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Management of anticoagulation before and after elective surgery

Author Section Editor Deputy Editor
Gregory YH Lip, MD, FRCPE, Lawrence LK Leung, MD Stephen A Landaw, MD, PhD
FESC, FACC

Last literature review version 18.3: septiembre 2010 | This topic last updated: junio 16,
2010
INTRODUCTION — The role for warfarin and other anticoagulants in many cardiovascular disorders
is well established and their use as prophylaxis against stroke or thromboembolism is increasing. As a
result, many patients undergoing elective surgery or an invasive procedure may be taking
anticoagulants. The management of anticoagulation in such patients both before and after such
procedures will be reviewed here.

Rapid, temporary reversal of excess warfarin anticoagulation, and the possible use of medications
affecting hemostasis in the perioperative period are discussed separately. (See "Correcting excess
anticoagulation after warfarin", section on 'Temporary reversal of warfarin' and "Perioperative
medication management", section on 'Medications affecting hemostasis'.)

Issues concerning the risks of continuing warfarin or antiplatelet agents during eye surgery are
discussed separately. (See "Cataract in adults", section on 'Antithrombotic agents' and "Anticoagulant,
antiplatelet, and fibrinolytic (thrombolytic) therapy in patients at high risk for ocular hemorrhage",
section on 'Ophthalmic surgery'.)

PROBLEM OVERVIEW — Although continuation of anticoagulation increases the risk of bleeding

following invasive procedures, interruption of such therapy increases the risk of thromboembolism in
patients taking anticoagulants to prevent thrombosis [1-3]. Accordingly, individual circumstances
should be carefully reviewed before an informed decision on modifying anticoagulation therapy is
made in the patient undergoing surgery or an invasive procedure. There is also concern about the
following issues in anticoagulated patients:

There is a requirement of several days for the anticoagulant effect to resolve after
warfarin therapy is discontinued, potentially delaying more urgent surgery.
Rebound hypercoagulability may occur following the abrupt cessation of anticoagulation.
Several days may be required after warfarin therapy is resumed to reestablish a therapeutic
and adequate level of anticoagulation.

The importance of these issues varies in part with the indication for anticoagulation (eg, prophylaxis
for thromboembolism versus actual treatment for an acute thrombotic episode). Accordingly, there is
no general consensus regarding management strategy in patients undergoing elective surgery who
are currently taking long-term anticoagulation. The type of procedure may also be important (see
'Type of surgery or procedure' below).

THROMBOTIC RISK IF ANTICOAGULATION IS STOPPED — Patients may be taking oral

anticoagulation as prophylaxis against the development of new thrombi or embolism (eg, atrial
fibrillation, severe myocardial dysfunction, prosthetic heart valve) or as actual treatment of acute
thrombus-related problems (eg, deep venous thrombosis or pulmonary embolism).

Cessation of oral anticoagulation used to treat an acute thrombotic event may exacerbate the

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condition, which may itself be life-threatening. The risk of underanticoagulation varies with the type
of thromboembolic event. While recurrent DVT carries some risk of fatal pulmonary embolism, the
consequences of arterial thromboembolism from atrial fibrillation or prosthetic heart valves are much
more serious, with 20 percent of episodes being fatal and 40 percent causing permanent disability
[4-7].

Appropriate use of alternative strategies, such as intravenous heparin or subcutaneous low molecular
weight heparin (LMW heparin) to provide antithrombotic coverage (ie, "bridging" anticoagulation)
during the period when warfarin is withdrawn or reintroduced has been utilized in an attempt to
minimize the risks involved. (See 'Use of bridging anticoagulation' below.)

Venous thromboembolism — Long-term anticoagulation is the recommended treatment for patients

at high risk of recurrence of venous thromboembolism. Discontinuation of warfarin in such patients is
associated with a significant risk of thromboembolism as high as 15 percent per year; warfarin
probably reduces this risk by about 80 percent [8-10].

After an acute episode of venous thromboembolism, the recurrence risk is much reduced over the
following three months [11]. Without anticoagulation, the early risk of recurrent venous
thromboembolism is approximately 50 percent, but treatment with warfarin for one month reduces
this risk to 8 to 10 percent, and to 4 to 5 percent after three months of warfarin therapy [10,12].
Thus, discontinuing oral anticoagulation within the first month after an acute venous thromboembolic
episode is associated with a high risk of recurrent venous thromboembolism [13]; this risk is reduced
if surgery is delayed and there is a longer period of warfarin treatment.

