Periprocedural Practice Guidelines of Patients Receiving Anticoagulant and Antiplatelet

Guideline Title
Therapy and Bridging Anticoagulation
Target Population: UK HealthCare Inpatient and Ambulatory Adult Patients

Guideline Author(s): George Davis, PharmD

Jagriti Chadha, MD
Paul Anaya MD, PhD
Thomas McLarney, MD
Eric Johnson, PharmD
Committee(s) Reviewed/Date Anticoagulation Subcommittee, Pharmacy and Therapeutics Committee
Current Version Approval Date January 2022
Periodic Review Annual
Guideline Overview This guideline is intended to provide recommendations for periprocedural management of anticoagulation and
antiplatelet agents for inpatient and ambulatory adult patients based on assessment of short-term risk for
thromboembolism and bleeding.
This guideline intended for UKHC adult patients on antithrombotic scheduled for elective inpatient or
outpatient procedures;
Not intended for urgent; semi-urgent, or emergent procedures as refer to critical bleeding and reversal
guidelines.
These guidelines are not intended to supersede clinical judgment and encourage risk-benefit discussions
between involved providers.
Antithrombotic and antiplatelet Apixaban Aspirin
medications addressed in the Dabigatran Clopidogrel
guideline Edoxaban Ticagrelor
Heparin, low Prasugrel
molecular weight Cangrelor
Heparin, Abciximab
unfractionated Eptifibatide
Fondaparinux Tirofiban
Rivaroxaban Dipyridamole
Warfarin Cilostazol
Vorapaxar
Implementation Anticoagulation Stewardship Folder on UK CareWeb
Strategy/Tools/Plan P&T Minutes and Newsletter
Referral during Multidisciplinary Anticoagulation Consults
 Perioperative Management of Patients Receiving Antithrombotic Therapy

Clinical Practice Considerations for All Agents

1. Practical considerations for periprocedural management of anticoagulant and antiplatelet agents

1.1. Patients should be assessed at least 7 days before elective surgery/procedures when possible to allow appropriate planning for
periprocedural management of antithrombotics considering the following principles:
1.1.1. Oral anticoagulation (OAC) may not warrant interruption for procedures with low bleeding risk.
1.1.2. Patients at highest risk for thromboembolism (TE) without excessive bleeding risk should be evaluated for bridging.
1.1.3. Intermediate-risk cases should be managed based on individual assessment considering patient- and procedure- specific
risk for bleeding and TE.
1.2. For reversal of anticoagulation for bleeding or emergent procedures, refer to UK HealthCare Anticoagulation Reversal
Guidelines
1.3. Refer to the UK HealthCare Epidural / Intraspinal Anticoagulant Guidelines for guidance in utilization of anticoagulants
and antiplatelet agents in patients receiving epidural analgesia

2. Estimate bleeding risk – (Table 2)

2.1. Periprocedural bleeding assessment should consider the risk of bleeding for antithrombotic therapy when administered in proximity of surgery
2.2. Need to distinguish risk of bleeding associated with bridging with therapeutic anticoagulation versus when anticoagulation is used for VTE
prophylaxis
2.3. Warfarin and aspirin may be continued during some procedures where bleed risk is low.

Table 2. Bleeding Risk for Surgery/Procedure

HIGH RISK MODERATE RISK LOW RISK
• Aortic aneurysm repair • Renal biopsy • Biopsies
• Bladder surgery • Resection of colon polyps • Cataract surgery
• Bowel polypectomy • Prostate biopsy • Colonoscopy with or without biopsy
• Coronary artery bypass grafting (CABG) • Pacemaker or defibrillator implantation • Coronary angiography
• Heart valve replacement • Major intraabdominal surgery • Dental procedures
• Intracranial surgery • Major intrathoracic surgery • Dermatologic surgery (most)
• Major cancer surgery • More invasive dental or ophthalmic procedures • Endodontics
• Major orthopedic surgery (hip or knee replacement) • Endoscopy with or without biopsy
• Peripheral artery bypass and other major vascular • Endovascular interventions
surgery • Laparoscopic cholecystectomy or hernia repair
• Prostate surgery • Prosthetics
• Reconstructive plastic surgery • Restorations
• Spinal surgery/Epidural procedure • Simple extractions

