Perioperative

Management of
Antithrombotic Therapy
ACCP Guidelines. CHEST 2012;141(2):e326S50S
BRIDGE Trial. N Engl J Med 2015;373:823-33

Perioperative Mgmt: Balancing Act

VTE RISK

Patient factors

Anticoagulation regimen
Comorbidities
VTE (1%/d, 40% 1m, 10% 2-3m, 5% >3m)
RR with AC of 80%
Arterial emboli (0.5%/d, 15% 1m; Afib -> 112%/y as per score)
RR with AC of 66%
Prosthetic heart valve (Mechanical 8-22%/y,
M>>A)
RR with AC of 75%
VTE (6% fatal, 2% disability), Stroke (20% fatal, 40%
disability)
N Engl J M 1997;336:1506-11

Perioperative Mgmt: Balancing Act

BLEEDING RISK
Patient factors

Anticoagulation regimen
Drug, intensity, duration, stability

Comorbidities

Age, liver disease, renal disease, clotting disorders; other drugs

Surgical factors

Johns Hopkins Surgical

Bleeding Classification
EBL: Minimal, <500ml,
500-1000, >1500
3% fatal; 50% another procedure; 1% disability

N Engl J M 1997;336:1506-11

Perioperative Mgmt: Urgent Surgery

WARFARIN
Same day: 4-PCC + VitK IV
Next day: VitK PO

DABIGATRAN
12-17h
Idarucizumab (Praxbind) - approved

Xa INHIBITORS
Rivaroxaban 5-9h
Apixaban 8-15h
Edoxaban 6-11h
Andexanet alfa, PRT064445 not FDA approved
PER977; Perosphere not FDA approved, also for dabigatran and LMWH
Antifibrinolytic agents (tranexamic acid, epsilon-aminocaproic acid)

N Engl J Med 2014; 371:2141. N Engl J Med 2015;

Perioperative Mgmt: VTE Risk

Mechanical Valve
HIGH RISK
Any mitral valve prosthesis
Older (caged-ball or tilting disc) aortic valve prosthesis
Recent (within 6 months) stroke or TIA
MODERATE RISK
Bileaflet aortic valve and at least one of:
Atrial fibrillation, prior stroke or transient ischemic
attack, hypertension, diabetes, congestive heart
failure, age >75 years
LOW RISK
Bileaflet aortic valve without atrial fibrillation and no
other risk factors for stroke

Perioperative Mgmt: VTE Risk AFib

HIGH RISK
CHADS2 score = 5-6
Recent (within 3 months) stroke or TIA
Rheumatic valvular heart disease
MODERATE RISK
CHADS2 score = 3-4
LOW RISK
CHADS2 score = 0-2 and no prior stroke or TIA

Perioperative Mgmt: VTE Risk VTE

HIGH RISK
Recent VTE (<3 months ago)
Severe thrombophilia (eg, antiphospholipid
antibodies)
MODERATE RISK
VTE within the past 3-12 months
Non-severe thrombophilia (eg, heterozygous factor V
mutation)
Recurrent VTE
Active cancer (treated within 6 months or palliative)
LOW RISK
Prior VTE >12 months ago and no other risk factors

Perioperative Mgmt: Bleeding risk

CCJM 2009;76:S37-S44

Perioperative Mgmt: Bleeding risk

HIGH RISK

Urologic surgery/procedures: TURP, bladder resection or tumor

ablation, nephrectomy or kidney biopsy (untreated tissue
damage after TURP and endogenous urokinase release)
Pacemaker or ICD implantation (separation of infraclavicular
fascia and no suturing of unopposed tissues may lead to
hematoma)
Colonic polyp resection, especially >1-2 cm sessile polyps
(bleeding occurs at transected stalk after hemostatic plug
release)
Vascular organ surgery: thyroid, liver, spleen
Bowel resection (bleeding may occur at anastomosis site)
Major surgery involving considerable tissue injury: cancer
surgery, joint arthroplasty, reconstructive plastic surgery
Cardiac, intracranial or spinal surgery (small bleeds can have
serious clinical consequences)

Case Vignette No. 1

A 68-year-old woman receiving

chronic warfarin for recurrent DVT
(most recent was 1 year ago) will
undergo two dental extractions that
will include local anesthetic
injections

Management Options
1. Stop warfarin at day -5 before
procedure, give therapeutic-dose
bridging with LMWH (eg, enoxaparin, 1
mg/kg bid)
2. Continue warfarin without dose
reduction and give prohemostatic
mouthwash (cyclokapron) around
procedure
3. Continue warfarin without dose
reduction
4. Stop warfarin 2 days before procedure
and resume after procedure

Patients Requiring Minor

Procedures

In patients who require minor dental surgery

and are receiving VKA therapy, we suggest
either continuing VKA with co-administration of
an oral prohemostatic agent or stopping VKAs
2-3 days before the procedure instead of
alternative strategies (Grade 2C).
In patients who require minor skin procedures
and are receiving VKA therapy, we suggest
continuing VKAs around the time of the
procedure and optimizing local hemostasis
instead of other strategies (Grade 2C).
In patients who require cataract surgery and
are receiving VKA therapy, we suggest
continuing VKAs around the time of the surgery
instead of other strategies (Grade 2C).

