Anticoagulation: peri-procedural holds 💉
Interactive algorithm for DOAC/warfarin peri-procedural holds based on bleeding risk, renal function, and drug type. ACCP/PAUSE trial evidence.
Peri-procedural anticoagulation
Based on ACCP (CHEST 2022), PAUSE, EHRA 2021 & ASRA 2018 — always confirm with local protocol
Recommendation
Select the anticoagulant the patient is taking.
Evidence base
- • PAUSE — Douketis JD et al. JAMA Intern Med 2019 (n = 3,007; apixaban, rivaroxaban, dabigatran — not edoxaban). Standardised DOAC interruption before elective surgery; low thromboembolism and major bleeding with no bridging.
- • BRIDGE — Douketis JD et al. N Engl J Med 2015. AF on warfarin (mean CHADS₂ 2.3; mechanical valves and recent VTE/stroke excluded) — no thromboembolism benefit from bridging and more major bleeding at low–moderate risk.
- • ACCP — Douketis JD et al. Perioperative Management of Antithrombotic Therapy. CHEST 2022;162(5):e207–e243. Warfarin interruption/bridging, DOAC interruption (Xa inhibitors 1–2 days; dabigatran 1–4 days), and suggestion against routine pre-op vitamin K.
- • EHRA — Steffel J et al. 2021 EHRA Practical Guide on NOACs in AF. Europace 2021;23(10):1612–1676. Source of the CrCl-tiered dabigatran hold intervals used here.
- • ASRA — Horlocker TT et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy (4th ed). Reg Anesth Pain Med 2018;43(3):263–309. Neuraxial hold intervals, catheter timing, and INR ≤ 1.4 threshold.
- • BSH — Keeling D et al. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematol 2016;175(4):602–613.
This is a decision-support tool only. Always verify with local peri-operative guidelines and discuss with the surgical/anaesthetic team. Individual patient factors may alter management.
Before you hold — key questions
- What is the indication? (AF, VTE, mechanical valve, etc.)
- Thrombotic risk vs bleeding risk of the procedure.
- Renal function — CrCl affects DOAC clearance, especially dabigatran (~80% renal).
- Timing of last dose and planned procedure time.
- Discuss with senior + local guideline; document the plan.
DOACs — general principles
- Factor Xa inhibitors (apixaban, rivaroxaban, edoxaban): relatively short half-life (~8–14 h); hold duration based on bleeding risk.
- Dabigatran: ~80% renally cleared; hold duration depends on CrCl. Contraindicated if CrCl < 30 (EMA/Ireland).
- No heparin bridging required for DOACs (PAUSE, n = 3,007 — apixaban, rivaroxaban, dabigatran). Edoxaban was not studied in PAUSE; managed similarly by extrapolation/EHRA guidance.
- No routine DOAC level testing recommended peri-operatively.
Warfarin
- Stop 5 days before procedure. Check INR day-of (target < 1.5; ≤ 1.4 for neuraxial per ASRA 2018 — some local policies require < 1.3).
- Bridging (LMWH): reserve for HIGH thrombotic risk only — mechanical mitral or older tilting-disc valve, stroke/TIA or VTE < 3 months, CHADS₂ 5–6 / CHA₂DS₂-VASc ≥ 7, or prior peri-operative stroke (per ACCP 2022). BRIDGE (AF on warfarin, mean CHADS₂ 2.3; mechanical valves and recent VTE/stroke excluded) found no thromboembolism benefit and more major bleeding at low–moderate risk.
- If INR still elevated (> 1.5) 1–2 days pre-op: ACCP 2022 suggests against routine vitamin K; low-dose vitamin K (1–2 mg PO) may be considered to avoid deferral — senior decision.
Restarting
- DOACs: typically resume 24 h post-procedure (48–72 h if high bleeding risk).
- Warfarin: resume evening of procedure or next day; takes 3–5 days to reach therapeutic INR.
- Escalate if unsure — always prioritise haemostasis.
Bleeding risk categories
- Minimal: cataract, minor dental, minor derm, pacemaker insertion.
- Low–moderate: cholecystectomy, hernia, arthroscopy, colonoscopy.
- High: cardiac, intracranial/spinal, major ortho, cancer surgery, procedures > 45 min.
- Neuraxial: epidural/spinal anaesthesia — strictest hold requirements.
Based on
GuidelineACCP — Perioperative Management of Antithrombotic Therapy (Douketis et al.) (CHEST 2022)GuidelineEHRA Practical Guide on NOACs in Atrial Fibrillation (Steffel et al.) (2021)GuidelineASRA — Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy (4th edition) (2018)
Educational reference only. Medical disclaimer