Periprocedural Anticoagulation Adult Inpatient and Ambulatory
Clinical Practice Guideline
Cover Sheet
Target Population: Inpatient and Ambulatory Adult Patients
CPG Contact:
Name: Sara Shull, PharmD, MBA, Drug Policy Manager
Phone Number: 608-262-1817
Email address: SShull@[Link]
Guideline Author(s):
Anne Rose, Pharm.D.
Coordinating Team Members:
Dr. Ann McBride; Dr. Patrick Pfau; Melissa Heim PharmD; Erin Robinson PharmD;
Nikki Lokker PharmD
Review Individuals/Bodies:
Inpatient Anticoagulation Committee
Ambulatory Anticoagulation Committee
Committee Approvals/Dates:
Anticoagulation Committee: November 2012
Pharmacy and Therapeutics: February 2013
Release Date:
Original: October 2011
Revised: February 2013
Clinical Practice Guideline (CPG)
Executive Summary
Guideline Title:
Periprocedural Anticoagulation Adult Inpatient and Ambulatory Clinical Practice Guideline
Guideline Overview
The following guideline provides recommendations for patients receiving antithrombotic therapy and who require
surgery or other invasive procedure. Evaluating thrombemobolic and bleeding risks are outlined as well as
considerations for continuation or discontinuation of antithrombotic therapy in the periprocedural time frame.
Risk assessment tools addressed in this guideline include:
Table_1: Bleeding Risk for Surgery/Procedure
Table_2: Periprocedural Risk for Thrombosis
Table_3: Risk Factors for Venous Thrombosis
Table_4: Anticoagulation Considerations for Endoscopic Procedures
Table_5: Dosing of Periprocedural Anticoagulation
Antithrombotic agents addressed in this guideline include:
Aspirin
Apixaban
Cilostazol
Clopidogrel
Dabigatran
Dipyridamole
Low Molecular Weight Heparin LMWH
Prasugrel
Rivaroxaban
Ticagrelor
Unfractionated Heparin
Warfarin
Practice Recommendations
1.
Assessment
1.1. Weigh the short-term risk for thromboembolism and bleeding for your individual patient
1.1.1 Not all patients will need pre-operative anticoagulation or bridging therapy.
1.1.2 Overall risk stratification should focus on the risk of thromboembolism since the
consequences of thromboembolism are more common and more often fatal compared
to consequences of major bleeding. (Class IIa, Level C)
1.2. Evaluate the bleeding risk of procedure or surgery - see table 1 (Class IIa, Level C)
1.3. Identify the indication for anticoagulation and risk of thrombosis if these agents were discontinued
- see table 2. (Class IIa, Level C)
1.3.1. For endoscopic procedures see table 4
2. Oral Anticoagulation Therapy Considerations For Perioperative Management
2.1. Warfarin
Pre-procedure INR
2.0 3.0
3.0 4.5
2.1.1.
2.1.2.
2.2
Check INR within 24 hours of surgery or procedure to ensure that it is less than 1.5 or
lower if otherwise indicated (Class IIb, Level C)
Restart warfarin on postoperative day 1 if hemostatsis is achieved and if approved by
surgeon (Class IIa, Level C)
[Link].
May start on postoperative day 0 if dose given 12 hours after surgery
or procedure and if approved by surgeon (Class IIa, Level C)
Dabigatran
2.2.1 Pre-operative parenteral anticoagulation is not needed in the majority of patients receiving
dabigatran. (Class IIb, Level C)
Renal Function (CrCl)
50 mL/min
< 50 mL/min
2.2.2
2.2.3
2.2.4
2.3
Warfarin Discontinuation Plan
Stop warfarin 5 days (hold 4 doses) before surgery or procedure
Stop warfarin 6 days (hold 5 doses) before surgery or procedure
Dabigatran Discontinuation Plan
Standard Bleeding Risk
Stop dabigatran 1 to 2 days before
surgical procedure
Stop dabigatran 3 to 5 days before
surgical procedure
High Bleeding Risk
Stop dabigatran 2 to 4 days before
surgical procedure
Stop dabigatran > 5 days before
surgical procedure
Dabigatran should be resumed as soon as possible after a procedure (Class IIb, Level C)
[Link] Onset of therapeutic anticoagulation with dabigatran occurs within 2 hours.
