From the Guidelines
Perioperative management of antithrombotic therapy should prioritize a balanced approach between minimizing bleeding risks and preventing thrombotic events, with decisions guided by the most recent and highest quality evidence.
Key Considerations
- The management strategy should be based on the type of anticoagulant, the patient's thrombotic risk, and the procedure's bleeding risk.
- For patients on warfarin, discontinuation 5 days before surgery and aiming for an INR <1.5 is recommended, with bridging therapy using low molecular weight heparin (LMWH) considered for high-risk patients 1.
- For direct oral anticoagulants (DOACs) like apixaban or rivaroxaban, interruption 2-3 days before low-bleeding-risk procedures and 3-4 days before high-bleeding-risk procedures is suggested, with adjustments for renal impairment 1.
- Aspirin for cardiovascular protection can often be continued for low-bleeding-risk procedures but may need to be discontinued 7-10 days before high-bleeding-risk surgeries.
- Restarting anticoagulants 24-72 hours after surgery, based on hemostasis status, is crucial, with DOACs resumed at full dose and warfarin requiring LMWH bridging until therapeutic INR is achieved 1.
Decision Making
- Team-based decision-making is essential, especially for high thrombotic risk patients or procedures with higher risks of adverse outcomes if bleeding occurs 1.
- The use of standardized risk stratification for procedural/surgical bleed risk and patient-specific thromboembolic risk can guide management decisions 1.
- Recent studies, such as the PAUSE study, support standardized perioperative DOAC management with low rates of major bleeding and thromboembolism 1.
Recommendations
- For warfarin, discontinue 5 days before surgery, aiming for INR <1.5, with bridging therapy for high-risk patients.
- For DOACs, interrupt 2-3 days before low-bleeding-risk procedures and 3-4 days before high-bleeding-risk procedures, adjusting for renal function.
- Aspirin can be continued for low-bleeding-risk procedures but consider discontinuation 7-10 days before high-bleeding-risk surgeries.
- Restart anticoagulants 24-72 hours post-surgery, based on hemostasis, with DOACs at full dose and warfarin with LMWH bridging until therapeutic INR.
These recommendations are based on the most recent and highest quality evidence, prioritizing morbidity, mortality, and quality of life outcomes 1.
From the FDA Drug Label
2.4 Discontinuation for Surgery and other Interventions
The FDA drug label does not answer the question.
From the Research
Perioperative Management of Antithrombotic Therapy
The management of antithrombotic therapy in the perioperative setting is a complex issue, requiring a balance between the risk of bleeding and the risk of thrombosis. The following are key considerations:
- The decision to discontinue anticoagulants such as warfarin or direct oral anticoagulants (DOACs) like apixaban or rivaroxaban should be based on the patient's risk of thrombosis and bleeding 2, 3, 4, 5, 6.
- For patients on warfarin, bridging therapy with a low-molecular-weight heparin may be necessary for those at high risk of thrombosis, but not for those on non-vitamin K antagonist oral anticoagulant drugs 3, 6.
- Aspirin can be continued for most procedures, but decisions should be individualized and taken after multidisciplinary discussion 3.
- The use of dual antiplatelet agents for patients with a recently inserted coronary artery stent should be continued if possible, but decisions should be individualized and taken after multidisciplinary discussion 3.
Discontinuation of Anticoagulants
The discontinuation of anticoagulants such as warfarin or DOACs should be based on the patient's risk of thrombosis and bleeding. The following are general guidelines:
- For patients on warfarin, the international normalized ratio (INR) should be measured before surgery, and warfarin should be discontinued 5-7 days before surgery if the INR is elevated 2, 4, 5.
- For patients on DOACs, the medication should be discontinued 24-48 hours before surgery, depending on the patient's renal function and the type of surgery 6.
Use of Aspirin for Cardiovascular Protection
Aspirin can be continued for most procedures, but decisions should be individualized and taken after multidisciplinary discussion. The following are general guidelines:
- For patients undergoing elective non-cardiac surgery, aspirin can be continued if the patient is at low risk of bleeding 2, 3.
- For patients undergoing cardiac surgery, aspirin should be discontinued 7-10 days before surgery if the patient is at high risk of bleeding 2, 3.
Bridging Therapy
Bridging therapy with a low-molecular-weight heparin may be necessary for patients at high risk of thrombosis who are discontinuing anticoagulants such as warfarin. The following are general guidelines: