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Periprocedural management of oral anticoagulant therapy

Last updated: December 1, 2021

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Oral anticoagulants include vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). Periprocedural management of patients on long-term oral anticoagulants (e.g., for the prevention of stroke and systemic thromboembolism) is a field of ongoing research and there is currently no universal validated strategy. Management of anticoagulants in the periprocedural period should be tailored to the patient and the procedure in consultation with the proceduralist and anesthetist. Although invasive procedures performed on patients receiving anticoagulants are associated with an increased risk of bleeding, discontinuing anticoagulants increases the risk of thrombosis. Therefore, anticoagulant therapy should not be routinely interrupted periprocedurally, but instead, the decision should be based on the periprocedural bleeding risk and the periprocedural thrombotic risk. Once interrupted, VKAs take time to achieve therapeutic anticoagulation on reinitiation, and hence, bridging anticoagulation with a short-acting parenteral anticoagulant is required in patients at high thrombotic risk. Bridging anticoagulation is not routinely required for patients on DOACs, as they have a short half-life and, if discontinued, can rapidly achieve therapeutic anticoagulation on reinitiation.

For life-threatening periprocedural bleeding in patients on anticoagulants, see “Anticoagulant reversal.”

The general approach to periprocedural management of anticoagulant therapy is described here. As guidelines vary, it is strongly encouraged to consult the proceduralist and the anesthetist early and to follow local protocols. [1][2]

The decision to interrupt ongoing anticoagulation therapy should be tailored to the patient and the procedure. The risk of periprocedural thrombosis should be weighed against the risk of periprocedural bleeding.

Elective procedures [1][2]

The following suggestions are based on the 2012 American College of Chest Physicians guideline and the 2017 American College of Cardiology (ACC) decision pathway, and apply to elective procedures. See “Periprocedural management of VKAs” and “Periprocedural management of DOACs” for further details.

Parenteral bridging anticoagulation is not required for DOACs. [2]

Most recommendations are based on clinical experience and trials in patients with nonvalvular atrial fibrillation. Exercise caution when applying these recommendations to patients with a mechanical heart valve or a history of venous thromboembolism. If available, adhere to institutional guidelines.

Emergency procedures

Patient-related risk factors [2][3][4]

The following factors are associated with an increased risk of periprocedural bleeding.

Consider delaying elective procedures until modifiable risk factors for periprocedural bleeding can be corrected or optimized.

Procedure-related risk factors

Procedure-related bleeding risk [1][2][5][6]
High bleeding risk procedures Low bleeding risk procedures
Urological procedures
Endoscopic procedures
Vascular and cardiac surgery
Orthopedic surgery
Neurosurgery
  • Intracranial surgery
  • Spinal surgery
  • N/A
Gynecological procedures
General, colon, and rectal surgery
Other
  • Reconstructive plastic surgery
  • Head and neck cancer surgery
  • Any surgery lasting > 45–60 minutes

Even relatively minor bleeding in certain compartments (e.g., intraocular, spinal, pericardial) may cause significant morbidity and mortality. [2]

Risk factors for periprocedural thrombosis [1][4]

Common clinical scenarios [1][4]

Atrial fibrillation, mechanical heart valves, and VTE are the most common conditions that require long-term anticoagulation. The following table provides guidance on determining the periprocedural thrombotic risk in patients with these conditions, but the ultimate decision of whether to discontinue anticoagulation should be made on a case-by-case basis, ideally in consultation with relevant specialists.

Periprocedural thrombotic risk [1][2][4]
High thrombotic risk
(> 10% annual risk of thrombotic event)
Moderate thrombotic risk
(5–10% annual risk of thrombotic event)
Low thrombotic risk
(< 5% annual risk of thrombotic event)
Nonvalvular atrial fibrillation

Mechanical heart valve

  • Valvular prostheses except for bileaflet aortic valve prosthesis
  • Stroke or TIA < 6 months before planned procedure
Venous thromboembolism
  • VTE > 12 months before planned procedure

Approach [2]

The decision of whether to interrupt VKAs is based on periprocedural bleeding risk. If VKAs are interrupted, the need for bridging anticoagulation is determined based on periprocedural thrombotic risk.