Patients at risk for arterial thromboembolism — The risk of recurrent arterial embolism from any
cardiac source is approximately 0.5 percent per day in the first month after an acute event [14]. This
risk is reduced by two-thirds with warfarin.

Arterial thromboembolism is most commonly associated with atrial fibrillation; embolic stroke is fatal
or associated with a severe neurologic deficit in over 60 percent of these patients [4,5]. Patients with
atrial fibrillation not due to valvular heart disease have an overall risk of systemic embolism of 4 to 5
percent per year in the absence of warfarin therapy; anticoagulation reduces the risk of embolization
by about two-thirds in this setting [6,15].

However, patients with atrial fibrillation are not a homogeneous group and the risk of stroke and
thromboembolism varies. Management should therefore be tailored to an individual patient's risk of
thromboembolism as compared to the risk of bleeding during surgery. It is possible to risk stratify
such patients based upon clinical and echocardiographic criteria. (See "Risk of embolization in atrial
fibrillation".)

Other causes of thromboembolism include a dilated and poorly contractile left ventricle or a left
ventricular aneurysm in which intraventricular thrombi may form and embolize [16-18].

Among patients with left ventricular dysfunction, one report found an 18 percent increase in
stroke risk for every 5 percent reduction in left ventricular ejection fraction, although the
absolute short-term risk was low [17]. Anticoagulation with warfarin was associated with an 81
percent reduction in total stroke risk while aspirin therapy reduced the risk by 56 percent. (See
"Indications for anticoagulation in heart failure".)

Among patients with left ventricular aneurysm, the frequency of left ventricular thrombi in
aneurysms reported by postmortem studies can range between 14 and 68 percent, a value
consistent with findings at the time of surgical aneurysmectomy (50 to 95 percent) [16].

Recommendations are available elsewhere for the management of patients with atrial fibrillation when
temporary cessation of warfarin is considered. (See "Antithrombotic therapy to prevent embolization

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in nonvalvular atrial fibrillation", section on 'Temporary cessation of anticoagulation'.)

Prosthetic heart valves — Systemic embolization (predominantly cerebrovascular events) occurs at

a frequency of approximately 0.7 to 1.0 percent per patient per year in patients with mechanical
valves who are treated with warfarin, 2.2 percent per patient per year with aspirin, and 4.0 percent
with no anticoagulation. A major advantage of the bioprosthetic valve is freedom from
anticoagulation.

The management of anticoagulation in such patients, both in general and in the perioperative period,
is discussed in depth separately. (See "Antithrombotic therapy in patients with prosthetic heart
valves", section on 'Discontinuing warfarin for surgical procedures'.)

BLEEDING RISK IF ANTICOAGULATION IS CONTINUED — The risk of bleeding occurring with

surgery in patients taking anticoagulant therapy is dependent upon patient age, the presence of other
disease states, the type of surgery [19], the anticoagulant regimen and intensity, the length of
warfarin therapy, the use of other drugs that affect hemostasis (eg, heparin, aspirin, antiplatelet
agents), the stability of anticoagulation, and the degree of anticoagulation as measured by the INR
[1,20,21].

Type of surgery or procedure — Prolonged, complex, and major surgery is much more likely to
cause significant bleeding problems than short, simple, and minor surgical procedures. As examples:

Most patients can undergo low-risk surgical procedures (eg, arthrocentesis, cataract surgery,
coronary arteriography) without alteration of their anticoagulation regimen [22,23]. In such
patients, oral anticoagulation with a vitamin K antagonist can be continued at or below the low
end of the therapeutic range (INR ≤2.0). (See "Cataract in adults", section on 'Antithrombotic
agents' and "Anticoagulant, antiplatelet, and fibrinolytic (thrombolytic) therapy in patients at
high risk for ocular hemorrhage", section on 'Ophthalmic surgery'.)

More complex or high-risk surgical procedures require discontinuation of oral anticoagulation,

followed by temporary perioperative coverage with unfractionated heparin or LMW heparin in
those patients who are at high risk of thromboembolism. (See 'Cessation and resumption of
warfarin' below.)
Gastroenterologic procedures — Management of anticoagulation in patients undergoing
gastroenterologic procedures depends upon the estimated bleeding risk for the contemplated
procedure as well as the estimated thrombotic risk if the patient is temporarily taken off
anticoagulation (table 1 and table 2 and table 3) [24].

