Should anticoagulant medications be held prior to surgery?

Perioperative Management of Anticoagulant and Antiplatelet Medications

Yes, anticoagulant and antiplatelet medications should generally be held prior to surgery, with specific timing based on the medication type, bleeding risk of the procedure, and patient's thrombotic risk. 1

Warfarin Management

Stop warfarin 5 days (five doses) before surgery to allow INR normalization to <1.5 for major procedures. 1, 2 This timing allows adequate clearance while minimizing thrombotic risk. 1

• Check INR the day before surgery to identify patients with elevated values requiring oral vitamin K 1.0-2.5 mg 2
• Resume warfarin 12-24 hours after surgery (evening of surgery or next morning) when adequate hemostasis is achieved 2, 3
• For minor procedures with lower bleeding risk, a shorter 2-3 day interruption targeting INR 1.5-1.8 may be sufficient 2

Aspirin Management

Continue aspirin perioperatively for patients with moderate-to-high cardiovascular risk or those undergoing CABG surgery. 1, 2, 4 The thrombotic risk outweighs bleeding risk in most surgical settings. 4

• Stop aspirin only for procedures where even minor bleeding is catastrophic: intracranial neurosurgery, spinal surgery within the medullary canal, or posterior chamber eye surgery 4
• For low cardiovascular risk patients undergoing elective surgery, stop aspirin ≤7 days before the procedure 1, 2
• Resume aspirin within 24 hours postoperatively when hemostasis is adequate 4

P2Y12 Inhibitor Management

Stop clopidogrel 5 days before surgery, prasugrel 7 days before surgery, and ticagrelor 3-5 days before surgery. 1, 2, 5 These intervals correspond to drug elimination half-lives and platelet turnover. 1

• For patients with recent coronary stents, defer elective surgery ≥6 weeks after bare-metal stent placement or ≥6 months after drug-eluting stent placement 2, 4
• If surgery cannot be deferred in stented patients, continue dual antiplatelet therapy perioperatively rather than stopping both agents 2
• Resume P2Y12 inhibitors within 24 hours after surgery when hemostasis is adequate 2, 4

Direct Oral Anticoagulants (DOACs)

Stop DOACs 1 day before low-to-moderate bleeding risk procedures and 2 days before high bleeding risk procedures in patients with normal renal function. 6

For dabigatran specifically:

• Normal/mild renal impairment (CrCl ≥50 mL/min): Last dose 2 days before low-risk surgery (skip 2 doses) or 3 days before high-risk surgery (skip 4 doses) 1
• Moderate renal impairment (CrCl 30-50 mL/min): Last dose 3 days before low-risk surgery (skip 4 doses) or 4-5 days before high-risk surgery (skip 6-8 doses) 1

For rivaroxaban and apixaban:

• Similar 2-5 day interruption depending on renal function and bleeding risk 1, 5
• Resume DOACs 1 day after low-to-moderate bleeding risk procedures and 2 days after high bleeding risk procedures 6

Bridging Anticoagulation Decision

Use bridging anticoagulation only for high-risk patients: mechanical heart valves, atrial fibrillation with recent stroke/TIA or CHA₂DS₂-VASc >4, or recent VTE (<3 months). 2, 4 Most patients do not require bridging. 2

Do not bridge low-risk patients: atrial fibrillation with CHADS₂ score ≤2, remote VTE, or bileaflet aortic valve without other risk factors. 2

Bridging Protocol When Indicated

• LMWH bridging: Give last preoperative dose 24 hours before surgery 2
• Resume LMWH 24-48 hours after low-moderate bleeding risk surgery or 48-72 hours after high bleeding risk surgery 2
• Unfractionated heparin bridging: Stop IV UFH 4-6 hours before surgery 2
• Continue bridging until INR returns to therapeutic range when resuming warfarin 1

Critical Pitfalls to Avoid

Never stop aspirin in patients with coronary stents placed within 6-12 months without cardiology consultation—the thrombotic risk is prohibitive. 4 Stent thrombosis carries 45% mortality. 7

• Do not routinely discontinue aspirin for dental procedures or minor surgeries; local hemostatic measures are sufficient 4
• Do not use heparin or LMWH as substitutes for antiplatelet therapy in stented patients—they do not prevent stent thrombosis 7
• Restart antiplatelet therapy as soon as hemostasis is achieved (typically 12-24 hours postoperatively) to minimize thrombotic risk 4, 5
• Perform thorough medication reconciliation as patients may not report over-the-counter NSAIDs with antiplatelet effects 5