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

3. Estimate short-term thromboembolic risk (Table 1)

3.1. The guidelines of the American College of Chest Physicians stratify patients into the following thrombotic risk categories:
3.1.1.High risk (> 10% risk of thrombotic events per year)
3.1.2.Moderate risk (5–10%)
3.1.3.Low risk (< 5%)
3.2. Major factors that increase thromboembolic risk are atrial fibrillation, prosthetic heart valves, and recent venous or arterial thromboembolism
3.3. For atrial fibrillation patients, annual risk of stroke should be determined using the CHA2DS2VASc score risk assessment tool
3.3.1. Stroke history and time since last event is important
3.4. Prosthetic heart valve type and position should be determined
3.4.1. Type - mechanical valve has higher thrombotic risk compared with tissue valve
3.4.2. Position - mitral valve has higher thrombotic risk compared with aortic valve
3.5. Indication of anticoagulation and antiplatelet agents and detailed thromboembolism history is important including time since last event and
number of events
3.5.1. Perioperative interruption of antithrombotic therapy should be distinguished from assessing patient risk for post-operative VTE (refer to
UK HealthCare Surgical VTE Risk Assessment)
Table 1. Periprocedural Risk for Thromboembolism and Recommendations for Bridging with Therapeutic Anticoagulation
TE Recommendations Indication for Anticoagulation Therapy
Risk for Bridging Bioprosthetic Mechanical
Stratum Therapy Atrial Fibrillation VTE
Heart Valve Heart Valve
• Recent VTE (< 3 mo), especially <6 weeks
• CHA2DS2VASc score ≥7
• Any mitral valve prosthesis considered higher risk
• Recent CVA/TIA (within 3
Use bridging with • Older (caged-ball or tilting • Active cancer with high VTE risk (e.g., metastatic)
months)
HIGH appropriate parenteral • Recent placement disc) aortic valve prosthesis • Severe thrombophilia (AT deficiency, protein C or S
• Rheumatic valvular heart
RISK anticoagulation < 3mo • CVA/TIA within 6 mo deficiency, homozygous Factor V Leiden, APLS,
disease
• Prior TE during interruption of both heterozygous Factor V Leiden and
• Prior TE during interruption
anticoagulant therapy prothrombin gene mutation)
of anticoagulant therapy
• Prior TE during interruption of anticoagulant therapy

• VTE within the past 3 to 12 months - (might

Bridging may be
• Bileaflet aortic valve consider VTE prophylaxis rather than full intensity
considered based on • CHA2DS2VASc score 5-6
prosthesis and one of the bridge therapy)
MODERATE assessment of • Consider bridge if CVA/TIA
following: afib, prior • Non-severe thrombophilia (e.g., heterozygous factor
RISK individual case and >3mo or mechanical valve
CVA/TIA/TE, HTN, DM, CHF, V Leiden mutation, heterozygous factor II mutation)
bleeding risk factors is present
age >75 years • Recurrent VTE
• Active cancer (treated within 6 months or palliative)

• Bioprosthetic valve >3mo

Suggest NOT to use
• Bileaflet aortic valve
LOW bridging during • CHA2DS2VASc score 0-4 • Single VTE occurred > 12 months ago and no other
• >3mo placement prosthesis without afib and no
RISK interruption of and no prior CVA/TIA persistent risk factors for recurrent VTE
prior CVA/TIA/TE, HTN, DM,
anticoagulation
CHF, age >75 years

CHA2DS2VASc indicates annual risk of stroke; CHF, congestive heart failure; CVA, cerebral vascular accident; DM, diabetes mellitus; HTN, hypertension; TE, thromboembolism; TIA,
transient ischemic attack.

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Figure 1. Heparin Bridging Algorithm

Bridging Protocol Initiation

• Consider invention
on warfarin or at Bleeding Risk of
slightly reduced INR INTERMED
(1.8)
LOW Procedure HIGH Assess Risk of thromboembolic Event (Table 2)
• For DOAC, refer to (Table 1)
Table 3