This subject is discussed in detail separately. (See "Management of anticoagulants in patients

undergoing endoscopic procedures", section on 'Elective procedures in anticoagulated patients'.)

Dental or excisional cutaneous procedures — In patients undergoing dental extraction,

warfarin anticoagulation is associated with a minimal risk of serious bleeding if the INR is within the
therapeutic range just prior to the contemplated surgery [25-30]. Tranexamic acid or aminocaproic
acid mouthwash, if available (eg, 4.8 to 5 percent aqueous solutions used four times per day for at
least two days), can be used to limit local postoperative bleeding [30-35]. The use of aspirin, NSAIDS,
or Cox-2 inhibitors for analgesia should be avoided.

However, there are documented cases of serious embolic events when warfarin has been withdrawn
prior to dental procedures. In a literature review of 542 documented cases in 493 patients in whom
continuous anticoagulation was withdrawn for a dental procedure (without heparin replacement),
there were five serious embolic complications (0.9 percent of cases) [26].

Anticoagulation is generally safe in patients undergoing excisional cutaneous surgery (eg, Mohs
surgery) if the INR is maintained within the therapeutic range [19,36-38]. As with dental procedures,

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cessation of prophylactic anticoagulation (warfarin or antiplatelet therapy) has been associated with a
risk of thromboembolic events [36-38].

Use of heparin — The risk of bleeding after the use of heparin is variable. A two-day course of
intravenous heparin before surgery is unlikely to cause much in the way of preoperative bleeding. The
general risk of bleeding associated with continuous intravenous heparin is less than 5 percent in
patients with acute venous thromboembolism; however, in patients with deep vein thrombosis who
are judged to be at high risk for bleeding, the incidence of major bleeding is approximately 11 percent
during the first five days of intravenous heparin therapy [21,39].

CESSATION AND RESUMPTION OF WARFARIN

Overview — After the cessation of oral warfarin, it usually takes a few days for the INR to fall to
below 2.0. One study prospectively evaluated 22 patients with a baseline INR of 2.6 in whom it was
deemed safe to discontinue warfarin [40]. In these patients the mean INR was 1.6 and 1.2 at 2.7 and
4.7 days after discontinuation of warfarin, respectively.

Once the INR is 2.0 or below, surgery can be performed with relative safety in most cases. Following
surgery and after warfarin is restarted, it takes about three to four days for the INR to rise above 2.0.
It is therefore estimated that if warfarin is withheld for four days before surgery and is restarted as
soon as possible afterwards, patients would have a subtherapeutic INR for approximately two days
before surgery and two days after surgery [13].

A slight elevation of the INR to about 1.5 should theoretically provide partial protection against
thromboembolism [41,42]. In support of this hypothesis, ultra-low dose warfarin (1 mg/day) has been
successfully used to prevent deep venous thrombosis in patients with malignancy in association with a
marginal rise in the INR [42]. (See "Drug-induced thrombosis and vascular disease in patients with
malignancy", section on 'Prophylactic anticoagulation'.)

If the patient has been adequately anticoagulated for some time prior to cessation of warfarin, it is
generally assumed that almost any preexisting thrombus would have either resolved or be
endothelialized, thereby minimizing the risk of embolism [17]. Among patients with nonvalvular atrial
fibrillation, for example, over 85 percent of thrombi resolve after four weeks of warfarin therapy as
determined by transesophageal echocardiography [43].

Nevertheless, although the INR itself may not be a good guide to a reduced risk of thromboembolism,
some patients have a significant reduction in their usual anticoagulant intensity during surgery and a
minor increase in the risk of thromboembolism is probably unavoidable [40]. Among patients with
atrial fibrillation, chronic low dose warfarin plus aspirin is much less effective than adjusted dose
warfarin in preventing embolic events (figure 1 and figure 2), demonstrating that such lesser degrees
of anticoagulation do not provide optimal protection [44]. (See "Antithrombotic therapy to prevent
embolization in nonvalvular atrial fibrillation".)