Minor surgery or procedure with low bleeding risk: Start 12 to 24 hours if approved by
surgeon (Class IIb, Level C)
Major surgery or high bleed risk surgery or procedure: Start 48 to 72 hours if approved by
surgeon (Class IIb, Level C)
Rivaroxaban
2.3.1 Pre-operative parenteral anticoagulation is not needed in the majority of patients receiving
rivaroxaban. (Class IIb, Level C)
Renal Function (CrCl)
> 30 mL/min
< 30 mL/min
2.3.2
2.3.3
2.3.4
Rivaroxaban Discontinuation Plan
Standard Bleeding Risk
Stop rivaroxaban 24 hours before
surgical procedure
Stop rivaroxaban 48 hours before
surgical procedure
High Bleeding Risk
Stop rivaroxaban 48 hours before
surgical procedure
Stop rivaroxaban 72 hours before
surgical procedure
Rivaroxaban should be resumed as soon as possible after a procedure (Class IIb, Level C)
[Link] Onset of therapeutic anticoagulation with rivaroxaban occurs within 2-4 hours
Minor surgery or procedure with low bleeding risk: Start 12 to 24 hours if approved by
surgeon (Class IIb, Level C)
Major surgery or high bleed risk surgery or procedure: Start 48 to 72 hours if approved by
surgeon (Class IIb, Level C)
2.4
Apixaban
2.4.1 Pre-operative parenteral anticoagulation is not needed in the majority of patients receiving
apixaban. (Class IIB, Level C)
Renal Function (Scr)
< 1.5 mg/dL
> 1.5 mg/dL
2.4.2
2.4.3
2.4.4
Apixaban Discontinuation Plan
Standard Bleeding Risk
Stop apixaban 24 hours before
surgical procedure
Stop apixaban 48 hours before
surgical procedure
High Bleeding Risk
Stop apixaban 48 hours before
surgical procedure
Stop apixaban 72 hours before
surgical procedure
Apixaban should be resumed as soon as possible after a procedure (Class IIb, Level C)
[Link] Onset of therapeutic anticoagulation with apixaban occurs within 3-4 hours
Minor surgery or procedure with low bleeding risk: Start 12 to 24 hours if approved by
surgeon (Class IIb, Level C)
Major surgery or high bleed risk surgery or procedure: Start 48 to 72 hours if approved by
surgeon (Class IIb, Level C)
3. Parenteral Anticoagulation for Perioperative Management
3.1. Consider therapeutic doses for risk of arterial thromboembolism (Class IIb, Level C) - See table 5
3.2. Therapeutic or prophylactic doses may be considered for venous thrombosis risks (Class IIb, Level
C) - See table 5
3.3. Start a low molecular weight heparin (LMWH) or unfractionated heparin (UFH) when INR < 2.0,
usually 48 hours after stopping warfarin. (Class IIa, Level C)
3.4 Prior to procedure
3.4.1 Stop therapeutic LMWH 24 hours before surgery or procedure (Class IIa, Level C)
3.4.2 Stop prophylactic LMWH or SQ UFH 12 hours before surgery or procedure (Class IIa,
Level C)
3.4.3 Stop IV therapeutic UFH 4 - 6 hours before surgery or procedure (Class IIa, Level C)
3.5 After procedure
3.5.1 Minor surgery or procedure with low bleeding risk: Start LMWH or UFH 12 to 24 hours if
approved by surgeon (Class IIa, Level C)
3.5.2 Major surgery or high bleed risk surgery or procedure: Start LMWH or UFH 48 to 72 hours if
approved by surgeon (Class IIa, Level C)
3.5.3 If therapeutic doses of LMWH or UFH were used pre-operatively may consider starting
prophylactic dosing in 24 hours (Class IIa, Level C)
4. Antiplatelet Therapy Considerations for Perioperative Management
4.1 Aspirin
4.1.1 Non-cardiac Surgery
Cardiovascular Event Risk
Aspirin Discontinuation Plan
Moderate to High Risk
Continue aspirin around the time of surgery