LOW INTERMED HIGH

LOW RISK PROCEDURES

Bridging may not be warranted based
Interrupt anticoagulation Bridge with appropriate parenteral
• Biopsies on risk/benefit assessment of patient
without bridging therapy anticoagulation (LMWH or UFH)
• Cataract Surgery specific factors
• Colonoscopy without
removal of large polyps
• Coronary angiography
• Ablation therapy
• Dental procedures • Bileaflet aortic • Mechanical mitral
• Prosthetics Cardiac • Age < 75 • Age 75 or older • Cage-ball or tilting disc aortic
Restorations • CVA/TIA within 6mo
•
• Simple extractions Valves •
•
No previous CVA/TIA
No HTN, DM, or CHF
• Previous CVA/TIA or HTN, DM, CHF

• Endodontics
• Dermatologic procedures
(minor) • CHA2DS2VASc score ≥7
• Endoscopy +/- biopsy •
• Endovascular interventions
• CHA2DS2VASc score 0- CHA2DS2VASc score 5-6 • Recent CVA/TIA (within 3 months)
• Laparoscopic AFib 4 and no prior CVA/ • Consider bridge if CVA/TIA >3mo or • Rheumatic valvular heart disease
cholecystectomy or hernia TIA mechanical valve is present
• Bronchoscopy +/- biopsy
• Prior TE during interruption of
• Uncomplicated procedures anticoagulant therapy

• VTE within the past 3 to 12 months - • Recent VTE (< 3 mo), especially <6 weeks
• Single VTE occurred > • Prior TE during interruption of
(might consider VTE prophylaxis rather
VTE 12 mo and no other
than full intensity bridge therapy) anticoagulant therapy
risk factors
• Non-severe thrombophilia (e.g., • Active cancer with high VTE risk (e.g.,
heterozygous factor V Leiden metastatic)
mutation, heterozygous factor II • Severe thrombophilia (AT deficiency,
mutation) protein C or S deficiency, homozygous
• Recurrent VTE Factor V Leiden, APLS, both heterozygous
• Active cancer (treated within 6 months Factor V Leiden and prothrombin gene
or palliative) mutation)
• Prior TE during interruption of
anticoagulant therapy

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Specific Anticoagulation Considerations for Periprocedural Management

1. Vitamin K Antagonist (Warfarin)

1.1. Patients should be assessed at least 7 days before elective surgery/procedures when possible to allow appropriate planning for periprocedural
management
1.1.1. Preprocedure INR: 2.0 – 3.0: Stop warfarin 5 days (hold 4 doses) before surgery or procedure
1.1.2. Preprocedure INR: 3.0 – 4.5: Stop warfarin 6 days (hold 5 doses) before surgery or procedure
1.2. Refer to Figure 1 to determine if bridge therapy is needed
1.3. Check INR within 24 hours of surgery or procedure to ensure that INR ≤ 1.5 or lower if otherwise indicated
1.4. 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
1.5. Restart warfarin on postoperative day 1 if hemostasis is achieved and if approved by surgeon
1.6. May start on postoperative day 0 if dose given 12 hours after surgery or procedure and if approved by surgeon

2. Direct oral anticoagulants (DOACs, e.g., apixaban, dabigatran, edoxaban and rivaroxaban)
2.1. Assessment of renal function is useful when evaluating direct oral anticoagulants and suggest to use Cockcroft-Gault equation to estimate
creatinine clearance.
2.2. Assess renal function at least 7 days before surgery or procedure to allow for planning of perioperative management.
2.3. Consider restarting DOAC on postoperative day 1 if hemostasis is achieved and if approved by surgeon
2.4. May start on postoperative day 0 if dose given 12 hours after surgery or procedure and if approved by surgeon

2.5. Apixaban (Eliquis®) ~25% renal clearance

Estimated Clcr Estimated Time of last dose of apixaban before procedure

(ml/min) t1/2 (hrs) Standard Risk of Bleeding High Risk of Bleeding
>80 15
24 hours 2 days
50-80 15
31-49 18 1-2 days 3-4 days
≤30 17 2 days 4 days

2.6. Dabigatran (Pradaxa®) ~80% renal clearance

Estimated Clcr Estimated Time of last dose of dabigatran before procedure

(ml/min) t1/2 (hrs) Standard Risk of Bleeding High Risk of Bleeding
>80 14 24 hours 2-3 days
50-80 17 24 hours 2-4 days
31-49 19 2 days 4 days
≤30 ~28 (22-35) 4 days >5 days

