Periprocedural management of oral anticoagulant therapy

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Oral anticoagulants include vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). Periprocedural management of patients on long-term oral anticoagulants (e.g., for the prevention of stroke and systemic thromboembolism) is a field of ongoing research and there is currently no universal validated strategy. Management of anticoagulants in the periprocedural period should be tailored to the patient and the procedure in consultation with the proceduralist and anesthetist. Although invasive procedures performed on patients receiving anticoagulants are associated with an increased risk of bleeding, discontinuing anticoagulants increases the risk of thrombosis. Therefore, anticoagulant therapy should not be routinely interrupted periprocedurally, but instead, the decision should be based on the periprocedural bleeding risk and the periprocedural thrombotic risk. Once interrupted, VKAs take time to achieve therapeutic anticoagulation on reinitiation, and hence, bridging anticoagulation with a short-acting parenteral anticoagulant is required in patients at high thrombotic risk. Bridging anticoagulation is not routinely required for patients on DOACs, as they have a short half-life and, if discontinued, can rapidly achieve therapeutic anticoagulation on reinitiation.

For life-threatening periprocedural bleeding in patients on anticoagulants, see “Anticoagulant reversal.”

The general approach to periprocedural management of anticoagulant therapy is described here. As guidelines vary, it is strongly encouraged to consult the proceduralist and the anesthetist early and to follow local protocols. ^[2][3]

The decision to interrupt ongoing anticoagulation therapy should be tailored to the patient and the procedure. The risk of periprocedural thrombosis should be weighed against the risk of periprocedural bleeding.

Elective procedures ^[2][3]

The following suggestions are based on the 2012 American College of Chest Physicians guideline and the 2017 American College of Cardiology (ACC) decision pathway, and apply to elective procedures. See “Periprocedural management of VKAs” and “Periprocedural management of DOACs” for further details.

• 7 days before the procedure
  • Assess periprocedural bleeding risk.
  • Assess periprocedural thrombotic risk.
• Low bleeding risk: Anticoagulation may be continued; consult the proceduralist and anesthetist.
• Increased bleeding risk
  • Low thrombotic risk: Interrupt oral anticoagulants (bridging anticoagulation not required).
  • Moderate or high thrombotic risk
    • VKAs: Interrupt VKAs with bridging anticoagulation (use clinical judgment).
    • DOACs: Interrupt DOACs in most cases; preferably in consultation with specialists.

Parenteral bridging anticoagulation is not required for DOACs. ^[3]

Most recommendations are based on clinical experience and trials in patients with nonvalvular atrial fibrillation. Exercise caution when applying these recommendations to patients with a mechanical heart valve or a history of venous thromboembolism. If available, adhere to institutional guidelines.

Emergency procedures

• Low bleeding risk: Anticoagulation may be continued; consult the proceduralist and anesthetist.
• Increased bleeding risk
  • Consider anticoagulation reversal before performing the procedure.
  • Determine the need for postprocedural bridging anticoagulation based on the periprocedural thrombotic risk.

Patient-related risk factors ^[3][4][5]

The following factors are associated with an increased risk of periprocedural bleeding.

• Age > 65 years
• Hypertension
• Active cancer
• Abnormal renal function ^[5]
• Abnormal liver function ^[5]
• History of alcohol consumption (≥ 8 drinks per week) or recreational drug use ^[5]
• Chronic bleeding diathesis
• Quantitative or qualitative platelet abnormality
• Major bleeding or ICH < 3 months before planned procedure ^[4]
• History of stroke (i.e., ischemic stroke, spontaneous or traumatic ICH)
• History of or predisposition to major bleeding
• History of bleeding due to a similar procedure
• History of bleeding during bridging anticoagulation
• Concomitant therapy with NSAIDs, steroids, antiplatelets, and/or anticoagulants
• Labile INR or supratherapeutic INR

Consider delaying elective procedures until modifiable risk factors for periprocedural bleeding can be corrected or optimized.

Procedure-related risk factors

Even relatively minor bleeding in certain compartments (e.g., intraocular, spinal, pericardial) may cause significant morbidity and mortality. ^[3]

Risk factors for periprocedural thrombosis ^[2][5]

• Patient-related factors
  • Past history of stroke (especially within the past 3 months)
  • Past history of VTE or risk factors for VTE
  • Rheumatic valvular heart disease
  • Atrial fibrillation
  • Significant cardiovascular disease , especially within the past year
  • Active cancer
  • Thromboembolism during prior interruption of anticoagulation
• Procedures associated with high risk of thromboembolism: e.g., carotid endarterectomy, valve replacement, major vascular surgery

Common clinical scenarios ^[2][5]

Atrial fibrillation, mechanical heart valves, and VTE are the most common conditions that require long-term anticoagulation. The following table provides guidance on determining the periprocedural thrombotic risk in patients with these conditions, but the ultimate decision of whether to discontinue anticoagulation should be made on a case-by-case basis, ideally in consultation with relevant specialists.

Approach ^[3]

• Consult specialists and follow institutional protocols if available.
• Assess the need to interrupt VKAs based on periprocedural bleeding risk.
• If VKAs are to be interrupted:
  • Determine the timing of VKA interruption based on preprocedural INR levels.
  • Determine the need for bridging anticoagulation based on periprocedural thrombotic risk.
• Resume VKAs 12–24 hours after the procedure; consider delaying VKA resumption if postprocedural bleeding risk is high.

