Periprocedural management of oral anticoagulation: When and how to hit “pause”

2. How far in advance of the procedure should the oral anticoagulant be withheld?

Warfarin may need to be stopped anywhere from 2 to 5 days prior to the procedure, depending on a number of variables.

Previous proximal deep vein thrombosis and pulmonary embolism are associated with a higher risk for recurrence than a distal DVT, and males have a higher recurrence risk than females.

Warfarin has a half-life of approximately 36 hours, so it can take 3 to 5 days for warfarin concentrations to drop to safe levels for procedures with low to moderate bleeding risk and 5 to 7 days for procedures with high bleeding risk.²¹ The 2012 CHEST guidelines recommend that warfarin therapy be discontinued 5 days prior to surgery to minimize the risk for bleeding.³ The Anticoagulation Forum, a leading expert panel that produced a set of useful anticoagulation guidelines in 2016, recommends stopping warfarin 4 to 5 days prior to a procedure.²¹ If the provider chooses to withhold warfarin before a procedure with minimal bleeding risk, it should be stopped 2 to 3 days prior.³

Consider checking INR values the week before. A 2017 consensus statement from the ACC recommends that the timing of warfarin discontinuation be based on an INR value taken 5 to 7 days prior to the surgical procedure.¹¹ This allows for a more tailored approach to preparing the patient for surgery. If the INR is below goal range, warfarin may need to be withheld for only 3 to 4 days prior to a procedure. Conversely, INRs above goal range may require warfarin to be held 6 or more days, depending on the degree of INR elevation.

While not always feasible in clinical practice, the CHEST guidelines recommend obtaining an INR value the day prior to the procedure to determine if the INR value is low enough to proceed with surgery, or if a low dose of oral vitamin K needs to be administered to ensure that the INR is in a safe range the following day.³

DOACs

DOACs can be withheld for much shorter durations preoperatively than warfarin.

Major orthopedic surgery and surgeries for major trauma or spinal cord injuries are associated with an exceedingly high rate of venous thromboembolism.

When withholding anticoagulants, the goal is to have a low amount of anticoagulant effect (12%-25%) present during low-risk procedures and a nominal amount of anticoagulant effect (3%-6%) present for high-risk procedures.²⁰ DOACs have much shorter half-lives than warfarin (7-19 hours vs 36-48 hours, respectively), so they can be withheld for much shorter durations preoperatively.²⁰ For patients undergoing procedures that are considered to have a minimal risk for bleeding (such as minor dental and dermatologic procedures), DOACs do not generally need to be withheld; however, it may be ideal to time the procedure when the DOAC is at a trough concentration (before the next dose is due).³

Coronary artery bypass surgery, heart valve replacement, and carotid endarterectomies carry the highest risk for acute ischemic stroke.

DOACs generally need to be withheld for only 1 to 3 days prior to major surgical procedures in patients with normal renal function (creatinine clearance [CrCl] >30 mL/min using the Cockcroft-Gault formula).²⁰ The available oral direct factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban) should generally be stopped 24 hours prior to a procedure that has a low bleeding risk, and 48 hours prior to procedures with high bleeding risk (TABLE 4^11,20).²⁰ These medications may need to be withheld for an additional 1 to 2 days in patients with acute kidney injury or stage IV kidney disease.²⁰

Dabigatran. About 80% of dabigatran is excreted renally, so its elimination is much more dependent on renal function than is that of the oral direct factor Xa inhibitors.²⁰ Therefore, it generally needs to be withheld for at least 1 to 2 days longer than the oral factor Xa inhibitors unless CrCl >80 mL/min (TABLE 4^11,20).²⁰