Low Risk
Stop 7-10 days before surgery
4.1.2
4.1.3
4.2
Cardiac surgery (ex. CABG): continue aspirin around the time of surgery (Class IIa Level C)
Restart aspirin 24 hours after surgery or procedure if approved by surgeon (Class IIa, LevelC)
Thienopyridine Platelet Aggregation Inhibitors: Clopidogrel/ Ticagrelor/ Prasugrel
4.2.1 Patients with a coronary stent on P2Y12 therapy who require surgery
Coronary Artery Stent Requiring Surgery
Discontinuation Plan
Bare Metal Stent (BMS)
Defer surgery at least 6 weeks after placement
Drug Eluding Stent (DES)
Defer surgery at least 6 months after placement
BMS or DES unable to defer surgery
Continue antiplatelet therapy around the time of surgery
4.2.2 Patients who require coronary bypass surgery on P2Y12 therapy:
Drug
Discontinuation Plan
Clopidogrel
Hold 5 days before surgery
Ticagrelor
Hold 5 days before surgery
Prasugrel
Hold 5 to 7 days before surgery
4.2.3
4.3
Restart within 24 to 48 hours after surgery if approved by surgeon
Dipyridamole and Cilostazol
4.3.1 Dipyridamole and cilostazol reversibly inhibit platelet function so the activity is dependant on
the half life. (Class IIb, Level C)
Drug and Half Life
Dipyridamole (10 hours)
Cilostazol (11-13 hours)
4.3.2
Discontinuation Plan
Stop 1-2 days before surgery
Stop 1-2 days before surgery
Restart 24 hours after surgery or proecedure if approved by surgeon (Class IIb, Level C)
Periprocedural Anticoaglation Adult Inpatient and Ambulatory Clinical Practice Guideline
B. Scope (disease/condition, treatment, clinical specialty)
1. Adult patients undergoing a procedure or surgery who are also receiving therapeutic antithrombotic
therapy
C. Methodology
1. A modified Grading of Recommendations Assessment, Development and Evaluation (GRADE)
developed by the American Heart Association and American College of Cardiology (Figure 1.) has
been used to assess the Quality and Strength of the Evidence in this Clinical Practice Guideline.1
D. Definitions (optional)
1. Periprocedural or Bridging Anticoagulation administration of a short acting anticoagulant during the
interruption of long-term antithrombotic therapy for major/minor surgery or procedures. Usually
administered for a 10-12 day period.2
2. Antithrombotic therapy: Any anticoagulant or antiplatelet medication
3. Anticoagulation therapy may include but is not limited to: warfarin, dabigatran, rivaroxaban, heparin,
enoxaparin
4. Antiplatelet therapy may include but is not limited to: aspirin, clopidogrel, ticagrelor, prasurgrel
E. Introduction
1. Patients receiving long term antithrombotic therapy who require surgery or an invasive procedure
present a difficult therapeutic dilemma for clinicians. Continuation of antithrombotic therapy until the
day of the surgery or procedure can increase the risk of bleeding, while discontinuation several days
before can place the patient at an increased risk for a thromboembolic episode. In this periprocedural
interval when antithrombotic therapy is halted, periprocedural anticoagulation (bridging therapy) with a
heparin product may be recommended for some patients.2,3
2. These are guidelines to provide clinicians with some guidance on an area of medicine where data from
randomized controlled trials are lacking and considerable controversy exists. Deviation from
these guidelines may be necessary and appropriate when caring for an individual patient.