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

2.7. Edoxaban (Savaysa®) ~50% renal clearance

Estimated Clcr Estimated Time of last dose of rivaroxaban before procedure

(ml/min) t1/2 (hrs) Standard Risk of Bleeding High Risk of Bleeding
>80 10-14
24 hours 2 days
50-79 Not available
31-49 Not available 1-2 days 3-4 days
≤30 Not available 2 days 4 days

2.8. Rivaroxaban (Xarelto®) ~33% renal clearance

Estimated Clcr Estimated Time of last dose of rivaroxaban before procedure

(ml/min) t1/2 (hrs) Standard Risk of Bleeding High Risk of Bleeding
>80 15
24 hours 2 days
50-79 15
31-49 18 1-2 days 3-4 days
≤30 17 2 days 4 days

3. Parenteral Anticoagulation for Periprocedural Management

3.1. Therapeutic or prophylactic doses may be considered for patients with venous thrombosis risks depending on thromboembolic risk (Table 1)
3.2. Consider therapeutic doses for patients who are at risk for arterial thromboembolism
3.3. For patients taking warfarin and bridging needed: Start a low molecular weight heparin (LMWH) or unfractionated heparin (UFH) when INR <
2.0, usually about 2 days after stopping warfarin
3.4. For patients taking novel oral anticoagulants and bridging needed: Start LMWH or UFH at time of next scheduled dose after last administered
dose
3.5. Fondaparinux is contraindicated for pre-procedural bridging due to long elimination half-life
3.5.1.Fondaparinux must be held for at least 5 days to assure full clearance (t ½ 17 - 21 hrs in normal renal function; longer in renal impairment).

3.6. Prior to procedure

3.6.1. Stop therapeutic LMWH 24 hours before surgery or procedure
3.6.2. Stop prophylactic LMWH or SQ UFH at 12 hours before surgery or procedure
3.6.3. Stop IV therapeutic UFH, argatroban, or bivalirudin at 4-6 hours before surgery or procedure

3.7. After procedure

3.7.1. Minor surgery or procedure with low bleeding risk: Start LMWH or UFH 12 to 24 hours pending approval from surgeon
3.7.2. Major surgery or high bleed risk surgery or procedure: Start LMWH or UFH 48 to 72 hours pending approval from surgeon
3.7.2.1. If therapeutic doses of LMWH or UFH were used pre-operatively may consider starting prophylactic dosing in 24 hours pending
approval from surgeon

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Anticoagulant Periprocedural Management References:

1. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of
the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of
Thoracic Surgeons. Circulation. 2019;140:e125–e151.
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 Evidence-Based Clinical Practice Guidelines (9th 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 College of Chest Physicians Evidence-Based
Clinical Practice Guidelines (9th edition). CHEST. 2012;141:e44S-e88S.
4. Eikelboom JW, Hirsh J, Spencer FA, et al. Antiplatelet drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition). Chest. 2012; 141:e89s-
119s
5. 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.
6. Pradaxa [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc; July 2020.
7. Xarelto [package insert]. Gurabo, PR: Janssen Pharmaceuticals, Inc; October 2019.
8. Eliquis [package insert]. Princeton, NJ: Bristol-Meyers Squibb, Inc; November 2019.
9. 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.
10. Siegal D, Yudin J, Kaatz S, Douketis JD, Lim W, Spyropoulos AC. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of
bleeding and thromboembolic rates. Circulation. 2012;126(13):1630.
11. 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.
12. 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.
13. 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.
14. Wii DM, McCool KH, Dowd MB, et al. Incidence and predictors of bleeding or thrombosis after polypectomy in patients receiving and not receiving anticoagulation therapy. J
Thromb Haemost. 2009;7(12):1982-9.
15. Rietbrock S, Heeley E, Plumb J, et al. Chronic atrial fibrillation: incidence, prevalence, and prediction of stoke using the congestive heart failure, hypertension, age > 75, diabetes
mellitus, and prior stroke or transient ischemic attack (CHADS2) risk stratification scheme. Am Heart J. 2008;156:57-64.
16. Douketis J. Perioperative anticoagulation managment in patients who are receiving oral anticoagulant therapy: a practical guide for clinicians. Thromb Res. 2002;108:3-13.
17. O'Donnell M, Kearon C, Johnson J, et al. Brief communication: Preoperative anticoagulant activity after bridging low molecular weight heparin for temporary interruption of
warfarin. Ann Intern Med. 2007;146:184-187.
18. Hirsh J, Bauer KA, Donati MD, et al. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133:14
19. 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 Chest Physician Foundation and American Heart Association Task Force on practice guidelines. Circulation. 2012;126:875-910.
20. Douketis JD, Spyropoulos AC, Kaatz S, et al; BRIDGE Investigators. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Aug 27;373(9):823-
33.
21. Rechenmacher SJ, Fang JC. Bridging Anticoagulation. J Am Coll Cardiol 2015;66:1392–403.
22. Douketis J. Perioperative anticoagulation managment in patients who are receiving oral anticoagulant therapy: a practical guide for clinicians. Thromb Res. 2002;108:3-13.
23. O'Donnell M, Kearon C, Johnson J, et al. Brief communication: Preoperative anticoagulant activity after bridging low molecular weight heparin for temporary interruption of
warfarin. Ann Intern Med. 2007;146:184-187.
24. Hirsh J, Bauer KA, Donati MD, et al. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133:14
25. 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 Chest Physician Foundation and American Heart Association Task Force on practice guidelines. Circulation. 2012;126:875-910.

