Guidelines for the perioperative management of anticoagulants

One discussion this week focused on the perioperative management of NOACs.


Reference:  DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 -. Record No. 227537, Periprocedural management of patients on long-term anticoagulation; [updated 2018 Oct 10, cited 2018 Oct 12; [about 26 screens]. Emory login required.

Summary: The information below is from DynaMed Plus (2018). To view full information on the topic, click on the citation above.

Vitamin K antagonists in patients undergoing major surgery or procedures

  • Consider continuing vitamin K antagonist (VKA) therapy in patients who require minor dental procedures, minor dermatological procedures, or cataract surgery.
  • In those having a minor dental procedure, consider coadministering an oral hemostatic agent or stopping the VKA 2 to 3 days before the procedure.
  • In those undergoing implantation of a pacemaker or an implantable cardioverter device, consider continuing VKA therapy.
  • In those having a major surgery or procedure, stop VKA therapy 5 days before surgery.
  • Resume VKA therapy 12-24 hours after surgery when there is adequate hemostasis.

Bridging therapy in patients undergoing major surgery or procedures

  • If at low risk for thrombosis, consider omitting bridging therapy.
  • If at moderate risk for thrombosis, assess individual patient- and surgery-related factors when considering bridging therapy.
  • If at high risk for thrombosis consider bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH).
  • For those receiving bridging therapy with UFH, stop UFH 4-6 hours before surgery.
  • For those receiving bridging therapy with therapeutic-dose LMWH, stop LMWH 24 hours before surgery.
  • For those receiving bridging therapy with UFH or therapeutic-dose LMWH and undergoing non-high-bleeding-risk surgery, consider resuming heparin 24 hours after surgery.
  • For those receiving bridging therapy with UFH or therapeutic-dose LMWH and undergoing high-bleeding-risk surgery, consider resuming heparin 48-72 hours after surgery.

Patients taking direct oral anticoagulation agents in patients undergoing major surgery or procedures

  • Current recommendations for stopping and resuming therapy of direct oral anticoagulant agents in the perioperative period are provided by the individual manufacturers.

Patients taking anticoagulants undergoing regional anesthesia

  • Neuraxial techniques may be performed in patients receiving prophylaxis with subcutaneous UFH with dosing regimens of 5,000 units twice daily, if activated partial thromboplastin time (aPTT) is normal.
  • Consider establishing individual risk of spinal hematoma in patients receiving heparin > 10,000 units or > 2 doses per day, and perform assessment to identify new or progressive neurodeficits.
  • For those receiving prophylactic-dose low-molecular-weight heparin (LMWH), delay needle placement until 10-12 hours after last dose of LMWH.
  • For those receiving therapeutic-dose LMWH, delay needle placement until ≥ 24 hours after last dose of LMWH.
  • For those taking warfarin, stop warfarin 4-5 days prior to planned surgery.

Patients taking antiplatelet agents undergoing major surgery or procedures

  • For those receiving aspirin for secondary prevention of cardiovascular disease and are having minor dental or dermatologic procedures or cataract surgery, consider continuing aspirin around the time of the procedure.
  • For those at moderate to high risk for cardiovascular events who require noncardiac surgery, consider continuing aspirin around the time of the procedure instead of stopping aspirin 7-10 days before surgery.
  • If at low risk for cardiovascular events and undergoing noncardiac surgery, consider stopping aspirin 7-10 days before surgery.

Patients taking antiplatelet agents undergoing regional anesthesia

  • Continue aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) unless the use of unfractionated heparin, low-molecular-weight heparin, or oral anticoagulants is anticipated in the early postoperative period.
  • Discontinue ticlopidine (14 days) and clopidogrel (7 days) prior to a neuraxial blockade.
  • Avoid neuraxial techniques in patients taking GPIIb/IIIa inhibitors, including abciximab, eptifibatide or tirofiban, until platelet function has recovered.

Mar PL, et al. Periprocedural management of anticoagulation in patients taking novel oral anticoagulants: Review of the literature and recommendations for specific populations and procedures. Int J Cardiol. 2016 Jan 1;202:578-85.

Full-text for Emory users.

Anticoag cessation map


Additional reading: 

Dubois V, et al. Perioperative management of patients on direct oral anticoagulants. Thrombosis Journal. 2017 May 15;15:14. doi:10.1186/s12959-017-0137-1.

Levy JH, et al. When and how to use antidotes for the reversal of direct oral anticoagulants: guidance from the SSC of the ISTH. Journal of Thrombosis and Haemostasis. 2016 Mar;14(3):623-7. doi:10.1111/jth.13227.

Yeung LYY, et al. Surgeon’s guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation. Trauma Surgery & Acute Care Open. 2016 Jul 13;1(1):1-7. doi:10.1136/tsaco-2016-000022.


More PubMed results on perioperative management of anticoagulants.

Created (HR) 10/12/18; updated (EL) 01/28/20.

1 thought on “Guidelines for the perioperative management of anticoagulants

  1. Pingback: Periprocedural bridging anticoagulation | Surgical Focus

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