F. Recommendations
1. Assessment
1.1. Weigh the consequences of short-term risk for thromboembolism and bleeding for your individual
patient.2
1.1.3 Not all patients will need periprocedural anticoagulation or bridging therapy.
1.1.4 Overall risk stratification should focus on the patient's risk of thromboembolism since
the consequences of thromboembolism are more common and more often fatal
compared to consequences of major bleeding. (Class IIa, Level C)
1.2. Evaluate the bleeding risk of procedure or surgery2 - see table 1 (Class IIa, Level C)
1.3. Warfarin and aspirin may be continued during some procedures where bleed risk is low.2,4,
1.3.1 Simple dental procedures (including extractions) if there is coadministration of an oral
prohemostatic agent. (If no oral prohemostatic agent is coadministered, then warfarin
should be held for 2-3 days before the procedure) (Class IIa, Level B)
[Link] Pro-hemostatic agents used in dental procedures may include but are not
limited to: oxycellulose, absorbable gelatin, collagen, fibrin glue
1.3.2 Cataract surgery (Class IIa, Level C)
1.3.3 Diagnostic or screening colonoscopies (Class IIa, Level C)
1.3.4 Some cutaneous surgeries (Class IIa, Level C)
1.3.5 For endoscopic procedures see table 4
1.4. Identify the indication for anticoagulation and risk of thrombosis if these agents were discontinued
- see table 2. (Class IIa, Level C)
1.4.1. For endoscopic procedures see table 4
1.5. Consider other risk factors for thromboembolism5-7(Class IIa, Level C)
1.5.1 Type of surgery or procedure
1.5.2 Other patient specific risk factors see table 3.
1.5.3 Duration off antithrombotic therapy
Evaluate the Risk of Bleeding
Table 1. Bleeding Risk for Surgery/Procedure2,5,8
High Risk
Aortic aneurysm repair
Bladder surgery
Bowel polypectomy
Coronary artery bypass grafting (CABG)
Heart valve replacement
Intracranial surgery
Major cancer surgery
Major orthopedic surgery (hip or knee replacement)
Peripheral artery bypass and other major vascular surgery
Prostate surgery
Reconstructive plastic surgery
Spinal surgery/Epidural procedure
Moderate Risk
Renal biopsy
Resection of colon polyps
Prostate biopsy
Pacemaker or defibrillator implantation
Major intraabdominal surgery
Major intrathoracic surgery
More invasive dental or ophthalmic
procedures
Low Risk
Cataract surgery
Dental procedures
Dental hygiene
Simple extractions
Restorations
Endodontics
Prosthetics
Cutaneous surgeries (most)
Laparoscopic cholecystectomy or hernia repair
Coronary angiography
Endoscopy with or without biopsy
Colonoscopy with or without biopsy
Evaluate the Risk of Thrombosis - Identify the indication for anticoagulation and risk of thrombosis if these agents were
discontinued
Table 2. Periprocedural Risk for Thromboembolism2,7
Risk
High:
Anticoagulation advised
Mechanical Heart
Valve
Atrial Fibrillation
*CHADS2 score Table 3
Venous
Thromboembolism
Any mechanical mitral valve
Older mechanical valve model (caged ball or
tilting disc) aortic valve
Recently placed mechanical valve (< 3 months)
Recent stroke or TIA (within 6 months)
With mechanical heart valve (any position)
With rheumatic valvular disease
With recent stroke or TIA (within 3 months)
CHADS2* Score of 5 or 6
VTE within previous 3 months
With severe thrombophilia (eg. Protein C, S or
Antithrombin III deficiency, Antiphospholipid
syndrome, Homozygous factor V Leiden
mutation)
Moderate:
Anticoagulation considered on a case by
case basis
Bileaflet aortic valve and 1 of the
following: atrial fibrillation, prior stroke
or TIA, hypertension, diabetes, heart
failure, age >75 years
Low:
Anticoagulation is generally not advised
Bileaflet aortic valve without atrial
fibrillation and no other risk factors for
stroke
CHADS2* Score of 3 or 4
CHADS2* Score of 0 or 2 (no prior
stroke or TIA)
VTE 3-12 months ago
Recurrent VTE
With non-severe thrombophilia (eg,
heterozygous factor V Leiden mutation,
heterozygous factor II mutation)
With active cancer (treated within 6
months or palliative)
Single VTE > 12 months ago and no
other risk factors
*CHADS2 has not been validated for VTE risk in atrial fibrillation. It is used for risk stratification to reduce stroke risk with aspirin vs warfarin.