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Periprocedural Antiplatelet Management

Table 1. Antiplatelet Agent Review
Drug Mechanism of Action Half-Life
Aspirin (Ecotrin ®) Irreversibly inhibits cyclooxygenase-1 and 2 Dose dependent: 3 hours at lower doses
Clopidogrel (Plavix ®) Irreversibly blocks the P2Y12 receptor (prodrug) Parent drug: ~6 hours; Active metabolite: ~30 minutes (platelets
affected for the remainder of their lifespan ~5-9 days)
Ticagrelor (Brilinta ®) Reversibly and noncompetitively blocks the P2Y12 receptor Parent drug: ~7 hours; Active metabolite: ~9 hours
Prasugrel (Effient ®) Irreversibly blocks the P2Y12 receptor (prodrug) Active metabolite: ~7 hours (range 2-15 hours)
Platelets affected for the remainder of their lifespan ~5-9 days
Ticlopidine (Ticlid ®) Active metabolite irreversibly blocks P2Y12 receptor 13 hours
Cangrelor (Kangreal ®) Selectively and reversibly binds to P2Y12 receptor ~3-6 minutes
Platelet function returns to normal within 1 hour after
discontinuation of infusion
Abciximab (Reopro ®) Binds to platelet glycoprotein IIb/IIIa receptors Plasma: ~30 minutes
Dissociation half-life from receptor: up to 4 hours
Eptifibatide (Integrilin ®) Binds to platelet glycoprotein IIb/IIIa receptors ~2.5 hours
Tirofiban (Aggrastat ®) Binds to platelet glycoprotein IIb/IIIa receptors ~2 hours
Dipyridamole Inhibits adenosine deaminase and phosphodiesterase ~10-12 hours
activity
Cilostazol Inhibits phosphodiesterase III leading to platelet inhibition ~11-13 hours
Vorapaxar (Zontivity ®) Antagonist of protease-activated receptor-1 expressed on Effective half-life: ~3-4 days
platelets Terminal elimination half-life: ~8 days

Table 2: Perioperative Recommendations for Antiplatelet Therapy (when Antiplatelet Therapy Used for Secondary Prevention)
PROCEDURAL ANTIPLATELET GUIDELINES FOR HOLDING THERAPY
BLEEDING RISK AGENT
• Aspirin (Ecotrin) • Aspirin: Continue without interruption
• Clopidogrel (Plavix) • All other antiplatelets: Continue without interruption in minor dental, derm, or ophth procedures.
• Low risk procedure
• Ticagrelor (Brilinta) • For all other low risk procedures, hold clopidogrel/ticagrelor 5 days prior to procedure and hold prasugrel
• Prasugrel (Effient) 7 days prior to procedure if approved by prescribing provider and surgeon
• Aspirin (Ecotrin)
• Aspirin: Continue without interruption
• Clopidogrel (Plavix)
• Medium risk procedure • All other antiplatelets: Hold clopidogrel/ticagrelor 5 days prior to procedure and hold prasugrel 7 days
• Ticagrelor (Brilinta)
prior to procedure if approved by prescribing provider and surgeon
• Prasugrel (Effient)
• Aspirin:
o Continue without interruption in high risk chronic pain procedures if approved by providers.
• Aspirin (Ecotrin)
o For UK Neurosurgical Intracranical procedures, current practice is hold aspirin;
• Clopidogrel (Plavix)
• High risk procedure o Consult surgeon and prescriber otherwise.
• Ticagrelor (Brilinta)
• Prasugrel (Effient)
• All other antiplatelets: Hold clopidogrel/ticagrelor 5 days prior to procedure and hold prasugrel 7 days
prior to procedure if approved by prescribing provider and surgeon

