Algorithm for anticoagulant discontinuation in individuals undergoing elective surgery

CrCl: creatinine clearance; DOAC: direct oral anticoagulant; IVC: inferior vena cava; LMW: low molecular weight; VKA: vitamin K antagonist; VTE: venous thromboembolism.

• Direct oral anticoagulants (DOACs) include dabigatran, apixaban, edoxaban, and rivaroxaban.
• Vitamin K antagonists include warfarin, acenocoumarol, phenprocoumon, and fluindione.

¶ The following applies to DOAC interruption:

• These intervals are for individuals with normal kidney function and factor Xa inhibitors regardless of kidney function.
• For individuals with CrCl 30 to 50 mL/min receiving dabigatran, longer intervals are used (omit from 2 days before a low/moderate bleeding risk procedure; omit from 4 days before a high bleeding risk procedure).
• The perioperative management from the PAUSE study (a population with atrial fibrillation) can be applied to individuals who are receiving a DOAC for VTE that was >30 days prior. If the individual had a VTE within the prior 30 days, DOAC interruption should be individualized and may include placement of a temporary IVC filter or shorter periods of DOAC interruption.
• Bridging is not used for DOACs.

Δ The following applies to VKA interruption:

• For warfarin, discontinue 5 days before the procedure.
• If bridging is needed for a high thromboembolic risk patient, start LMW heparin at therapeutic dose approximately 3 days before surgery, with the last preoperative dose approximately 24 hours before surgery.
• Resume warfarin postoperatively once hemostasis is assured (typically the evening of the day of surgery or the day after surgery). Resume LMW heparin approximately 2 to 3 days after surgery (determined by the bleeding risk of the procedure) and discontinue LMW heparin after stable warfarin anticoagulation.
• The overlap period between LMW heparin and warfarin depends on the patient's thromboembolic risk.