Calculating a CHADS2 Score2,9
Congestive Heart Failure
C
Hypertension
H
Age 75
A
Diabetes
D
Secondary prevention in patients with prior ischemic
S
stroke, TIA, or systemic thromboembolic event
0 points Low Risk
1-2 points Intermediate Risk
3 points High Risk
1 point
1 point
1 point
1 point
2 points
Table 3. Risk Factors for Developing Venous Thromboembolism5,6
Age > 40 years
Personal or Family History of SVT, DVT/PE
BMI > 25
History of malignancy
Swollen legs (current)
Central venous access
Oral contraceptive or hormone replacement therapy Present cancer or treatment with chemotherapy
Acute myocardial infarction (<1 month)
Heart failure exacerbation (<1 month)
History of inflammatory bowel disease
Serious lung dx ex. Pneumonia (<1 month)
Leg plaster cast or brace
Type of surgery/procedure
Table 4. Anticoagulation Considerations for Endoscopic Procedures2,4,8
Endoscopic Procedure
High or Moderate Thromboembolic Risk
Diagnostic or Screening
Continue warfarin management
Low biopsy risk
Removal of < 10 mm polyps with cold
snare/forceps
Large polyp removal (> 10 mm)
Sphincterotomy
Esophageal Dilation
Fine Needle Aspiration
Low Thromboembolic Risk
Consider holding warfarin and proceeding when INR < 1.5*
Continue warfarin management
Consider holding warfarin and proceeding when INR < 1.5*
Hold warfarin and bridge peri-procedural
anticoagulation
Hold warfarin and bridge peri-procedural
anticoagulation
Hold warfarin and proceed when INR < 1.5*
* May consider using peri-procedural anticoagulation
Hold warfarin and proceed when INR < 1.5*
2. Oral Anticoagulation Therapy Considerations For Perioperative Management
2.1. Warfarin2,4,7,10
2.1.1. Assess INR at least 7 days before surgery or procedure to allow for planning of perioperative
management.2 If bridge therapy is needed see section: 3.0 (Class IIa Level C)
Pre-procedure INR
2.0 3.0
3.0 4.5
2.1.2.
2.1.3.
2.1.4.
2.2
Warfarin Discontinuation Plan
Stop warfarin 5 days (hold 4 doses) before surgery or procedure
Stop warfarin 6 days (hold 5 doses) before surgery or procedure
Check INR within 24 hours of surgery or procedure to ensure that it is less than 1.5 or
lower if otherwise indicated (Class IIb, Level C)
If timing of surgery does not allow for gradual reduction of INR from withholding
warfarin alone, administration of phytonadione (vitamin K) or fresh frozen plasma may
be necessary. (Class IIb, Level C)
Restart warfarin on postoperative day 1 if hemostatsis is achieved and if approved by
surgeon (Class IIa, Level C)
[Link].
May start on postoperative day 0 if dose given 12 hours after surgery
or procedure and if approved by surgeon (Class IIa, Level C)
Dabigatran2,3,11
2.2.1 Assess renal function at least 7 days before surgery or procedure to allow for planning of
perioperative management. Pre-operative parenteral anticoagulation is not needed in the
majority of patients receiving dabigatran. (Class IIb, Level C)
Renal Function (CrCl)
50 mL/min
< 50 mL/min
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
2.2.7
Dabigatran Discontinuation Plan
Standard Bleeding Risk
Stop dabigatran 1 to 2 days before
surgical procedure
Stop dabigatran 3 to 5 days before
surgical procedure
High Bleeding Risk
Stop dabigatran 2 to 4 days before
surgical procedure
Stop dabigatran > 5 days before
surgical procedure
Consider stopping dabigatran for > 5 days for patients undergoing major surgery, spinal
puncture, or placement of a spinal or epidural catheter or port in whom complete
hemostasis may be required (Class IIb, Level C)
Dabigatran should be resumed as soon as possible after a procedure (Class IIb, Level C)
[Link]
Onset of therapeutic anticoagulation with dabigatran occurs within 2 hours.
