Patients taking oral anticoagulants or anti-platelet therapy and undergoing elective surgical procedures should be managed with the following guidelines.
For patients requiring aspirin therapy who are undergoing and elective non-cardiac surgery, continuing aspirin through the surgery is suggested.
For patients with atrial fibrillation, taking vitamin K antagonists or undergoing an elective surgery or procedure with low to moderate risk of thromboembolism, temporary use of therapeutic heparin doses during interruption of vitamin K antagonists is not recommended.
For a patient with the mechanical heart valve with low to moderate risk of thrombosis embolism who require vitamin K antagonist interruption for an elective surgery or procedure, heparin bridging is not suggested.
For patients receiving a direct oral and anticoagulant who will be undergoing an elective surgery or procedure, discontinuing therapy is suggested with the timing dependent on the specific agent and the bleeding risk of the procedure.
Discontinuation of Dabigatran for 1 to 4 days before an elective surgery or procedure or one to two days prior for apixaban, edoxaban, or rivaroxaban, with the specific timing dependent on the bleeding risk of the procedure.
In the prospective perioperative management study (PAUSE) enroll 3007 DOAC treated patients with atrial fibrillation who underwent an elective surgical or non-surgical procedure results standard DOAC therapy was postoperative bleeding rate of 1.3% up to 1.85% and thromboembolic processes ranging from .16% 2.60% :using standard perioperative DOAC protocol.
The timing of postoperative DOAC resumption is based on the risk of bleeding associated with the surgical or non-surgical procedure and assessment of surgical site hemostasis, including blood loss.
In general, DOACs are resumed no earlier than 24 hours after a low to moderate surgical or non-surgical risk procedure and 48 to 72 hours after a high bleeding risk procedure with allowances for extended delay of 2 to 3 days for patient such as those undergoing hematuria following a radical prostatectomy, or if there’s concerned about surgical site bleeding after cardiac, intracranial, or spinal surgery.