What is the recommendation for holding anticoagulation (blood thinner) or antiplatelet (platelet inhibitor) therapy preoperatively in patients scheduled for surgery?

Preoperative Anticoagulation and Antiplatelet Management

For most patients undergoing elective surgery, warfarin should be stopped 5 days preoperatively to achieve INR ≤1.5, while aspirin should be continued perioperatively unless the bleeding risk clearly outweighs cardiac benefit. 1

Warfarin Management

Timing of Discontinuation

• Stop warfarin 5 days before major surgery to allow adequate decay of anticoagulant effect, achieving INR ≤1.5 at the time of procedure 2, 1
• Warfarin's half-life of 36-42 hours requires at least 5 days for elimination of most anticoagulant effect, though elderly patients may experience delayed decay 1
• Check INR the day before surgery to confirm INR ≤1.5 before proceeding 3

Minor Procedures

• Continue warfarin for minor procedures (dental work, skin procedures, cataract surgery) with target INR 1.5-1.8 1
• A shorter interruption interval of 2-3 days may suffice for minor procedures to achieve INR 1.5-1.8 1

Bridging Anticoagulation

High-risk patients requiring bridging:

• Any mechanical mitral valve replacement 1
• Mechanical aortic valve with additional risk factors 1
• Recent venous thromboembolism (<3 months) 1
• Atrial fibrillation with CHADS₂ score ≥5 1

Bridging protocol:

• Start therapeutic LMWH when INR falls below 2.0 (typically 48 hours after stopping warfarin) 1
• Last preoperative LMWH dose must be 24 hours before surgery, not 12 hours—34% of patients have therapeutic anticoagulation at surgery when dosed 12 hours prior 1, 3
• Stop IV unfractionated heparin 4-6 hours before surgery 2, 1

Postoperative Resumption

• Resume warfarin at usual maintenance dose on evening of surgery or next morning 1, 3
• For high bleeding risk procedures, delay therapeutic anticoagulation for 48-72 hours 1, 3
• Continue bridging until INR ≥2.0 for 2 consecutive days 1

Direct Oral Anticoagulants (DOACs)

Elective Surgery Timing

Apixaban should be discontinued at least 48 hours prior to elective surgery with moderate or high bleeding risk, and at least 24 hours prior to procedures with low bleeding risk. 4

Standardized approach by bleeding risk:

• Minimal bleeding risk (minor dental/skin procedures): Continue DOAC or stop on day of procedure 5
• Low to moderate bleeding risk (cholecystectomy, hernia repair): Stop DOAC 1 day before, restart 1 day after 5
• High bleeding risk (major cancer surgery, joint replacement): Stop DOAC 2 days before, restart 2 days after 5

Bridging Not Required

• Bridging anticoagulation during the 24-48 hours after stopping DOACs is not generally required 4
• This standardized approach achieves thromboembolism rates of 0.2-0.4% and major bleeding rates of 1-2% 5

Emergent/Urgent Surgery

• Emergent surgery (<6 hours): Consider reversal agents if DOAC levels elevated—bleeding rates up to 23%, thromboembolism up to 11% 5
• Urgent surgery (6-24 hours): Laboratory testing to measure DOAC levels may guide use of reversal agents (prothrombin complex concentrates, idarucizumab, andexanet-α) 5

Antiplatelet Management

Aspirin

Continue aspirin perioperatively in patients with coronary stents or moderate-to-high cardiovascular risk. 2

• Continue aspirin chronically in patients with prior coronary stenting undergoing noncardiac surgery 2
• Continue aspirin when risk of cardiac events outweighs bleeding risk in nonemergency surgery without prior stenting 2
• Initiation or continuation of aspirin provides no benefit in elective noncardiac noncarotid surgery without previous coronary stenting 2

Dual Antiplatelet Therapy (DAPT)

Critical timing considerations:

• Continue DAPT during first 4-6 weeks after bare-metal stent (BMS) or drug-eluting stent (DES) implantation, unless bleeding risk outweighs stent thrombosis prevention 2
• Elective noncardiac surgery should not be performed within 30 days after BMS or within 12 months after DES implantation 2
• Elective surgery should not be performed within 14 days of balloon angioplasty if aspirin must be discontinued 2

P2Y12 Inhibitors (Clopidogrel/Prasugrel)

• In patients with stents requiring surgery that necessitates P2Y12 inhibitor discontinuation: continue aspirin and restart P2Y12 inhibitor as soon as possible after surgery 2
• Stop clopidogrel/prasugrel 5-7 days before surgery in patients without recent coronary stent 6
• Management decisions should be determined by consensus of treating clinicians and patient 2

Critical Pitfalls to Avoid

• Never give high-dose vitamin K routinely for preoperative warfarin reversal—creates hypercoagulable state and makes re-anticoagulation difficult 1
• Never start therapeutic LMWH within 24 hours post-surgery for high bleeding risk procedures—major bleeding occurs in 20% of patients 3
• Never give last preoperative LMWH dose <24 hours before surgery—34% have therapeutic levels at surgery when dosed 12 hours prior 1, 3
• Never stop warfarin only 2-3 days preoperatively for major surgery—results in mean INR of 1.8, insufficient for most procedures 1
• Fresh frozen plasma is preferred over vitamin K for emergency surgery requiring immediate reversal 1