Minor surgery or procedure with low bleeding risk: Start 12 to 24 hours if approved by
surgeon (Class IIb, Level C)
Major surgery or high bleed risk surgery or procedure: Start 48 to 72 hours if approved by
surgeon (Class IIb, Level C)
[Link]
Use caution when restarting dabigatran within 48 to 72 hours postoperatively
especially in procedures associated with high bleeding risks
Dabigatran therapy should not be changed to warfarin post-operatively if being used for the
same indication (Class IIb, Level C)
Monitor serum creatinine and creatinine clearance post-operatively to determine if a dose
adjustment is needed
2.3
Rivaroxaban2,3,12
2.3.1 Assess renal function at least 7 days before surgery or procedure to allow for planning of
perioperative management. Pre-operative parenteral anticoagulation is not needed in the
majority of patients receiving rivaroxaban. (Class IIb, Level C)
Renal Function (CrCl)
> 30 mL/min
< 30 mL/min
2.3.2
2.3.3
2.3.4
2.3.5
2.4
Rivaroxaban Discontinuation Plan
Standard Bleeding Risk
Stop rivaroxaban 24 hours before
surgical procedure
Stop rivaroxaban 48 hours before
surgical procedure
High Bleeding Risk
Stop rivaroxaban 48 hours before
surgical procedure
Stop rivaroxaban 72 hours before
surgical procedure
Rivaroxaban should be resumed as soon as possible after a procedure (Class IIb, Level C)
[Link] Onset of therapeutic anticoagulation with rivaroxaban occurs within 2-4 hours
Minor surgery or procedure with low bleeding risk: Start 12 to 24 hours if approved by
surgeon (Class IIb, Level C)
Major surgery or high bleed risk surgery or procedure: Start 48 to 72 hours if approved by
surgeon (Class IIb, Level C)
Rivaroxaban therapy should not be changed to warfarin if being used for the same
indication (Class IIb, Level C)
Apixaban13
2.4.1 Assess renal function at least 7 days before surgery or procedure to allow for planning of
perioperative management. Pre-operative parenteral anticoagulation is not needed in the
majority of patients receiving apixaban. (Class IIb, Level C)
Renal Function (Scr)
< 1.5 mg/dL
> 1.5 mg/dL
2.4.2
2.4.3
2.4.4
2.4.5
Apixaban Discontinuation Plan
Standard Bleeding Risk
Stop apixaban 24 hours before
surgical procedure
Stop apixaban 48 hours before
surgical procedure
High Bleeding Risk
Stop apixaban 48 hours before
surgical procedure
Stop apixaban 72 hours before
surgical procedure
Apixaban should be resumed as soon as possible after a procedure (Class IIb, Level C)
[Link] Onset of therapeutic anticoagulation with apixaban occurs within 3-4 hours
Minor surgery or procedure with low bleeding risk: Start 12 to 24 hours if approved by
surgeon (Class IIb, Level C)
Major surgery or high bleed risk surgery or procedure: Start 48 to 72 hours if approved by
surgeon (Class IIb, Level C)
Apixaban therapy should not be changed to warfarin if being used for the same indication
(Class IIb, Level C)
2,4,10,14
3. Parenteral Anticoagulation for Perioperative Management
3.1 Consider therapeutic doses for patients who are at risk for arterial thromboembolism (Class IIb,
Level C) - See table 5
3.2
Therapeutic or prophylactic doses may be considered for patients with venous thrombosis risks
(Class IIb, Level C) - See table 5
3.3
Start a low molecular weight heparin (LMWH) or unfractionated heparin (UFH) when INR < 2.0,
usually 48 hours after stopping warfarin. (Class IIa, Level C)
Table 5. Dosing of Periprocedural Anticoagulation11,15
Drug
Therapeutic Dose
Prophylactic Dose
Enoxaparin
1 mg/kg SQ every 12 hours
40 mg SQ every 24 hours
(Formulary)
(Round to nearest prefilled syringe size)
Dalteparin*
100 units/kg SQ every 12 hours
5000 units SQ every 24 hours
(Non- Formulary) OR
200 units/kg SQ every 24 hours
(Round to nearest prefilled syringe size)
UFH
Refer to UWHC Guidelines for
