When to Hold Anticoagulation

General Principles

Goal is to reduce risk of both thrombotic events and bleeding peri-operatively
Plans should be personalized for each patient based on thrombotic and bleeding risk taking in to account the patient’s risk factors and the inherent risk of the procedure
Always ask the proceduralist to confirm their requirements for holding anti-coagulation

Recommend delaying elective surgeries for patients with high risk of thrombosis; if procedure is necessary, consider bridging
Atrial fibrillation: acute risk of thrombus formation generally low, considered safe to hold anticoagulation pre-op
Prosthetic heart valves: mitral and mechanical valves high risk; aortic valve moderate risk if also has history of Afib, CHF, CVA, or age>75
DVT/PE: high risk within 3 months of event; moderate risk at 3-12 months or with active cancer; low risk at >12 months
CVA: high risk within 3 months or if also has prosthetic heart valve OR Afib and CHA2DS2- VASc ≥6

High risk: vascular, cardiac, large joint orthopedic surgeries, renal biopsy, cancer resections
Low risk: surgery lasting <45 min, ophthalmologic, dental, bedside procedures, LN biopsy
Certain low risk procedures may not require holding anti-coagulation; always ask the proceduralist to confirm

Medication	Hold Time	Special Considerations
DOAC	1-3 days prior, depending on bleeding risk of procedure	If CrCl<50, consider holding an additional day prior (2-4 days total) If CrCl<30, consider holding additional 2 days prior (3-5 days total)
Warfarin	5 days prior
Heparin	24 hours prior
LMWH	Drip: 4-6 hours prior, keep on for cath SubQ: 12 hours prior
Aspirin	5-7 days prior	Consider recent PCI or ACS. If part of DAPT, discuss with cardiology (i.e. within first year) Continue aspirin for those undergoing CABG, CEA, peripheral vascular surgery
P2Y12 Inhibitors	Clopidogrel: 5 days Ticagrelor: 3-5 days Prasugrel: 7 days	Consider recent PCI or ACS. If part of DAPT, discuss with cardiology (i.e. within first year)

Does not decrease risk of thrombotic events for most patients
Afib alone does not require bridging
Recommend bridging for patients on warfarin at high risk (CVA or proximal VTE within 3 months, mechanical valves) or patients with prior thrombotic events during disruption of anticoagulation
Most commonly use LMWH or heparin to bridge, continue post-op until INR within therapeutic range

Generally, restart anti-coagulation at 24hr post-op for lower risk procedures or 48hr for higher risk procedures if adequate hemostasis has been achieved