This document discusses perioperative management of patients taking anticoagulants who are undergoing surgery or procedures. It provides guidance on stopping anticoagulants before surgery based on bleeding risk level. For patients taking warfarin, it recommends not stopping too early and resuming therapeutic low molecular weight heparin no earlier than 48 hours postoperatively. For patients taking direct oral anticoagulants, it advises missing a dose rather than stopping completely for low bleeding risk procedures. The document aims to balance thrombotic and bleeding risks during the perioperative period.
This document discusses perioperative management of patients taking anticoagulants who are undergoing surgery or procedures. It provides guidance on stopping anticoagulants before surgery based on bleeding risk level. For patients taking warfarin, it recommends not stopping too early and resuming therapeutic low molecular weight heparin no earlier than 48 hours postoperatively. For patients taking direct oral anticoagulants, it advises missing a dose rather than stopping completely for low bleeding risk procedures. The document aims to balance thrombotic and bleeding risks during the perioperative period.
This document discusses perioperative management of patients taking anticoagulants who are undergoing surgery or procedures. It provides guidance on stopping anticoagulants before surgery based on bleeding risk level. For patients taking warfarin, it recommends not stopping too early and resuming therapeutic low molecular weight heparin no earlier than 48 hours postoperatively. For patients taking direct oral anticoagulants, it advises missing a dose rather than stopping completely for low bleeding risk procedures. The document aims to balance thrombotic and bleeding risks during the perioperative period.
This document discusses perioperative management of patients taking anticoagulants who are undergoing surgery or procedures. It provides guidance on stopping anticoagulants before surgery based on bleeding risk level. For patients taking warfarin, it recommends not stopping too early and resuming therapeutic low molecular weight heparin no earlier than 48 hours postoperatively. For patients taking direct oral anticoagulants, it advises missing a dose rather than stopping completely for low bleeding risk procedures. The document aims to balance thrombotic and bleeding risks during the perioperative period.
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Perioperative management in
patients with risk for thrombosis
Sabine Eichinger Dept. of Medicine I Medical University of Vienna, Austria Perioperative Management
Bleeding risk Thrombotic risk
Stop Bridging antithrombotics Atrial Fibrillation
Risk of cerebral infarction
CHADS2 Risk/year Non surgical (%) 0 1.9 (1.2-3.0)
1 2.8 (2.0-3.8)
2 4.0 (3.1-5.1)
3 5.9 (4.6-7.3)
4 8.5 (6.3-11.1)
5 12.5 (8.2-17.5)
6 18.2 (10.5-27.4)
Kaatz, J Thromb Haemost 2010
Atrial Fibrillation
Risk of cerebral infarction
CHADS2 Risk/year 30 days Non surgical (%) postoperative (%) 0 1.9 (1.2-3.0) 1.01 (0.83-1.21)
1 2.8 (2.0-3.8) 1.62 (1.46-1.79)
2 4.0 (3.1-5.1) 2.05 (1.87-2.24)
3 5.9 (4.6-7.3) 2.63 (2.26-3.04)
4 8.5 (6.3-11.1) 3.62 (2.66-4.80)
5 12.5 (8.2-17.5) 3.65 (1.83-6.45)
6 18.2 (10.5-27.4) 7.35 (2.42-16.3)
Kaatz, J Thromb Haemost 2010
Anticoagulation and perioperative management
Low bleeding risk
• Tooth extraction • Root canal procedures • Small skin excisions • Endoscopic procedures with low bleeding risk • Cataract surgery • Minor bleeding: OR 3.3 (95% CI 1.7-6.2); Jamula, Thromb Res 2009 • Perioorbital bleeding and retrobulbar anesthesia: 1/136 (<1%) Katz, Ophthalmology 2003
Dunn, Arch Intern Med 2003
Anticoagulation and perioperative management
High bleeding risk
• Intracranial or intraspinal surgery
• Coronary artery bypass • Major vascular surgery • Major orthopedic surgery • Major cancer surgery • Reconstructive plastic surgery • Urogenital surgery • Colonpolypectomie (particularly > 1 cm Ø) • Prostate- or kidney biopsy Thromboembolic risk categories
Thromboembolic Atrial Mechanical Heart Venous
Risk Fibrillation Valves Thromboembolism
Mitral valve Older aortic valve High CHADS2 5,6 VTE < 3 mo (caged-ball, tilting disk) Stroke/TIA < 3 mo
• Last therapeutic dose of LMWH 24 h before surgery • Resume therapeutic LMWH not before 48 h postop. • LMWH bridging preoperatively only in patients at high thrombotic risk Anticoagulation and perioperative management
Practical advice
• Do not stop VKA too early
• Last therapeutic dose of LMWH 24 h before surgery • Resume therapeutic LMWH not before 48 h postop. • LMWH bridging preoperatively only in patients at high thrombotic risk • VKA postoperative: start low - go slow Perioperative Management
D i r e c t or a l OP anticoagulants
Stop Start DOAC and perioperative management
Low bleeding risk
• Do not stop DOAC
• Perform intervention at trough level • OD dosing: halt morning dose until after intervention • BID dosing: miss morning dose Low bleeding risk Dabigatran, Apixaban day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3
Rivaroxaban day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3
P R E O P E R AT I VE P O S T O P E R AT I VE Dabigatran – perioperative management
Elective surgery/interventions
Last intake before surgery
Renal function Half life (CrCl in ml/min) High bleeding risk Standard risk or major surgery
≥ 80 ~ 13 h >48 h >24 h
≥ 50 to < 80 ~ 15 h >72 h >36 h
≥ 30 to < 50 ~ 18 h >96 h >48 h
EHRA guidelines, Heidbuchel, Eur Heart J 2013
Rivaroxaban, Apixaban – perioperative management
Elective surgery/interventions
Last intake before surgery
Renal function (CrCl in ml/min) High bleeding risk or Standard risk major surgery
≥ 80 >48 h >24 h
≥ 50 to < 80 >48 h >24 h
≥ 30 to < 50 >48 h >24 h
≥ 15 to < 30 >48 h >36 h
EHRA guidelines, Heidbuchel, Eur Heart J 2013
Rivaroxaban – perioperative management
High bleeding risk
day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3
PREOPERATIVE P O S T O P E R AT I VE usual thromboprophylaxis Direct oral anticoagulants
Restart after surgery
• Not licensed for postoperative thromboprophylaxis
except for elective hip/knee replacement. • Immediate and complete hemostasis resume DOAC after 6-8 hours. • Maximum concentration within 2-3 h. • Start therapeutic dose not before 48-72 h postop. • Use LMWH at prophylactic dose until safe to use therapeutic dose. RE-ly – dabigatran in atrial fibrillation
0,6 50 0,4 40 0,2 30 20 0 CV death stroke 10 0 CV death stroke
Healey, Circulation 2012
Direct oral anticoagulants – perioperative management
Practical advice
• Prescribe DOAC exactly as licensed
• Check contraindications • Dose according to indication an renal function • check renal function and ensure proper diuresis • Collect standardized bleeding and thrombotic history • Lower dose in case of higher bleeding risk • Use platelet function inhibitors together with DOAC with caution • Avoid long acting NSARs • No preoperative heparin bridging