5000 units SQ every 12 hours
therapeutic dosing of IV heparin
OR
5000 units SQ every 8 hours
* Patients will be therapeutically interchanged to the formulary product enoxaparin during admission
3.4
Prior to procedure2,4,10,14
3.4.1 Stop therapeutic LMWH 24 hours before surgery or procedure (Class IIa, Level C)
3.4.2 Stop prophylactic LMWH or SQ UFH 12 hours before surgery or procedure (Class IIa,
Level C)
3.4.3 Stop IV therapeutic UFH 4 - 6 hours before surgery or procedure (Class IIa, Level C)
3.5
After procedure2,10,15
3.5.1 Minor surgery or procedure with low bleeding risk: Start LMWH or UFH 12 to 24 hours if
approved by surgeon (Class IIa, Level C)
3.5.2 Major surgery or high bleed risk surgery or procedure: Start LMWH or UFH 48 to 72 hours if
approved by surgeon (Class IIa, Level C)
3.5.3 If therapeutic doses of LMWH or UFH were used pre-operatively may consider starting
prophylactic dosing in 24 hours (Class IIa, Level C)
4. Antiplatelet Therapy Considerations for Perioperative Management
4.1 Aspirin2
4.1.1 Non-cardiac Surgery
Cardiovascular Event Risk
Aspirin Discontinuation Plan
Moderate to High Risk
Continue aspirin around the time of surgery
Low Risk
Stop 7-10 days before surgery
4.1.2
4.1.3
4.2
Cardiac surgery (ex. CABG): continue aspirin around the time of surgery (Class IIa Level C)
Restart aspirin 24 hours after surgery or procedure if approved by surgeon (Class IIa, Level C)
Thienopyridine Platelet Aggregation Inhibitors: Clopidogrel/ Ticagrelor/ Prasugrel2,16,17
4.2.1 Patients with a coronary stent on P2Y12 therapy who require surgery
Coronary Artery Stent Requiring Surgery
Discontinuation Plan
Bare Metal Stent (BMS)
Defer surgery at least 6 weeks after placement
Drug Eluding Stent (DES)
Defer surgery at least 6 months after placement
BMS or DES unable to defer surgery
Continue antiplatelet therapy around the time of surgery
4.2.3 Patients who require coronary bypass surgery on P2Y12 therapy:
Drug
Discontinuation Plan
Clopidogrel
Hold 5 days before surgery
Ticagrelor
Hold 5 days before surgery
Prasugrel
Hold 5 to 7 days before surgery
4.2.3
Restart within 24 to 48 hours after surgery if approved by surgeon
4.3
Dipyridamole and Cilostazol2,16
4.3.1 Dipyridamole and cilostazol reversibly inhibit platelet function so the activity is dependant on
the half life. (Class IIb, Level C)
Drug and Half Life
Dipyridamole (10 hours)
Cilostazol (11-13 hours)
4.3.2
Discontinuation Plan
Stop 1-2 days before surgery
Stop 1-2 days before surgery
Restart 24 hours after surgery or proecedure if approved by surgeon (Class IIb, Level C)
5. Endoscopic procedures2,4,8
5.1 Screening or diagnostic endoscopic procedure: anticoagulation may be resumed the same day
(Class IIb, Level C)
5.2 Biopsy obtained: anticoagulation may be resumed the same day (Class IIa, Level C)
5.3 Snare polypectomy, sphincterotomy, esophageal dilation or fine needle aspiration performed:
anticoagulation may be resumed the next day (Class IIa, Level C)
6. Communication (Class IIb, Level C)
6.1 Surgeons or proceduralist should contact to the clinician managing antithrombotic therapy at least 7
days before surgery to develop a perioperative plan
6.2 Surgeons or proceduralist should communicate to the clinician managing antithrombotic therapy if the
needs are different then what has been outlined in this guideline
6.3 Patients should be given written instructions (ex. Calendar) outlining the perioperative plan for holding
antithrombotic therapy, the use of bridging therapy (if needed), laboratory needs, and when to restart
antithrombotic therapy
6.4 Surgeons or proceduralists should communicate to the clinician managing warfarin when
anticoagulation may be restarted either through telephone conversation or documentation within
electronic medical record.