Reversing warfarin — Reversing the activity of vitamin K antagonists depends upon the amount of
time available before the surgical or invasive procedure. The following guidelines are most
appropriate [35]:

Fully elective surgery — In patients with an INR between 2.0 and 3.0 who are undergoing
elective surgery that requires temporary cessation of anticoagulation, warfarin should be withheld for
approximately three to four days to allow the INR to fall to a level of 1.5 to 2.0 before surgery
[13,40,45]. Warfarin should be withheld for approximately five days if the surgeon feels it is
necessary to reduce the INR to a lower or normal level in order to reduce the risk of bleeding (eg, less
than 1.5) [40].

Semi-urgent surgery — If more rapid reversal of warfarin anticoagulation is required (eg, over

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one to two days), warfarin should be withheld and a small dose (eg, 1.0 to 2.0 mg) of intravenous
vitamin K1 administered. In one study, in which the vitamin K1 dose was 0.5 to 1.0 mg, such
treatment resulted in an INR of ≤1.4 in 57 percent of the patients at a median elapsed time of 27
hours [46]. (See "Correcting excess anticoagulation after warfarin", section on 'Temporary reversal of
warfarin'.)

Urgent surgery — If urgent reversal of warfarin anticoagulation is required (eg, less than one
day), warfarin should be withheld and a higher dose (eg, 2.5 to 5.0 mg) of intravenous vitamin K1
administered. If more immediate correction is required (eg, minutes to hours), this can be achieved
via the use of those prothrombin complex concentrates which contain adequate amounts of factor VII
or fresh frozen plasma, in addition to vitamin K [47]. A discussion of how such rapid reversal of the
warfarin effect can be accomplished can be found elsewhere. (See "Correcting excess anticoagulation
after warfarin", section on 'Significant or life-threatening bleeding'.)

The risk of rebound hypercoagulability — As mentioned above, rebound hypercoagulability may

occur following the abrupt cessation of anticoagulation. Accordingly, alternative preoperative and/or
postoperative prophylaxis against thromboembolism with unfractionated heparin (UFH) or LMW
heparin should be considered in high risk patients (eg, prosthetic valve in the mitral position, venous
thromboembolism within the previous four weeks, or active malignancy) for the period during which
the INR is less than 2.0 [48-50].

The clinical effects of rebound hypercoagulability after stopping warfarin are unlikely to be significant,
despite biochemical evidence for this phenomenon and the recommendation by some investigators
that warfarin should be withdrawn gradually [51-53].

In one study of 19 patients, for example, thrombin and fibrin formation increased after abrupt
cessation of warfarin therapy but no patient had a thromboembolic event [53].

In another report, however, 32 patients were randomly assigned to receive abrupt or gradual
withdrawal of warfarin [52]. Very high levels of thrombin activation were seen in a few patients
treated with abrupt withdrawal, two of whom developed a thrombotic event (one recurrent deep
vein thrombosis and one thrombosis in a varicose vein).

Surgery itself increases the risk of thromboembolism as documented by changes in hemostatic

markers, which are also part of the acute phase response and wound healing process [54]. High levels
of hemostatic markers, such as fibrin D-dimer, an index of intravascular thrombogenesis and fibrin
turnover, are predictive of postoperative thrombosis [55,56]. Although there is evidence that surgery
increases the risk of venous thromboembolism, there is no evidence that surgery itself increases the
risk of arterial thromboembolism, apart from risks associated with particular procedures, such as
carotid surgery [57].

Use of bridging anticoagulation — The risk of a short period of underanticoagulation is uncertain,

especially since randomized studies of heparin versus placebo bridging among warfarin-treated
patients who need procedures have not been conducted. Because of the lack of evidence-based
information indicating those patients in whom bridging anticoagulation is or is not warranted, there is
considerable variation in the use of this modality [58].

Of the available non-randomized studies of this question [48,59-68], the following three prospective
observational cohort studies are instructive concerning the thrombotic and hemorrhagic risks
attendant to the use or non-use of bridging therapy in this setting.

The first study involved a cohort of 1024 individuals whose warfarin therapy was temporarily withheld
on 1293 different occasions for an outpatient invasive procedure (colonoscopy; oral, dental, or
ophthalmic surgery; epidural injection; prostate or breast biopsy; dermatologic procedure). The

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following observations were made [61]:

The duration of warfarin therapy interruption was variable, although >80 percent had
warfarin therapy withheld for ≤5 days. Bridging therapy with heparin or LMW heparin was given
in only 8.3 percent of the procedures.

