Can an adult patient with a history of cardiovascular disease, including atrial fibrillation (AFIB), hypertension, diabetes, and heart failure, manage surgery while on anticoagulation therapy, such as warfarin or novel oral anticoagulants (NOACs), like apixaban (eliquis) or rivaroxaban (xarelto)?

Can Patients with Atrial Fibrillation Safely Undergo Surgery?

Yes, patients with atrial fibrillation can safely manage surgery, but perioperative anticoagulation management must be carefully tailored based on stroke risk (CHA₂DS₂-VASc score), bleeding risk of the procedure, and type of anticoagulant used. 1, 2

Risk Stratification Before Surgery

Calculate the CHA₂DS₂-VASc score to determine thromboembolic risk:

• High-risk patients (CHA₂DS₂-VASc ≥2, or ≥1 with mechanical valves or prior stroke) require bridging anticoagulation when oral anticoagulants are interrupted 1
• Low-risk patients (CHA₂DS₂-VASc <2 and in sinus rhythm) may have anticoagulation stopped for up to 1 week without bridging 1

The 2024 ESC guidelines recommend anticoagulation for CHA₂DS₂-VA ≥2 (note: this score excludes sex as a criterion), and consideration for CHA₂DS₂-VA = 1 1

Perioperative Anticoagulation Management Strategy

For Low Bleeding Risk Procedures

Continue anticoagulation without interruption for procedures like cataract surgery, pacemaker/ICD implantation, catheter ablation, and coronary angiography 1, 3

• Radiofrequency catheter ablation performed with therapeutic INR does not increase bleeding risk and reduces embolic risk 1
• Pacemaker/defibrillator implantation with therapeutic INR has lower bleeding risk than bridging with heparin 1

For Warfarin Management in Moderate-to-High Bleeding Risk Surgery

For low thromboembolic risk patients:

• Stop warfarin up to 1 week before surgery and allow INR to normalize without bridging 1
• Resume warfarin after adequate hemostasis is achieved 1

For high thromboembolic risk patients (mechanical valves, prior stroke, CHA₂DS₂-VASc ≥2):

• Bridging with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is common practice, though data for LMWH are limited 1, 2

For DOAC Management (Apixaban, Rivaroxaban, Dabigatran)

DOACs are preferred over warfarin in eligible patients without mechanical valves or moderate-to-severe mitral stenosis 1, 2

Timing of DOAC interruption depends on renal function and bleeding risk:

• For normal renal function: Hold for 1 day (2 doses for dabigatran/apixaban; 1 dose for rivaroxaban) before elective surgery 1
• For procedures requiring complete hemostasis (spinal puncture, epidural catheter, major surgery): Discontinue ≥48 hours before surgery 1
• In the ROCKET AF trial, rivaroxaban was held for 2 days before elective surgery and 24 hours before semi-urgent procedures 1

Critical caveat: DOACs must be used with extreme caution for procedures where cardiac perforation is possible (e.g., catheter ablation) due to lack of approved reversal agents in case of cardiac tamponade 1

Rate Control Optimization Before Surgery

Optimize rate control before elective surgery to reduce perioperative cardiac complications:

• Target resting heart rate <100-110 bpm 2
• Beta-blockers are first-line therapy for rate control in patients without contraindications 1, 2
• Continue beta-blockers throughout the perioperative period, as withdrawal increases risk of perioperative AF 3, 2
• Allow ideally 2-4 weeks on beta-blocker therapy to achieve stable rate control before elective surgery 2

Alternative rate control agents:

• Use diltiazem or verapamil only if LVEF >40% and beta-blockers are contraindicated 1, 3, 2
• Never use nondihydropyridine calcium channel blockers (diltiazem, verapamil) if there is any concern for heart failure with reduced ejection fraction, as they may be harmful 2

Postoperative Anticoagulation Resumption

Resume oral anticoagulation as soon as safely possible after surgery:

• Typically within 24-72 hours based on surgical hemostasis and surgeon approval 2
• For DOACs, anticoagulation is achieved promptly upon resumption, unlike warfarin which requires days 1
• Continue anticoagulation indefinitely based on CHA₂DS₂-VASc score, regardless of whether the patient remains in sinus rhythm 3

Critical Pitfalls to Avoid

Do not rely on aspirin alone for stroke prevention in AF patients with elevated stroke risk—aspirin is significantly less effective than oral anticoagulation and is not recommended 1, 2

Spinal/epidural hematoma risk is increased in patients on anticoagulation undergoing neuraxial anesthesia or spinal puncture 4

• Risk factors include: indwelling epidural catheters, concomitant NSAIDs or antiplatelet agents, history of difficult spinal procedures, and spinal deformity 4
• Monitor frequently for neurological impairment (back pain, tingling, numbness, muscle weakness, loss of bowel/bladder control) 4

Bleeding risk is increased when combining oral anticoagulants with antiplatelet therapy ("triple therapy"), which carries high annual risk of fatal and nonfatal bleeding 1

• Avoid combining anticoagulants and antiplatelet agents unless the patient has an acute vascular event or needs interim treatment for procedures 1

For patients with renal impairment: Dose adjustments are critical for DOACs, and rivaroxaban should be avoided if CrCl <15 mL/min 4