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, PAUSE trial & BSH guidelines — always confirm with local protocol
Recommendation
Select the anticoagulant the patient is taking.
Evidence base
- • PAUSE — Douketis JD et al. N Engl J Med 2019. Standardised DOAC interruption before elective surgery; low MACE and bleeding with no bridging.
- • BRIDGE — Douketis JD et al. N Engl J Med 2015. Bridging vs placebo in moderate-risk AF on warfarin — no thromboembolism benefit from bridging.
- • CHEST / ACCP — peri-operative antithrombotic therapy (current edition); bleeding-risk categories and bridging when on warfarin.
- • BSH and national formularies — DOAC peri-operative tables (including renal adjustment for dabigatran).
- • Neuraxial — ASRA / national anaesthetic society recommendations for block timing vs last anticoagulant dose.
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 (85% 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 (~12 h); hold duration based on bleeding risk.
- Dabigatran: 85% renally cleared; hold duration depends on CrCl. Contraindicated if CrCl < 30.
- No heparin bridging required for DOACs (PAUSE trial, n = 3,007).
- No routine DOAC level testing recommended peri-operatively.
Warfarin
- Stop 5 days before procedure. Check INR day-of (target < 1.5; < 1.3 for neuraxial).
- Bridging: only for HIGH thrombotic risk (mechanical mitral valve, CHA₂DS₂-VASc ≥ 7, VTE < 3 months). BRIDGE trial shows no benefit for low–moderate risk.
- If INR slow to drop, consider vitamin K 1–2 mg PO.
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.