MDCalc

Perioperative Anticoagulation Management Algorithm

Assesses bleeding risk and recommends perioperative management with anticoagulation therapy.

This tool offers general guidelines for stopping and resuming anticoagulation in the perioperative period. Patients with known bleeding disorders require an individual risk assessment that may fall outside these general guidelines. 

The appropriate resumption of anticoagulation after surgery should be determined based on individual patient factors, surgical complications, and the case-specific clinical scenario.

Medication

Surgery/procedure bleeding risk

See Evidence for more details.

Date of the planned surgery/procedure

Result:

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Advice

General:

  • Incorporate suggestions with shared decision-making, considering patient-specific factors (e.g., comorbidities).
  • Some patients may require longer preoperative DOAC interruption, including those with severe renal or hepatic impairment or concurrent use of CYP3A4 or P-glycoprotein pathway inhibitors.
  • Results are based on recommendations for elective procedures/surgery.
  • For urgent surgeries (within 24 hours), DOAC levels may be considered.

Heparin bridging:

While this tool provides information on heparin bridging (e.g., LMWH) during interruption of warfarin therapy, it is only necessary in certain contexts.

  • Heparin bridging is suggested for elective procedures/surgery in patients with the following clinical scenarios:
    • Mechanical heart valve and:
      • Older-generation mechanical heart valve

      • Mitral valve  with risk factors for stroke (e.g.,  Prior stroke or TIA with prior discontinuation of anticoagulation, prior valve thrombosis, rheumatic heart disease, atrial fibrillation, hypertension, diabetes, heart failure, age ≥75 years)

      • Recent (<3 months) thromboembolic event

    • Atrial fibrillation and:
      • CHA2DS2VASc ≥7
      • Recent (<3 months) stroke or TIA
      • Rheumatic valvular heart disease
    • VTE and:
      • Recent (<3 months) VTE

      • Severe thrombophilia (protein C, S, or antithrombin deficiency; homozygous or double heterozygous factor V Leiden or prothrombin gene mutation) or antiphospholipid antibody syndrome

      • Active pancreatic, gastric, esophageal, or primary brain cancers, or myeloproliferative neoplasms
  • Otherwise, heparin bridging is not suggested for low-to-moderate risk patients for elective procedures/surgery.
  • Heparin bridging is not recommended during DOAC interruption for elective procedures/surgery.

Please refer to the 2022 CHEST clinical guidelines for more detailed recommendations and clarifications.

Management
  • Full-dose, subcutaneous bridging is suggested for high thrombotic risk populations with the last dose given the AM of the day prior to the procedure (i.e., day -1) at half the total daily dose.
  • Suggested bridging doses include:
    • Enoxaparin, 1 mg/kg BID or 1.5 mg/kg daily 

                                                      or

    • Dalteparin, 100 IU/kg BID or 200 IU/kg daily
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