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.

• 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.