This guideline will consider whether and when anticoagulants and antiplatelet agents should be stopped before elective surgery and invasive procedures, when agents can be restarted and how to manage patients on these drugs who require emergency surgery.
A BSH guideline on warfarin (Keeling et al, 2011) addressed the issue of perioperative management and is updated in this article to include the issue of perioperative management of patients on direct oral anticoagulants (DOACs) and antiplatelet agents, which are becoming frequent clinical queries. This guideline will consider whether and when anticoagulants and antiplatelet agents should be stopped before elective surgery and invasive procedures, when agents can be restarted and how to manage patients on these drugs who require emergency surgery. If an anticoagulant or antiplatelet effect persists, haemostasis may be improved by the use of pre-operative parenteral tranexamic acid, which has been shown to reduce blood loss and transfusion requirements in both cardiac and trauma surgery, without increasing thrombotic complications (McIlroy et al, 2009; Shakur et al, 2010).
For agents with a slow offset and onset of action, bridging therapy with an alternative drug at a full treatment dose can be considered in patients deemed to be at high risk of thrombosis; this mainly concerns whether treatment dose low molecular weight heparin (LMWH) or unfractionated heparin (UFH) should be given when warfarin is temporarily discontinued. Thromboprophylaxis with low dose LMWH is not regarded as ‘bridging’.
For some invasive procedures, such as dentistry (Perry et al, 2007) (see also http://www.sdcep.org.uk/published-guidance/anticoagulants-and-antiplatelets/), joint injections (Ahmed & Gertner, 2011), cataracts (Jamula et al, 2009), pacemaker insertion (Ahmed et al, 2010; Airaksinen et al, 2013) and certain endoscopic procedures (Veitch et al, 2016), anticoagulation may not need to be stopped. Procedures that require anticoagulation to be stopped will vary in their bleeding risk and, importantly, the consequences of bleeding will depend on the site of surgery and local anatomy. Although some have grouped procedures into lower or higher risk (Spyropoulos & Douketis, 2012; Baron et al, 2013) we think the operating surgeon, dentist, or interventional radiologist has to assess the risk of bleeding for the individual patient and discuss both this and the plan for peri-operative anticoagulation with them. The plan must be recorded clearly in the notes, including a plan for when the patient is discharged.
Declaration of Interests
The BSH paid the expenses incurred during the writing of this guidance. None of the authors had conflicts of interest to declare. All authors have made a declaration of interests to the BSH and Task Force Chairs which may be viewed on request.