Six patients (0.6 percent; 95% CI 0.2-1.3) experienced major bleeding and an additional 17
patients (1.7 percent; 95% CI 1.0-2.6) experienced a clinically significant, nonmajor bleeding
episode. Four of the six patients with major bleeding and 10 of the 17 patients with nonmajor
clinically significant bleeding had received periprocedural bridging therapy, for an overall
bleeding rate in bridged patients of 13 percent.

Postprocedural thromboembolism within 30 days occurred in seven patients (0.7 percent; 95%
CI 0.3-1.4). None of the seven patients had received periprocedural bridging therapy; two of
these patients would have been considered to be at high risk for thromboembolism (ie, recent
VTE or active malignancy).

The authors concluded that perioperative anticoagulation may be unnecessary for a significant
proportion of low- to intermediate-risk outpatients who have undergone long-term anticoagulation,
whose warfarin therapy must be interrupted for a brief period (ie, ≤5 days), and that bridging therapy
with unfractionated or LMW heparin may result in significant and potentially avoidable perioperative
hemorrhage.

Similar conclusions were reached in a second study involving a cohort of 345 individuals with
nonvalvular atrial fibrillation undergoing an invasive procedure. Warfarin therapy was temporarily
withheld on 342 different occasions for a mean period of 6.6 days. The following observations were
made [62]:

The three-month cumulative incidence of thromboembolism was 1.1 percent and did not differ
significantly between those who did or did not receive bridging therapy with unfractionated or
LMW heparin.

Of interest, despite not receiving bridging therapy after brief warfarin cessation, none of the 43
patients with a prior thromboembolic event, and none of the 51 patients with a CHADS2 score
≥3 developed postoperative thromboembolism during the three-month follow-up period.

The three-month cumulative incidence of major bleeding was 2.7 percent for those receiving
bridging therapy. Of the 10 episodes of major bleeding, six occurred in five patients given
bridging therapy with LMW heparin.

The authors indicated that they currently utilize bridging with LMW heparin only for those patients at
highest risk (eg, prior stroke, CHADS2 score ≥4) while taking into account the procedure-associated
risk of bleeding.

The third study employed bridging with sub-therapeutic doses of LMW heparin (eg, 3800 IU of
nadroparin or 4000 IU of enoxaparin once daily the night before the procedure for those at low risk of
thrombosis or 3800 or 4000 IU of these agents twice daily for those at high thrombotic risk) in 103
patients undergoing surgery and 225 non-major invasive procedures. Results included [63]:

For the 182 patients in the low-risk group, thromboembolic, major bleeding, and minor bleeding
events occurred in 0.54, 0.54, and 3.3 percent, respectively.
For the 146 patients in the high-risk group, thromboembolic, major bleeding, and minor
bleeding events occurred in 1.8, 4.1, and 6.2 percent, respectively.
Resumption of warfarin — Warfarin therapy should be restarted 12 to 24 hours post-surgery,

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provided that surgical hemostasis has been achieved [35].

CESSATION AND RESUMPTION OF THE HEPARINS

Unfractionated heparin — The biologic half-life of intravenous unfractionated heparin (UFH) is

approximately 45 minutes [35,69]. Thus, most bridging anticoagulation studies have suggested that
intravenous UFH should be stopped 4 to 5 hours before the planned surgery or procedure, a time
interval that is approximately 5 elimination half-lives of UFH.

LMW heparin — The biologic half-life of subcutaneous LMW heparin is approximately 4 to 6 hours
[35,69]. Thus, most bridging anticoagulation guidelines have suggested that the last dose of
subcutaneous LMW heparin should be given 24 hours before the planned surgery or procedure, a time
interval that is approximately 5 elimination half-lives of LMW heparin.

However, because some studies have shown residual anticoagulant effect at 24 hours after stopping
therapeutic-dose LMW heparin [11,70], it has been recommended that, on the day before surgery or
the procedure, therapeutic-dose LMW heparin should be administered at one-half of the usual total
daily dose [35].

Resumption of treatment — The onset of anticoagulation after both UFH and LMW heparin is
similar, at around one hour after administration, with peak anticoagulant activity at around three to
five hours. Thus, if post-operative or post-procedural anticoagulation is contemplated, these agents
should not be employed too early following the operation, in order to insure that hemostasis has been
secured at the operative or procedural site [71]. This requires both a pre-procedural estimate of the
anticipated risk of bleeding as well as a post-procedural determination of the adequacy of hemostasis
[35].