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Notes:
• To determine risk of procedure, see Table 2 on Page 2 of these guidelines.
• These guidelines are not intended to supersede clinical judgment. Risk-benefit discussions between involved providers is strongly encouraged.
• The time that antiplatelet therapy should resume post-procedure is dependent on hemostasis and surgeon preference.
• These guidelines may not apply to pregnant females who take aspirin to prevent miscarriage.

Table 4: Periprocedural Management of Antiplatelet Therapy by Original Indication

TYPE OF PREVENTION PERIPROCEDURAL HOLDING OF ANTIPLATELET THERAPY
• Recent PCI • Continue aspirin without interruption.
• All other antiplatelet agents: Hold for 5 days prior to procedure for clopidogrel/ticagrelor and 7 days prior to
procedure for prasugrel if approved by prescribing provider and surgeon
• Notes:
• Balloon angioplasty: Delay elective procedure at least 14 days after angioplasty
• Bare metal stents (BMS): Delay elective procedure at least 30 days after BMS while on dual antiplatelet
therapy (DAPT)
• Coronary drug eluting stents (DES): Preferred to delay elective procedures for 6 - 12 months after DES
while on DAPT
• If risk of delaying procedure outweighs stent thrombosis risk, consider delaying elective procedure for 3
months
• Peripheral stents: Hold for 5 days prior to procedure for clopidogrel/ticagrelor if approved by prescribing
provider and surgeon
• Transcatheter aortic valve replacement (TAVR): Preferred to delay elective procedures for 3 months
after TAVR placement while on DAPT
• In emergency procedures needed within first 30 day of stent placement or with elective surgeries with
minor risk of serious bleeding dual antiplatelet therapy may be continued through the operation if
approved by surgeon.
• Primary prevention (no history of stroke or MI) and • Aspirin: Hold for 7 days prior to procedure
other indications not mentioned in this table • All other antiplatelet agents: Hold clopidogrel/ticagrelor 5 days prior to procedure and hold prasugrel 7 days
prior to procedure if approved by prescribing provider and surgeon
• Secondary prevention (history of stroke, CAD/MI, • See Table 4 below by risk of procedure
PAD, venous or arterial thrombosis)

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Table 5: VERIFYNOW® Assay Recommendations

VERIFYNOW ASSAY
TYPE OF PROCEDURE GUIDELINES FOR CONSIDERATION
• CABG • Reasonable to make decisions about surgical delay based on tests of platelet inhibition rather than arbitrary use of
a specified period of surgical delay
• Use up to the discretion of operating cardiothoracic surgeon
• Please refer to the Emergency Reversal Guidelines

Table 6: Considerations for Other, Less Common Antiplatelet Agents

RISK OF PROCEDURE ANTIPLATELET AGENT GUIDELINES FOR HOLDING THERAPY

• Low, Medium, or High Risk Procedure • Cangrelor (Kangreal) • Cangrelor: No antiplatelet effect after an hour of
• Abciximab (Reopro) discontinuation
• Eptifibatide (Integrilin) • Abciximab: Recommended discontinue 24 hours
• Tirofiban (Aggrastat) prior to surgery
• Dipyridamole (Persantine) • Eptifibatide: Recommended to discontinue 2-4
• Cilostazol hours prior to surgery
• Vorapaxar (Zontivity) • Tirofiban: Recommended to discontinue 2-4 hours
prior to surgery
• Dipyridamole: Recommended to discontinue 1-2
days prior to surgery
• Cilostazol: Recommended to discontinue 1-2 days
prior to surgery
• Vorapaxor: Recommended to discontinue 40-50
days prior to surgery

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Figure 1. Determining pre-procedural management of antiplatelet therapy

