When should anticoagulation (Anti-Coagulation) therapy be restarted after surgery?

From the Guidelines

Anticoagulation therapy should be restarted as early as 12 to 24 hours postoperatively for patients on Vitamin K Antagonists (VKAs) and as early as 6 hours postoperatively for patients on Direct Oral Anticoagulants (DOACs) after low or moderate bleeding risk procedures, once hemostasis is achieved. The decision to restart anticoagulation therapy after surgery depends on various factors, including the type of anticoagulant, the surgical procedure, and the patient's bleeding risk.

• For VKAs, such as warfarin, it is reasonable to restart therapy 12 to 24 hours postoperatively, at the previous therapeutic dose, with additional monitoring as needed 1.
• For DOACs, such as apixaban, rivaroxaban, dabigatran, or edoxaban, therapy can be resumed as early as 6 hours postoperatively, once hemostasis is achieved, due to their rapid onset of action 1. The timing of anticoagulation resumption also depends on the bleeding risk associated with the surgery, with low-to-moderate-bleed-risk procedures allowing for earlier resumption compared to high-bleed-risk procedures 1. Key considerations include balancing the risk of thromboembolism against the risk of surgical site bleeding, and individualizing the decision based on patient-specific factors, such as the presence of mechanical heart valves, recent venous thromboembolism, or atrial fibrillation with high CHADS2 scores.
• In general, patients with high bleeding risk may require delayed anticoagulation resumption, potentially with bridging therapy using heparin products before oral anticoagulants are restarted 1.

From the FDA Drug Label

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

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

From the Research

Restarting Anticoagulation Therapy

The decision to restart anticoagulation therapy after surgery or major bleeding is complex and depends on various factors, including the type of surgery, the patient's thromboembolic risk, and the risk of bleeding.

• Studies have shown that anticoagulants can be restarted relatively early after surgery, with a low risk of thrombosis and bleeding complications 3, 4, 5.
• The timing of anticoagulation restart varies depending on the patient's condition and the type of anticoagulant used. For example, one study found that anticoagulants were restarted significantly earlier after emergency surgery compared to major bleeding, with no difference between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) 3.
• Another study found that a standardized periprocedural anticoagulation regimen with low-molecular-weight heparin was associated with a low risk of thromboembolic and major bleeding complications in patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin therapy 4.
• A prospective inception cohort management study found that an individualized bridging protocol with low-molecular-weight heparin was effective and safe for outpatients on oral anticoagulants undergoing invasive procedures or surgery, with a low risk of thromboembolic events and major bleeding episodes 5.

Specific Considerations

Certain patient populations, such as those with prosthetic valves or intracranial bleeding, require special consideration when restarting anticoagulation therapy.

• One study found that anticoagulation can be safely withheld for a short period, up to 7-14 days, in patients with intracranial bleeding and a prosthetic valve, with a low probability of thromboembolic events 6.
• Another study found that restarting anticoagulation therapy after major bleeding was associated with a decreased risk of thrombotic events, but an increased risk of rebleeding, highlighting the need for careful consideration of the risks and benefits of anticoagulation restart 7.

Key Findings

Key findings from the studies include:

• Anticoagulants can be restarted relatively early after surgery, with a low risk of thrombosis and bleeding complications.
• The timing of anticoagulation restart varies depending on the patient's condition and the type of anticoagulant used.
• Individualized bridging protocols with low-molecular-weight heparin can be effective and safe for outpatients on oral anticoagulants undergoing invasive procedures or surgery.
• Special consideration is required for patient populations with prosthetic valves or intracranial bleeding.