 1.
- The choice between different anticoagulants (e.g., warfarin vs. DOACs) should consider the patient's specific needs, the urgency for anticoagulation, and the patient's ability to adhere to the prescribed regimen.
Recent Guidelines and Recommendations
Recent guidelines, such as those from the American College of Chest Physicians and the American Heart Association, emphasize the importance of tailoring the resumption of anticoagulation to the individual patient's risk factors and the type of surgery performed 1. These guidelines suggest that for most patients, anticoagulation can be safely resumed once hemostasis is achieved, with the timing dependent on the surgical procedure's bleeding risk. For example, the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline recommends restarting VKA as early as 12 to 24 hours postoperatively for low or moderate bleeding risk procedures, and considering the resumption of DOACs when full anticoagulation is clinically appropriate, potentially as early as 6 hours postoperatively if hemostasis has occurred 1.
Clinical Decision Making
In clinical practice, the decision to resume anticoagulation should be made on a case-by-case basis, taking into account the latest evidence and guidelines, as well as the patient's unique clinical circumstances. This includes considering the patient's risk of thromboembolism, their risk of bleeding, and any other factors that might influence the safety and efficacy of anticoagulation therapy. Close monitoring postoperatively for both bleeding and thrombotic complications is essential to ensure the best possible outcomes for patients requiring anticoagulation therapy.
From the FDA Drug Label
Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.
The timing for resuming anticoagulation in the postoperative period is as soon as adequate hemostasis has been established. This is a general guideline and may vary depending on the individual patient's condition and the type of surgery or procedure performed. It is essential to consider the benefits and risks of anticoagulation therapy in each patient and to follow the recommended dosage and administration guidelines for apixaban tablets 2.
From the Research
Resuming Anticoagulation Postoperatively
The timing for resuming anticoagulation in the postoperative period is crucial to balance the risk of bleeding and thromboembolism.
- According to 3, warfarin therapy should be stopped five days before major surgery and restarted 12 to 24 hours postoperatively.
- The decision to bridge with low-molecular-weight heparin or other agents depends on the balance between the risk of thromboembolism and the risk of bleeding 4, 3.
- A study published in 5 found that perioperative bridging anticoagulation, especially with full-therapeutic dose low-molecular-weight heparin, markedly increases the risk of postoperative bleeding complications in general and visceral surgery.
Considerations for Resuming Anticoagulation
When considering resuming anticoagulation postoperatively, several factors should be taken into account, including:
- The type of surgery and the patient's underlying condition 4, 6
- The risk of thromboembolism and bleeding 4, 3, 5
- The use of bridging anticoagulation and the choice of anticoagulant 4, 3, 5
- The patient's renal function and the presence of other comorbidities 5
New Anticoagulants and Perioperative Management
New anticoagulants, such as dabigatran, apixaban, and rivaroxaban, have been developed and are being used in the perioperative period 3, 7.