Case Vignette No. 2

A 54-year-old man with a
mechanical mitral valve
replacement on long-term warfarin
therapy is scheduled for total hip
replacement

Management Options
1. Stop warfarin 5 days preop, administer
therapeutic-dose bridging with LMWH
(eg, enoxaparin, 1 mg/kg bid) preop and
postop
2. Stop warfarin 5 days preop, administer
low-dose LMWH preop and postop (eg,
dalteparin, 5000 IU QD)
3. Continue warfarin but reduce dose by
50% starting 5 days preop
4. Stop warfarin 5 days preop and resume
after procedure

Patients at High Risk having Major

Surgery

In patients who require temporary interruption

of a VKA before surgery, we recommend
stopping VKAs approximately 5 days before
surgery instead of stopping VKAs a shorter
time before surgery (Grade 1C).
In patients who require temporary interruption
of a VKA before surgery, we recommend
resuming VKAs approximately 12-24 hrs after
surgery (evening of or next morning) and when
there is adequate hemostasis instead of later
resumption of VKAs (Grade 2C).
In patients with a mechanical heart valve, atrial
fibrillation or VTE at high risk for TE, we
suggest bridging anticoagulation instead of no
bridging during interruption of VKA therapy

Perioperative Administration of
Bridging

In patients who are receiving bridging

anticoagulation with therapeutic-dose SC
LMWH, we suggest administering the last
preoperative dose of LMWH approximately 24 h
before surgery instead of 12 h before surgery
(Grade 2C).
In patients who are receiving bridging
anticoagulation with therapeutic-dose SC
LMWH and are undergoing high bleeding-risk
surgery, we suggest resuming therapeutic-dose
LMWH 48-72 h after surgery instead of
resuming LMWH within 24 h after surgery
(Grade 2C).

Case Vignette No. 3

A 69-year-old man with chronic
atrial fibrillation and hypertension
(CHADS2 score = 1) is undergoing a
abdominal surgery for cancer

Management Options
1. Stop warfarin 5 days preop, administer
therapeutic-dose bridging with LMWH
(eg, enoxaparin, 1 mg/kg bid) preop and
postop
2. Stop warfarin 5 days preop, administer
low-dose LMWH preop and postop (eg.,
daltearin, 5000 IU qd)
3. Continue warfarin but reduce dose by
50% starting 5 days preop
4.

Stop warfarin 5 days preop and resume

after procedure

Patients at Low Risk for TE Having

Major Surgery
In patients with a mechanical heart valve, atrial
fibrillation or VTE at low-risk for TE, we suggest
no bridging instead of bridging anticoagulation
during interruption of VKA therapy (Grade 2C).

BRIDGE Trial

BRIDGE Trial

BRIDGE Trial

BRIDGE Trial Critique

Small number with mitral stenosis (<2%) or highrisk nonvalvular AF (<14% had CHADS2score 4)
About 90% of the procedures were minor (including
endoscopies, cardiac catheterizations, dental
procedures, and minor dermatologic and orthopedic
procedures, which comprised about 75% of the total
minor surgeries).
NO bridging strategy for lower-risk AF and minor
procedures.
Maybe wait for PERIOP-2 trial before stopping
bridging in high-risk patients.

MKSAP!
58M is seen for preop evaluation prior to umbilical hernia
repair in 1wk. He has increasing pain at the site of his
umbilical hernia, but no incarceration. He exercises
regularly without symptoms. No h/o stroke or transient
ischemic attack. Medical history is notable for aortic
valve replacement with bileaflet mechanical prosthesis
performed 3 years ago for a bicuspid aortic valve and
decreasing exercise capacity. Medications are warfarin
and low-dose aspirin.
On examination, BP 124/72, HR 70/min. Cardiovascular
examination reveals a regular rhythm, a mechanical S2,
and a grade 1/6 early systolic crescendo-decrescendo
murmur at the cardiac base without radiation. Laboratory
studies show a normal serum creatinine level. ECG
performed 2m ago showed NSR. An ECHO 2m ago
showed normal LVEF and normal function of the
mechanical aortic valve prosthesis.

MKSAP!
In addition to continuing aspirin and stopping warfarin
5 days before surgery, which of the following is the
most appropriate management for preoperative
anticoagulation bridging?
A. IV unfractionated heparin
B. Prophylactic-dose subcutaneous enoxaparin
C. Therapeutic-dose subcutaneous enoxaparin
D. No bridging anticoagulation

CHEST Guideline. CHEST 2016; 149(2):31552

Antithrombotic Therapy for VTE

For VTE and no cancer, as long-term AC therapy, we suggest

dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B),
or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and
suggest VKA therapy over low-molecular-weight heparin (LMWH;
Grade 2C).

For VTE and cancer, we suggest LMWH over VKA (Grade 2B),
dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C),
or edoxaban (Grade 2C).

For VTE treated with AC, we recommend against an IVC filter (Grade
1B).

For DVT, we suggest not using compression stockings routinely to

prevent PTS (Grade 2B).

For subsegmental PE and no proximal DVT, we suggest clinical

surveillance over anticoagulation with a low risk of recurrent VTE
(Grade 2C), and anticoagulation over clinical surveillance with a high
risk (Grade 2C).

We suggest thrombolytic therapy for pulmonary embolism with