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. 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.
- • 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 (~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; < 1.3 for neuraxial).
- Bridging (LMWH): reserve for HIGH thrombotic risk only — mechanical mitral valve, recent VTE/stroke < 3 months, or very high stroke risk (per ACCP guidance). 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 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.