However, for most minor procedures associated with a low bleeding risk, therapy with LMW heparin or
UFH can usually be resumed at 24 hours post-procedure, whereas for those undergoing major surgery
or those with a high bleeding risk procedure, such treatment should be delayed for 48 to 72 hours
after hemostasis has been secured [35].

SPECIAL CONSIDERATIONS — A number of clinical situations require special consideration. These

are discussed below.

Venous thromboembolism — The management of anticoagulation in patients with previous

venous thromboembolic disease depends upon the temporal relationship to surgery or an invasive
procedure (table 4).

Within the first month after an acute episode of venous thromboembolism, the incidence of
recurrence without anticoagulation is about 1 percent per day. While postoperative intravenous
heparin doubles the rate of bleeding, there is a net reduction in serious morbidity in such
patients, since the risk of postoperative recurrent venous thromboembolism is high. Thus,
heparin therapy is recommended both before and after surgery [13].

By two to three months after an acute episode of venous thromboembolism, the risk of
recurrence is significantly reduced so that preoperative heparin therapy is probably not justified
unless there are other risk factors for thromboembolism (eg, prolonged hospitalization and
confinement to bed) [13]. However, because of an expected increase in the risk of venous
thromboembolism after surgery, these patients should be treated postoperatively with heparin.

At more than three months after an episode of venous thromboembolism, preoperative

anticoagulation is not needed and postoperative intravenous heparin is also probably not
necessary. (See "Treatment of deep vein thrombosis", section on 'Length of treatment'.)

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In this setting, the bleeding associated with postoperative intravenous heparin offsets any beneficial
effect from the prevention of major thromboembolic events [13]. Prophylactic measures that reduce
the thrombotic risk, such as subcutaneous LMW heparin or compression stockings, are associated with
a lower risk of bleeding than intravenous heparin and are safer alternatives [2].

Arterial thromboembolism — The approach is somewhat different in patients at risk for

arterial thromboembolism, because the thromboembolic risk is similar both before and after surgery.
Furthermore, the risk of bleeding is much higher in such patients after surgery if heparin is continued
or the INR is maintained at around 2.0. Thus, preoperative treatment with intravenous heparin is
advised if oral anticoagulation is stopped. Postoperative therapy with intravenous heparin is probably
useful for patients undergoing minor surgery where the risk of bleeding is low. In contrast, the net
benefit of using intravenous heparin in reducing long-term disability after major surgery is small
because of the high risk of serious bleeding.

If the risk of acute arterial thromboembolism is low, as in patients with nonvalvular atrial fibrillation
receiving warfarin for thromboprophylaxis, postoperative intravenous heparin therapy probably
increases, rather than decreases, serious morbidity. Restarting warfarin on the second postoperative
day and the use of low risk regimens, such as subcutaneous heparin, if warfarin was discontinued
preoperatively, are preferable to minimize the risk of bleeding.

Unfractionated heparin should be stopped four hours before surgery with the expectation that
the anticoagulation effect will have worn off at the time of surgery [72]. If LMW heparin has
been used, it should be stopped, preferably 24 hours before surgery [73], with the same
expectation.

These recommendations may not apply to patients undergoing minor procedures such as skin
biopsy or dental extractions [26,32,36]. However, it is important to confirm that the INR does
not exceed the therapeutic range. Although uninterrupted anticoagulation may be continued in
most patients, we and many other clinicians withhold warfarin for two to four days prior to the
procedure, and reinstitute therapy after the procedure [72].

Elective surgery should be avoided in the first month after arterial thromboembolism. If surgery
is essential, preoperative and postoperative heparin therapy is recommended as described
above for venous thromboembolism, but only if the risk of postoperative bleeding is low.

In patients receiving warfarin as prophylaxis against arterial embolization, such as low risk
patients with a prosthetic heart valve or nonvalvular atrial fibrillation, the risk of
thromboembolism is not high enough to warrant routine preoperative or postoperative therapy
with intravenous heparin, especially in view of the bleeding risk [6,74].

If the surgical intervention itself is associated with a high risk of postoperative venous
thromboembolism (VTE), the brief use of subcutaneous low-dose heparin or LMW heparin in doses
used for prophylaxis against VTE has been suggested [72]. (See "Antithrombotic therapy to prevent
embolization in nonvalvular atrial fibrillation", section on 'Temporary cessation of anticoagulation' and
"Prevention of venous thromboembolic disease in surgical patients", section on 'Risk factors for VTE'.)