VKA interruption [2][4]

VKA interruption is the temporary discontinuation of VKAs a few days before an elective invasive procedure to minimize periprocedural bleeding risk.

Bridging anticoagulation [2]

Periprocedural bridging anticoagulation involves the temporary administration of a short-acting parenteral anticoagulant after VKA interruption for an invasive procedure. The timing of bridging anticoagulation initiation (i.e., pre- or postprocedurally) is based on periprocedural bleeding risk. Protocols may vary between institutions.

Preprocedural bridging anticoagulation [2]

  • Timing
  • Agents
  • Reassess INR 24 hours before the procedure.
    • INR normal or subtherapeutic: Procedure can be performed.
    • Persistently elevated INR: Consider delaying the procedure till the desired INR is achieved.

Postprocedural bridging anticoagulation and resumption of VKA [1][2]

DOAC interruption [2]

The decision of whether to interrupt DOAC therapy is based on periprocedural bleeding risk.

  • High or uncertain periprocedural bleeding risk (patient and procedure-related): Interrupt DOAC.
  • Low periprocedural bleeding risk (patient and procedure-related)
    • Interruption may not always be necessary (consult proceduralist and anesthetist).
    • The procedure should be timed to coincide with the lowest plasma concentration of the DOAC.

Bridging anticoagulation with a parenteral agent is typically not required for DOACs. [2][7]

Timing [2]

The timing of DOAC interruption is based on periprocedural bleeding risk and creatinine clearance.

Factor Xa inhibitors

Timeframe for preoperative discontinuation of factor Xa inhibitors [2]
Creatinine clearance Periprocedural bleeding risk
Low High or uncertain
≥ 30 mL/min ≥ 24 hours ≥ 48 hours
15–29 mL/min ≥ 36 hours No data
< 15 mL/min Unknown

Dabigatran

Timeframe for preoperative discontinuation of dabigatran [2][7]
Creatinine clearance Periprocedural bleeding risk
Low High or uncertain
≥ 80 mL/min ≥ 24 hours ≥ 48 hours
50–79 mL/min ≥ 36 hours ≥ 72 hours
30–49 mL/min ≥ 48 hours ≥ 96 hours
15–29 mL/min ≥ 72 hours ≥ 120 hours
< 15 mL/min No data No data

DOAC reinitiation [2]

  1. Doherty JU et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll Cardiol. 2017; 69 (7): p.871-898. doi: 10.1016/j.jacc.2016.11.024 . | Open in Read by QxMD
  2. Urban P, Mehran R, Colleran R, et al. Defining High Bleeding Risk in Patients Undergoing Percutaneous Coronary Intervention. Circulation. 2019; 140 (3): p.240-261. doi: 10.1161/circulationaha.119.040167 . | Open in Read by QxMD
  3. Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations. Journal of Vascular and Interventional Radiology. 2019; 30 (8): p.1168-1184.e1. doi: 10.1016/j.jvir.2019.04.017 . | Open in Read by QxMD
  4. Gotoh S, Yasaka M, Nakamura A, Kuwashiro T, Okada Y. Management of Antithrombotic Agents During Surgery or Other Kinds of Medical Procedures With Bleeding: The MARK Study. Journal of the American Heart Association. 2020; 9 (5). doi: 10.1161/jaha.119.012774 . | Open in Read by QxMD
  5. Daniels PR. Peri-procedural management of patients taking oral anticoagulants. BMJ. 2015 : p.h2391. doi: 10.1136/bmj.h2391 . | Open in Read by QxMD
  6. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative Management of Antithrombotic Therapy. Chest. 2012; 141 (2): p.e326S-e350S. doi: 10.1378/chest.11-2298 . | Open in Read by QxMD
  7. Douketis JD et al. Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant. JAMA Intern Med. 2019; 179 (11): p.1469. doi: 10.1001/jamainternmed.2019.2431 . | Open in Read by QxMD
  8. Spyropoulos AC et al. Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. J Thromb Haemost. 2016; 14 (5): p.875-885. doi: 10.1111/jth.13305 . | Open in Read by QxMD
  9. Douketis JD et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015; 373 (9): p.823-833. doi: 10.1056/nejmoa1501035 . | Open in Read by QxMD