Table 4.
VKAs | ➢ Elective surgery |
• Minor bleeding risk surgery: no change in oral anticoagulation therapy is needed but keep INR levels in the lower therapeutic range. | |
• Low/high bleeding risk surgery: take the last dose 3–5 days before surgery; when INR is ≤1.5, surgery can be performed safely. | |
➢ VKAs should be resumed on day 1 or 2 after surgery depending on the patient’s hemostatic status, but no less than 12 h after the procedure. ➢ If high risk of thromboembolism 1, bridging therapy with UFH or LMWH 2 needs to be implemented. ➢ In case of urgent/emergent surgery, immediately discontinue. If needed, reversal with vitamin K or fresh-frozen plasma/PCCs. | |
NOACs | ➢ Elective surgery |
Take the last dose before surgery according to CrCl: | |
• Minor bleeding risk surgery: ≥12 h or 24 h 1 • Low bleeding risk surgery: - apixaban/edoxaban/rivaroxaban ≥24 h 2 - dabigatran ≥ 24–48 h 3 | |
• High bleeding risk surgery: - apixaban/edoxaban/rivaroxaban ≥48 h 4 - dabigatran ≥48–96 h 5 | |
➢ No bridging with heparin required. ➢ In case of urgent/emergent surgery immediately discontinue. If needed, reversal with idaracizumab (dabigatran) or PCCs or aPCCs. |
aPCCs, activated prothrombin complex concentrate; CrCL, creatinine clearance; INR, international normalized ratio; LMWH, low molecular weight heparin; NOACs, non-vitamin K antagonist oral anticoagulants; PCCs, prothrombin complex concentrate; UFH, unfractionated heparin; VKAs, vitamin K antagonists. 1 Patients with at least one of the following: AF with a CHA2DS2-VASc score ≥ 4, mechanical prosthetic heart valves, newly inserted biological prosthetic heart valves, mitral valvular repair (within the past 3 months), recent venous thromboembolism (within 3 months), thrombophilia. 2 CrCl > 30 mL/min: ≥24 h; CrCl < 29 mL/min: ≥36 h; CrCl < 15 mL/min: not indicated. 3 CrCl ≥ 80 mL/min: ≥24 h; CrCl 50–79 mL/min: ≥36 h; CrCl 30–49 mL/min: ≥48; CrCl < 29 mL/min: not indicated. 4 CrCl > 15 mL/min: ≥48 h; CrCl < 15 mL/min: not indicated. 5 CrCl ≥ 80 mL/min: ≥48 h; CrCl 50–79 mL/min: ≥72 h; CrCl 30–49 mL/min: ≥96; CrCl < 29 mL/min: not indicated.