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Antiplatelet References:
1. Hall R, Mazer CD. Antiplatelet drugs: a review of their pharmacology and management in the perioperative period. Anesth Analg. 2011;112(2):292-318
2. Eikelboom JW, Hirsh J, Spencer FA, et al. Antiplatelet drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition). Chest.
2012;141:e89s-119s
3. Schoos, M, Chandrasekhar, et al. Causes, timing, and impact of dual antiplatelet therapy interruption for surgery (from the Patterns of Non-adherence to Anti-platelet
Regimens In Stented Patients Registry). Am J Cardiol. 2017;120(6):904-10.
4. Plavix [package insert]. Bridgewater, NJ: Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership; 2019.
5. Ecotrin [package insert]. Morristown, NJ: Bayer Corporation; 1938.
6. Brilinta [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2019.
7. Effient [package insert]. Indianapolis, IN: Eli Lilly and Company; 2019.
8. Kangreal [package insert]. Parsippany, NJ: The Medicines Company; 2015.
9. Reopro [package insert]. Indianapolis, IN: Eli Lilly and Company; 1997.
10. Integrilin [package insert]. Whitehouse Station, NJ: Merck and Co., Inc.; 1998.
11. Aggrastat [package insert]. West Point, PA: Merck and Co., Inc.; 1998.
12. Dipyridamole [package insert]. Eatontown, NJ: West-Ward Pharmaceuticals Corp.; 2011.
13. Pletal [package insert]. Rockville, MD: Otsuka America Pharmaceutical Inc.; 2015.
14. Zontivity [package insert]. Whitehouse Station, NJ: Merck and Co., Inc.; 2013.
15. Ferraris VA, Saha SP, Oestreich JH, et al. 2012 Update to The Society of Thoracic Surgeons Guideline on Use of Antiplatelet Drugs in Patients Having Cardiac and
Noncardiac Operations. Ann Thorac Surg. 2012;94:1761–81.
16. Preoperative Testing and Medication Management. The Ohio State University Wexner Medical Center; Approved 28 Jun 2017. Accessed 12 Dec 2017.

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Periprocedural Antithrombotic Management for Lumbar Puncture

Reference: Dodd KC, et al. Pract Neurol 2018;18:436–446. doi:10.1136/practneurol-2017-001820)

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 Perioperative Management of Patients Receiving Antithrombotic Therapy

Management of Periprocedural Anticoagulation (UKHC Cardiac Catherization Lab)

PROCEDURE ANTICOAGULANT ELECTIVE EMERGENT

Right heart Warfarin Can be done without stopping warfarin if INR <3.0 Can be done without stopping warfarin
catheterization DOAC* Can be done without stopping DOAC Can be done without stopping DOAC
Left heart catheterization Warfarin Can be done without stopping warfarin if INR <3.0 Can be done without stopping warfarin
(such as coronary Stop DOAC before procedure based on estimated
DOAC* Can be done without stopping DOAC
angiography and PCI) creatine clearance (see Table below)
CTO PCI, PCI with Warfarin Stop warfarin – INR should be <1.6** Can be done without stopping warfarin
hemodynamic Stop DOAC before procedure based on estimated
DOAC* Can be done without stopping DOAC
support, Complex PCI creatine clearance (see Table below)
Warfarin Stop warfarin – INR should be <1.6** Can be done without stopping warfarin
Endomyocardial biopsy Stop DOAC before procedure based on estimated
DOAC* Can be done without stopping DOAC
creatine clearance (see below Table)
* DOAC: direct oral anticoagulant including apixaban, dabigatran, edoxaban, rivaroxaban
** Biopsy with higher INR will be considered on a case by case basis for transplant patients after ≥3 months from transplantation

Direct Factor Xa inhibitors Estimated Creatinine Clearance (Clcr, mL/min) Days to Hold

Apixaban (Eliquis®) >15 2 days

50-95 2 days
Edoxaban (Savaysa®)
15-49 3 days
50-95 2 days
Rivaroxaban (Xarelto®)
15-49 3 days
>80 2 days
50-79 3 days
Dabigatran (Pradaxa®)
30-49 4 days
15-29 5 days

Creatinine clearance (Clcr) calculator: http://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation/

References
http://akn.allina.com/content1/groups/patient-care/@akn-pharmacy/documents/patient_care_documents/243996.pdf
http://akn.allina.com/content1/groups/patient-care/@akn-pharmacy/documents/patient_care_documents/243992.pdf

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