Anticoagulant and anti-platelet drug therapy decisions balance bleeding risk of the procedure against thrombotic risk of the patient.
Warfarin Stopped 5 days before surgery; checking INR the day before or morning of with target ≤1.4-1.5.
Bridging with heparin is generally not needed.
Consider it only for high thrombotic risk: mechanical mitral valve, older-generation aortic valve, recent stroke/VTE (<3 months), or severe thrombophilia.
Resume 12-24 h post-op once hemostasis is secure.
DOACs (apixaban, rivaroxaban, edoxaban, dabigatran)
Low-bleed-risk surgery: last dose 2 days before surgery High-bleed-risk surgery: last dose 3 days before surgery Dabigatran with CrCl <50: pause longer. No bridging. Resume 24 h after low-risk and 48-72 h after high-risk surgery. Neuraxial/spinal anesthesia needs longer intervals (about 72 h for most).
Heparins IV unfractionated heparin: stop 4-6 h before surgery Therapeutic LMWH: last dose ~24 h before Prophylactic LMWH: stop ~12 h before.
Antiplatelets
Aspirin:usually continue if used for secondary prevention (prior MI, stent, stroke).
For primary prevention only, it can be stopped ~7 days prior.
Clopidogrel: stop 5 days. Prasugrel: 7 days. Ticagrelor:3-5 days.
Coronary stents: defer elective surgery ≥6 months after a drug-eluting stent (ideally 12 months after ACS) and ≥1 month after bare-metal. If surgery can’t wait, usually continue aspirin and involve cardiology.
Neurosurgery, some spine and eye procedures may need stricter rules.
Check renal function, since it changes DOAC and LMWH timing.
Document the exact last dose time.
Reassess for urgent surgery; reversal agents (vitamin K, PCC, idarucizumab, andexanet) are a separate pathway.