Anticoagulation

• This is a general approach based on observational data - use your clinical judgement and discuss with surgeons, pharmacy, and hematology as needed.
• For management of urgent anticoagulation reversal, please see the Hematology section.
• Stepwise approach:

1. Assess the risk of thromboembolism
2. Assess the risk of bleeding for the proposed surgery
3. Assess the need for bridging

1.     Assess the risk of thromboembolism

Thromboembolic Risk	Mechanical Heart Valve	Atrial Fibrillation	Venous Thromboembolism (DVT/PE)
Low (<4% per year)	Bileaflet aortic valve prosthesis without thromboembolic risk factors	CHADS-VASc score 2-3 or CHADS2 score of 0-2 without prior CVA/TIA	Single VTE > 12 months ago with no ongoing risk factors for VTE
Moderate (4-10% per year)		CHADS-VASc score 4-5 or CHADS2 score of 3-4	VTE in last 3-12 months Recurrent VTE Non severe thrombophilia (heterozygous factor V Leiden, prothrombin gene mutation) Active cancer
High (>10% per year)	Bileaflet aortic valve prosthesis + any thromboembolic risk factor including atrial fibrillation, prior thromboembolism, hypercoagulable conditions, LVEF <30% >1 mechanical heart valve Older generation mechanical AVR Mechanical MVR	CHADS-VASc score ≥6 or CHADS2 score of 5-6 Recent CVA/TIA (<3 months) Rheumatic atrial fibrillation	Recent VTE (<3 months) Severe thrombophilia (protein C/S deficiency, ATII, APLA, or multiple abnormalities)

 2.     Assess the risk of bleeding for the proposed surgery

High (2-day risk of major bleed ~2-4%)

Low (2 day risk of major bleed 0-2%)

Cardiac valve replacement CABG AAA repair Neurosurgical/urologic/head and neck/abdominal/breast cancer surgery Bilateral knee replacement Laminectomy Transurethral prostate resection Kidney biopsy PEG placement Endoscopic FNA Multiple tooth extractions Vascular and general surgery Any major operation (duration > 45min) Polypectomy, variceal treatment, biliary sphincterotomy, pneumatic dilation

Cholecystectomy Abdominal hysterectomy Endoscopic biopsy, biliary/pancreatic stenting without sphincterotomy/FNA PPM, AICD placement, EP studies Simple dental extractions Carpal tunnel repair Knee/hip replacement Shoulder, foot, hand surgery Arthroscopy D&C Skin cancer excision Abdominal hernia repair Hemorrhoid surgery Axillary node dissection Hydrocele repair Eye surgery Noncoronary angiography Bronchoscopy with biopsy CVC removal Biopsies of skin, bladder, prostate, thyroid, breast, lymph node

 

3.     Assess the need for bridging

• Anticoagulation may be continued for procedures with very low bleeding risk, in discussion with the proceduralist.
• Patients at high risk for thromboembolic events without excessive bleeding risk should be bridged. Patients at low risk for thromboembolic events should not be bridged.
• Individuals with moderate thromboembolic risk should be treated on a case-by-case basis and can sometimes interrupt anticoagulation without bridging.

4.     Assess the need for bridging

• Anticoagulation may be continued for procedures with very low bleeding risk, in discussion with the proceduralist.
• Patients at high risk for thromboembolic events without excessive bleeding risk should be bridged. Patients at low risk for thromboembolic events should not be bridged.
• Individuals with moderate thromboembolic risk should be treated on a case-by-case basis and can sometimes interrupt anticoagulation without bridging.

Bridging regimens: Enoxaparin 1mg/kg SQ BID or Heparin gtt.

• UFH should be stopped 4-6 hours before high bleeding risk procedures.
• LMWH should be held at least 24 hours prior to procedure.

Warfarin management

• Give last dose 6 days prior to procedure.
• Goal INR on day of procedure < 1.5.
• For post-op bridging, stop bridge after INR is in therapeutic range.

	Low Bleeding Risk	High Bleeding Risk
No bridge	Post-procedure, resume warfarin on evening of surgery
Bridge	Pre-op bridge: start 36 hours after last warfarin dose; last dose enoxaparin 24 hours prior to procedure. Post-op bridge: Start 24 hours after procedure or when safe per surgeon. Resume warfarin on POD #0 or when safe per surgeon.	Pre-op bridge: start 36 hours after last warfarin dose; last dose enoxaparin 24H prior to procedure. Post-op bridge: Start 48-72 hours after procedure or when safe per surgeon. Consider heparin gtt if high risk for bleeding. Resume warfarin on POD #0 or when safe per surgeon.

 

Direct oral anticoagulant management

Generally, do not require bridging due to rapid offset and onset.

• Bridging is generally reserved for postoperative patients at high risk for thromboembolic events who require extended interruption of therapy.
• Dabigatran: For those at high risk of thromboembolism, consider administering reduced dose (110-150mg daily) on evening after surgery and POD #1 prior to restarting full dose.
• Rivaroxaban/Apixaban: For those at high risk of thromboembolism, consider administering a reduced dose (rivaroxaban 10mg QD or apixaban 2.5mg BID) on evening after surgery and POD #1 prior to resuming full dose.

