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perioperative anticoagulation

Risk of hemorrhage from procedure vs. risk of thrombosis === perioperative prophylaxis for venous thromboembolism === - see prophylaxis for venous thromboembolism - see perioperative antiplatelet therapy Management: 1) low risk procedures a) direct oral anticoagulants should be stopped 24-36 hours prior to procedure in low to intermediate-risk patients (2-3 days) [2,19] b) low risk procedures may be done without interruption of warfarin [2] 1] adjustment to INR of about 2.0 prior to procedure 2] ref [2] suggests perioperative target INR is 1.3-1.5 c) includes 1] dental extractions 2] cataract surgery 3] upper endoscopy 4] colonoscopy with or without polypectomy [20] 5] dermatologic procedures 6] pacemaker placement [20] 2) high risk procedures/low risk patients - stop direct oral anticoagulant (DOAC) 24-36 hours prior to procedure in low to intermediate-risk patients (2-3 days) [2,19] (presumably sooner in patients with renal insufficiency) [2] - restart DOAC 1-3 days after procedure (depending on bleeding risk) [14] - stop DOAC 24 hours prior to GI endoscopy & resume 24 hours after for low risk procedures & 48 hours later for high risk procedures in patients with atrial fibrillation [21] - stop warfarin 5 days prior to procedure - recheck INR to ensure that it is < 1.5 on the day of surgery - restart warfarin within 12-24 hours if hemostasis is secure (allow about 5 days for therapeutic anticoagulation) - newer aortic valve prosthesis have < 5% annual risk of thromboembolism, thus bridging anticoagulation unnecessary for otherwise low-risk patients [2] 3) high-risk procedures/patients* - stop direct oral anticoagulant 2-3 days before surgery in patients with normal kidney function (GFR = > 50 mL/min) [2] - 3 days before surgery [2] - if GFR = 31-50 mL/min: 2-3 days apixaban, 1-2 days rivaroxaban, 2-4 days dabigatran - if GFR = < 30 mL/min: > 3 days apixaban, 2-3 days rivaroxaban, > 4 days dabigatran [2] - stop warfarin 5 days prior to procedure [2] - start intravenous heparin when INR falls below 2.5, - ~ 2 days after stopping warfarin - adjust aPTT to 60-80 sec - stop heparin 4-6 hours prior to surgery - if LMW heparin is used, administer last full dose of LMW heparin 24 hours before surgery; - stop LMW heparin 12 hours before surgery [2] - restart heparin after surgery as soon as considered safe (24 hours) [2,20] - restart LMW heparin at 24 hours [16]; at full dose 48-72 hours after procedure with high-risk of hemorrhage if hemostasis is secure [2] - restart warfarin within 12-24 hours if hemostasis is secure (allow about 5 days for therapeutic anticoagulation) - stop heparin when INR is therapeutic - restart dabigatran, rivaroxaban, apixaban 24 hours after surgery 4) therapeutic doses of LMW heparin may be used as alternative to heparin as bridging therapy - no benefit for post-operative bridging with LMW heparin regardless if anticoagulation is for atrial fibrillation or mechanical heart valve [17] 5) consider vit K 1-2 mg PO if INR remains elevated * risk factors for perioperative thrombosis [2] - use HAS-BLED score to assess perioperative bleeding risk [14] - DVT within 1 year or history of recurrent DVT - intermediate risk = DVT with 3-12 months - high risk = DVT within < 3 months - atrial fibrillation with - CHA2DS2-VASC score >= 7 - CHADS score not a factor [7] - prior thromboembolism or stroke [5] - mechanical valve [2]; aortic mechanical valve [2] - moderate-severe mitral stenosis - maybe not atrial fibrillation - bridging for patients with atrial fibrillation increases 30-day combined risk for myocardial infarction, major bleeding, thromboembolism, hospitalization & death [7] - bridging for patients with atrial fibrillation does not prevent thromboembolism, but does increase the risk of bleeding [8] - bridging indicated for patients with recent TIA or stroke, & for patients with rheumatic valvular heart disease [2] - prior stroke - high risk = ischemic stroke within 6 months - active malignancy (treated within 6 months or palliatively) - example of preoperative evaluation of patient with atrial fibrillation scheduled for resection of colon cancer with history of stroke 3 months prior - assessed at moderate risk of thrombosis & high risk of bleeding [19] - stop DOAC 2 days prior to surgery, no bridging necessary [19] - high risk of bleeding in general precludes perioperative bridging [19] - hypercoagulable state = intermediate risk - mechanical heart valve - high risk = older mechanical valve or mitral valve replacement - any mitral valve prosthesis [2] - moderate-severe mitral stenosis [2]

Related

perioperative antiplatelet therapy prophylaxis for venous thromboembolism (VTE)

General

perioperative management anticoagulation

References

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  2. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Bordeaux JS et al. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol 2011 Sep; 65:576. PMID: 21782278
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  9. ASGE Standards of Practice Committee, Anderson MA et al Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009 Dec;70(6):1060-70. PMID: 19889407
  10. Prescriber's Letter 20(5): 2013 Managing Antithrombotics Before Minor Procedures Detail-Document#: 290521 (subscription needed) http://www.prescribersletter.com
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  14. Doherty JU, Gluckman TJ, Hucker WJ et al 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 2017;69(7):871-898 PMID: 28081965 http://www.onlinejacc.org/content/early/2017/01/05/j.jacc.2016.11.024 https://www.sciencedirect.com/science/article/pii/S0735109716370851 - Barnes GD ACC Decision Pathway for Periprocedural Anticoagulation J Am Coll Cardiol. Jan 9 2017 https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/01/07/16/41/2017-acc-expert-consensus-decision-pathway-for-anticoagulation
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  16. Geriatrics at your Fingertips, 21st edition, 2019 Reuben DB et al (eds) American Geriatric Society ISSNL 1553-152X, ISBN 978-1-886775-62-6
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  18. Shaw JR, Li N, Vanassche T et al. Predictors of preprocedural direct oral anticoagulant levels in patients having an elective surgery or procedure. Blood Adv. 2020;4(15):3520-3527 PMID: 32756938 PMCID: PMC7422107 Free PMC article https://ashpublications.org/bloodadvances/article/4/15/3520/461694/Predictors-of-preprocedural-direct-oral
  19. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
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