Recommendations for Periprocedural Management

Referenced studies that support the recommendations are summarized in the Online Data Supplement.

COR	LOE	Recommendations
1	B-R *	1. In patients with AF (excluding those with recent stroke or TIA, or a mechanical valve) and on oral anticoagulation with either warfarin* or DOAC† who are scheduled to undergo an invasive procedure or surgery, temporary cessation of oral anticoagulation without bridging anticoagulation is recommended.1–4
	B-NR †
1	A	2. In patients with AF on warfarin anticoagulation and an annual predicted risk of thromboembolism of ≥5% undergoing pacemaker or defibrillator implantation or generator change, continued anticoagulation is recommended in preference to interruption of warfarin and bridging anticoagulation with heparin to reduce the risk of pocket hematoma.5–7
2a	A	3. In patients with AF with CHA2DS2-VASc score ≥2 or equivalent risk of stroke, on DOAC anticoagulation and undergoing pacemaker or defibrillator implantation or generator change, either uninterrupted or interrupted DOAC is reasonable.8–10
1	B-NR	4. In patients with AF on DOAC and scheduled to undergo an invasive procedure or surgery that cannot be performed safely on uninterrupted anticoagulation, the timing of interruption of DOAC should be guided by the specific agent, renal function, and the bleeding risk of the procedure (Table 18).4,11,12
2a	B-NR	5. In patients with AF on DOAC that has been interrupted for an invasive procedure or surgery, in general, resumption of anticoagulation the day after low bleeding risk surgery and between the evening of the second day and the evening of the third day after high bleeding risk surgery is reasonable, as long as hemostasis has been achieved and further bleeding is not anticipated.4
3: Harm	B-R	6. In patients with AF on warfarin anticoagulation, who are undergoing surgeries or procedures for which they are holding warfarin, except in patients with mechanical valve or recent stroke or TIA, bridging anticoagulation with low-molecular-weight heparin should not be administered.1,3,13–15

^*B-R LOE applies to the data on warfarin.

^†B-NR LOE applies to the data on DOAC.