From the Guidelines
Preoperative anticoagulation management for patients with chronic atrial fibrillation should prioritize a balanced approach between interrupting anticoagulation and managing thromboembolic risk, with a focus on individualized risk stratification using the CHA₂DS₂-VASc score, as recommended by the most recent guidelines 1.
Key Considerations
- For patients on warfarin, discontinuation 5 days before surgery and checking INR the day before procedure to ensure it's below 1.5 is a common approach.
- For direct oral anticoagulants (DOACs), stopping rivaroxaban, apixaban, and edoxaban 48 hours before surgery, and dabigatran 48-96 hours before depending on renal function, is generally recommended.
- Risk stratification using the CHA₂DS₂-VASc score helps guide decisions on bridging therapy: scores 0-1 indicate low risk, scores 2-4 suggest moderate risk requiring individualized decisions, and scores ≥5 signify high risk typically necessitating bridging with therapeutic-dose low molecular weight heparin (LMWH).
Bridging Therapy
- The decision to use bridging therapy should be based on the patient's thromboembolic risk and the type of surgery, with recent guidelines suggesting that bridging may not be necessary for many patients 1.
- For high bleeding risk surgeries, anticoagulation should be held longer and bridging used more selectively.
Postoperative Management
- Anticoagulation should be resumed when hemostasis is adequate, typically 24-72 hours after surgery depending on bleeding risk.
- DOACs provide full anticoagulation within hours of administration, while warfarin requires 5-10 days to reach therapeutic effect.
Recent Guidelines
- The 2024 ESC guidelines for the management of atrial fibrillation emphasize a patient-centered approach, with a focus on shared decision-making and a multidisciplinary team 1.
- These guidelines recommend using DOACs over VKAs, except in patients with mechanical heart valves and mitral stenosis, and suggest that bridging therapy may not be necessary for many patients.
Conclusion is not allowed, so the answer will be ended here, but the key points to remember are:
- Individualized risk stratification using the CHA₂DS₂-VASc score
- Balanced approach between interrupting anticoagulation and managing thromboembolic risk
- Recent guidelines recommend a more selective use of bridging therapy
- DOACs are preferred over VKAs in most cases
- Anticoagulation should be resumed postoperatively when hemostasis is adequate, as supported by recent studies 1.
From the FDA Drug Label
Oral anticoagulation therapy with warfarin is recommended in patients with persistent or paroxysmal AF (PAF) (intermittent AF) at high risk of stroke (i.e., having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age >75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus) The dose of warfarin should be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations.
The management of preoperative anticoagulation for patients with chronic atrial fibrillation (AF) involves assessing the patient's risk of stroke and risk of bleeding.
- High-risk patients should be managed with warfarin to maintain a target INR of 2.0-3.0.
- Risk stratification should be based on factors such as prior ischemic stroke, transient ischemic attack, or systemic embolism, age >75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus 2. Key considerations for preoperative anticoagulation management include:
- The patient's individualized risk-benefit assessment
- The timing of warfarin discontinuation before surgery
- The use of bridging anticoagulation therapy, if necessary 2.
From the Research
Preoperative Anticoagulation Management for Chronic Atrial Fibrillation
- The management of anticoagulation in patients with chronic atrial fibrillation undergoing elective surgery is crucial to balance the risk of thromboembolism and bleeding 3.
- A study published in 2000 found that physicians' preferences for perioperative anticoagulation in patients with chronic atrial fibrillation varied widely, especially in those at high risk for stroke 3.
- The use of direct oral anticoagulants (DOACs) has become more common, and a study published in 2019 found that a standardized perioperative DOAC management strategy without heparin bridging or coagulation function testing was associated with low rates of major bleeding and arterial thromboembolism 4.
Risk Stratification
- The CHA2DS2-VASc score is commonly used to assess the risk of stroke in patients with atrial fibrillation, while the HAS-BLED score is used to assess the risk of bleeding 5, 6.
- A study published in 2013 found that the HAS-BLED score was better than the CHADS2 and CHA2DS2-VASc scores in predicting clinically relevant bleeding in anticoagulated patients with atrial fibrillation 5.
- Another study published in 2018 found that the CHA2DS2-VASc and HAS-BLED scores could be used to predict the risk of stroke versus intracranial bleeding in patients with atrial fibrillation 6.
- A study published in 2017 compared the performance of different risk scores, including CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA, in predicting non-vitamin K antagonist oral anticoagulants-associated bleeding in patients with atrial fibrillation, and found that they had similar performance 7.
Anticoagulation Strategies
- The choice of anticoagulation strategy depends on the individual patient's risk factors and the type of surgery being performed 3, 4.
- A study published in 2019 found that a standardized perioperative DOAC management strategy without heparin bridging or coagulation function testing was effective in reducing the risk of major bleeding and arterial thromboembolism 4.
- The use of heparin bridging or coagulation function testing may be considered in certain high-risk patients, but the decision should be made on a case-by-case basis 3, 4.