Direct Oral Anticoagulant	Renal Function	Low Bleeding Risk	High Bleeding Risk
Dabigatran (BID dosing)	CrCl >50 mL/min	Give last dose 2 days prior to procedure (skip 2 doses) Restart POD #1	Give last dose 3 days prior to procedure (skip 4 doses) Restart POD #2-3 with guidance from surgeon
	CrCl 30-50 mL/min	Give last dose 3 days before procedure (skip 4 doses) Restart POD #1	Give last dose 4-5 days before procedure (skip 6 to 8 doses) Restart POD #2-3 with guidance from surgeon
Rivaroxaban (Daily dosing)	CrCl > 30 mL/min	Give last dose 2 days before procedure (skip 1 dose) Restart POD #1	Give last dose 3 days before procedure (skip 2 doses) Restart POD #2-3 with guidance from surgeon
Apixaban (BID dosing)	CrCl > 50 mL/min	Give last dose 2 days before procedure (skip 2 doses) Restart POD #1	Give last dose 3 days before procedure (skip 4 doses) Restart POD #2-3 with guidance from surgeon
	CrCl 30-50 mL/min	Give last dose 3 days before procedure (skip 4 doses) Restart POD #1	Give last dose 4 days before procedure (skip 6 doses) Restart POD #2-3 with guidance from surgeon

*If very high bleeding risk or neuraxial anesthesia/manipulation, consider longer periods of interruption.

 

Antiplatelet Agents

• Can generally continue aspirin for low bleeding risk procedures (see above).
• High risk cardiac patients with recent BMS (< 6 weeks) or DES (< 6 Months) on dual antiplatelet therapy should have non-urgent surgery delayed. If surgery cannot be delayed discuss stopping and resuming antiplatelet agents with surgeon and cardiologist.
• Aspirin Monotherapy
  • In the absence of coronary stents continuing aspirin perioperatively does not have proven benefit in preventing cardiac complications; decision to continue is individualized based on ischemic and bleeding risk.
  • If holding aspirin, stop 7-10 days pre-op and restart 24 hours post-op.
• ADP receptor/P2Y12 antagonists:
  • In general, clopidogrel, prasugrel, and ticagrelor should be stopped five, seven, and three to five days prior to necessary procedures, respectively.
  • Consider a loading dose with clopidogrel resumption.

Beta Blockers

• A systematic review informing the 2014 ACC/AHA guidelines showed a reduction in perioperative MI but no mortality benefit with beta blockade. The two trials that previously had showed significant mortality benefit have had their methods and results called into question.
• Beta-blockade carries the risk of perioperative bradycardia, hypotension, and CVA. These adverse effects often outweigh the benefits of reducing the incidence of perioperative MI.
• Data on whether there is benefit to starting beta blockers weeks or months in advance of non-cardiac surgery are lacking.
   

2014 ACC/AHA Guidelines on Beta Blocker Use

• Beta blockers should be continued if tolerated in patients already taking them.
• Otherwise there is no compelling evidence to start beta blockers in patients.
• Class IIb recommendation to start beta-blockers in those undergoing vascular surgery, those with >3 RCRI risk factors, but ideally would start weeks to months prior to surgery. Starting on day of surgery may be more likely to cause harm.

Bottom Line: No good data to support starting beta blockers in the pre-operative period, but they should be continued in those already on beta blockers.

Statins

• There is emerging evidence that statins may prevent perioperative cardiac complications in high-risk patients, especially those undergoing vascular surgery.
• While data are insufficient to universally recommend statin therapy:
  • Continue statins for patients already taking them (Class I).
  • Consider initiating statins in patients undergoing vascular surgery (Class IIa).
  • Consider initiating statins in patients with ≥1 RCRI clinical risk factor undergoing intermediate-risk surgery (Class IIb).

Bottom line: Consider starting statins preoperatively in anyone who should otherwise be on a statin.
 

Douketis JD, et al. Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis: 9th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e326S-350S

Douketis JD, Berger PB, Dunn AS, et al. The Perioperative Management of Antithrombotic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice guideline (8th Edition). Chest 2008;133:299S-33S.

Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J.Am.Coll.Cardiol. 2014 12/9;64(22):e77-e137.

Kapoor AS, Kanji H, Buckingham J, Devereaux PJ, McAlister FA. Strength of evidence for perioperative use of statins to reduce cardiovascular risk: systematic review of controlled studies. BMJ 2006;333:1149

Levy JH, et al. Managing New Oral Anticoagulants in the Perioperative and Intensive Care Unit Setting. Anesthesiology 2013;118:1466-1474.

Spyropoulos AC and Douketis JD. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood 2012;120:2954-2962.

Wijeysundera DN, Duncan D, Nkonde-Price C, Virani SS, Washam JB, Fleischmann KE, et al. Perioperative Beta Blockade in Noncardiac Surgery: A Systematic Review for the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J.Am.Coll.Cardiol. 2014 12/9;64(22):2406-2425.