G. External References
1. Tricoci P, Allen J, Kramer J, Califf R, Smith S. Scientific evidence underlying the ACC/AHA Clinical
Practice Guidelines. JAMA. 2009;301(8):831-841.
2. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy:
Antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians Evidenceth
Based Clinical Practice Guidelines (9 Edition). CHEST. 2012;141:e326S-e350S.
3. Ageno W, Gallus AS, Wittkowsky A, et al. Oral anticoagulant therapy: Antithrombotic therapy and
prevention of thrombosis: American Colelge of Chest Physicians Evidence-Based Clinical Practice
Guidelines (9th edition). CHEST. 2012;141:e44S-e88S.
4. Anderson MA, Ben-Mencachem T, Gan SI, et al. Management of antithrombotic agents for endoscopic
procedures: ASGE Standards of Practice Committee. Gastrointest Endosc. 2009;70(6):1060-70.
5. Bahl V, Hu H, Henke P, et al. A validation study of a retrospective venous thromboembolism risk scoring
method. Ann Surg. 2010;251:344-350.
6. Gould MK, Garcia DA, Wren SM, et al. Prevention of venous thromboembolism in nonorthopedic surgical
patients: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition).
Chest. 2012;141:e227s-277s.
7. Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term interruption of warfarin
therapy. Arch Intern Med. 2008; 168(1):63-9.
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9. Rietbrock S, Heeley E, Plumb J, et al. Chronic atrial fibrillation: incidence, prevalence, and prediction of
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low molecular weight heparin for temporary interruption of warfarin. Ann Intern Med. 2007;146:184-187.
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17. Jneid H, Anderson JL, Wright RS, et al. ACCF/AHA focused update of the guidelines for the management
of patients with unstable angina/non-ST elevation myocardial infarction: a report of the American College of
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H. Benefits/Harms of Implementation
1. Benefit: Provides a standardized approach for management and monitoring of peri-procedural
anticoagulation
2. Harms:
2.1. Choosing to continue anticoagulation therapy may result in bleeding intra or post procedure or
surgery.
2.2. Discontinuing anticoagulation therapy may result in a thromboembolic event while the patient is
not anticoagulated.
I.
Qualifying Statements (optional)
These are guidelines to provide clinicians with some guidance on an area of medicine where data from
randomized controlled trials are lacking and considerable controversy exists. Deviation from
these guidelines may be necessary and appropriate when caring for an individual patient
J. Implementation Strategy
1. Recommendations provided by this guideline will be disseminated to clinical staff through a series of
clinical inservices and through the use of implementation tools outlined below.
K. Implementation Tools/Plan
1. UW Health Ambulatory Anticoagulation Newsletter
2. UW Health Anticoagulation Website: [Link]/anticoagulation
3. Creation of smart text for documenting periprocedural plan in the electronic medical record.
L. Disclaimer
It is understood that occasionally patients will not match the conditions considered in the guideline and
clinical judgment should be used when developing a treatment plan.