The decision of whether to interrupt VKAs is based on periprocedural bleeding risk. If VKAs are interrupted, the need for bridging anticoagulation is determined based on periprocedural thrombotic risk.

VKA interruption ^[3][5]

VKA interruption is the temporary discontinuation of VKAs a few days before an elective invasive procedure to minimize periprocedural bleeding risk.

• High periprocedural bleeding risk: Interrupt VKA.
• Uncertain periprocedural bleeding risk
  • Patient-related factors for periprocedural bleeding present: Interrupt VKA
  • No patient-related factors for bleeding: Consider interruption.
• Low periprocedural bleeding risk: VKAs may be continued.
  • Patient-related factors for periprocedural bleeding present: Consider interruption.
  • No patient-related factors for bleeding: Do not interrupt VKA.
• Timing (if VKA is interrupted): Assess INR 5–7 days before the procedure.
  • INR 1.5–1.9: Interrupt VKA 3–4 days before the procedure.
  • INR 2.0–3.0: Interrupt VKA 5 days before the procedure.
  • INR > 3.0: Interrupt VKA ≥ 5 days before the procedure.

Bridging anticoagulation ^[3]

Periprocedural bridging anticoagulation involves the temporary administration of a short-acting parenteral anticoagulant after VKA interruption for an invasive procedure. The timing of bridging anticoagulation initiation (i.e., pre- or postprocedurally) is based on periprocedural bleeding risk. Protocols may vary between institutions.

• High periprocedural thrombotic risk: Bridging anticoagulation is typically required.
  • Low periprocedural bleeding risk: Initiate preprocedural bridging anticoagulation.
  • High periprocedural bleeding risk (e.g., ICH within the past 3 months)
    • Consider postprocedural bridging anticoagulation. ^[3]
    • If feasible, consider delaying the procedure in patients with a thromboembolic event in the past 3 months.
• Moderate periprocedural thrombotic risk
  • Low periprocedural bleeding risk: Use clinical judgment; consult the proceduralist.
  • High periprocedural bleeding risk
    • Consider interrupting VKA without bridging anticoagulation.
    • OR consider postprocedural bridging anticoagulation.
• Low periprocedural thrombotic risk: Do not bridge.

Preprocedural bridging anticoagulation ^[3]

• Timing
  • Initiate bridging anticoagulation when the patient's INR is in the subtherapeutic range.
  • OR after 2–3 missed doses of VKA, if INR is not being monitored.
• Agents
  • LMWH, e.g., enoxaparin : Administer the last dose 24 hours before the procedure.
  • UFH : Administer the last dose 4–6 hours before the procedure.
  • Nonheparin anticoagulants : indicated for patients with a history of heparin-induced thrombocytopenia
• Reassess INR 24 hours before the procedure.
  • INR normal or subtherapeutic: Procedure can be performed.
  • Persistently elevated INR: Consider delaying the procedure till the desired INR is achieved.

Postprocedural bridging anticoagulation and resumption of VKA ^[2][3]

• All patients
  • Ensure procedural site hemostasis.
  • Assess postprocedural bleeding risk based on the following:
    • Intraprocedural findings and adequacy of hemostasis (consult the proceduralist)
    • Patient-related factors for periprocedural bleeding
    • Procedure-related bleeding risk
  • Low postprocedural bleeding risk: Resume VKAs 12–24 hours after the procedure. ^[2][3]
  • High or uncertain postprocedural bleeding risk: Consider delaying VKA resumption. ^[3]
• Additional measures in patients at moderate or high periprocedural thrombotic risk
  • Consider overlapping VKAs with a parenteral anticoagulant (i.e., postprocedural bridging anticoagulation).
    • Low postprocedural bleeding risk: Initiate bridging anticoagulation 24 hours after the procedure. ^[3]
    • High or uncertain postprocedural bleeding risk: Consider delaying bridging anticoagulation until 48–72 hours after the procedure. ^[3]
  • Agents and dosage: same as for preprocedural bridging anticoagulation ^[3]
  • Monitor INR closely.
  • Discontinue the parenteral agent once INR is in the therapeutic range.

DOAC interruption ^[3]

The decision of whether to interrupt DOAC therapy is based on periprocedural bleeding risk.

• High or uncertain periprocedural bleeding risk (patient and procedure-related): Interrupt DOAC.
• Low periprocedural bleeding risk (patient and procedure-related)
  • Interruption may not always be necessary (consult proceduralist and anesthetist).
  • The procedure should be timed to coincide with the lowest plasma concentration of the DOAC.

Bridging anticoagulation with a parenteral agent is typically not required for DOACs. ^[3][8]

Timing ^[3]

The timing of DOAC interruption is based on periprocedural bleeding risk and creatinine clearance.

Factor Xa inhibitors

Dabigatran

DOAC reinitiation ^[3]

• Consult the proceduralist before reinitiating DOACs.
• Ensure procedural site hemostasis.
• Consider reinitiating of DOAC 24–72 hours after the procedure, depending on the postprocedural bleeding risk and postprocedural creatinine clearance.