The approach is different in high risk patients with atrial fibrillation (eg, prior thromboembolism,
rheumatic heart disease, left ventricular dysfunction) or prosthetic heart valves (eg, those with older
generation mechanical valves or atrial fibrillation), in whom there is a delicate balance between the
risks of bleeding and thromboembolism [6,74]. In this setting, a number of options exist and the
appropriate treatment of such patients is unclear and controversial [72,74].

However, it is our preference in this setting to administer intravenous heparin until five to six hours

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before the procedure, to be restarted as soon as surgical hemostasis has been assured [72]; the dose
is adjusted to achieve an activated PTT that is 2.0 times control. Warfarin is then reinstituted prior to
discharge from the hospital; the INR should be in the therapeutic range for at least 48 hours before
heparin is discontinued.

Pacemaker insertion — A substantial number of patients who require the insertion of a permanent
pacemaker are receiving oral anticoagulation for various reasons. Elective pacemaker insertion is
often performed in the outpatient setting and the issue of anticoagulation is an important concern.
One study compared the outcome of 37 patients undergoing outpatient pacemaker implantation while
continuing on warfarin therapy with 113 patients not receiving warfarin; there was no difference in
the incidence of any complications, including those related to the wound [75]. The use of a cut-down
technique, rather than a subclavian puncture, to gain venous access is preferred and a catheter
electrode with a small cross sectional area and small introducer should be used to reduce the
probability of venous damage; pocket hemostasis must be meticulous.

Mechanical prosthetic heart valves — Recommendations regarding the perioperative management

of anticoagulation in patients with prosthetic heart valves are presented separately. (See
"Antithrombotic therapy in patients with prosthetic heart valves", section on 'Discontinuing warfarin
for surgical procedures'.)

Percutaneous coronary intervention — Management of anticoagulation as well as antiplatelet

therapy in patients undergoing percutaneous coronary intervention is discussed separately. (See
"Antithrombotic therapy for intracoronary stent implantation: General use", section on 'Patients who
require warfarin'.)

SUMMARY AND RECOMMENDATIONS — The risk of thromboembolism in patients who discontinue

anticoagulation before an invasive procedure must be weighed against the risk of bleeding if these
agents are continued. Accordingly, individual circumstances should be carefully reviewed before an
informed decision on modifying anticoagulation therapy is made in the patient undergoing surgery or
an invasive procedure. (See 'Problem overview' above.)

Low risk surgical procedures — Most patients can undergo low-risk surgical procedures (eg,
arthrocentesis, cataract surgery, coronary arteriography) without alteration of their anticoagulation
regimen, provided that their INR is within the therapeutic range. (See 'Bleeding risk if anticoagulation
is continued' above.)

Patients at risk for bleeding — For patients with a high risk of procedural bleeding, the
preprocedural INR should be ≤1.5. We recommend that patients at low risk for thrombosis stop
warfarin five days preoperatively rather than for a shorter interval (Grade 1B). This will allow
adequate time for the INR to normalize. (See 'Cessation and resumption of warfarin' above.)

Once surgical hemostasis has been achieved, we recommend that warfarin therapy be resumed 12 to
24 hours post-surgery, rather than for a shorter or longer interval (Grade 1C). (See 'Resumption of
warfarin' above.)

Patients at risk for thrombosis

Elective surgery should be avoided, if at all possible, in the first month after an acute episode of
venous thromboembolism. If avoidance of elective surgery is not possible, we recommend that
warfarin be withheld for five days and bridging anticoagulation with therapeutic doses of
intravenous heparin or LMW heparin be given before and after the procedure while the INR is
below 2.0 (Grade 1C). (See 'Venous thromboembolism' above and 'Use of bridging
anticoagulation' above.)

If acute venous thromboembolism has occurred within two weeks AND the risk of bleeding

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 associated with the use of bridging anticoagulation is high, the temporary use of a vena caval
filter should be considered. (See "Inferior vena cava filters".)

Elective surgery should be avoided, if at all possible, in the first month after arterial
thromboembolism. If surgery is essential, bridging anticoagulation is recommended as described
above for venous thromboembolism. (See 'Arterial thromboembolism' above and 'Use of bridging
anticoagulation' above.)
Stopping and starting bridging anticoagulation

Bridging anticoagulation with unfractionated heparin should be stopped four to five hours before
surgery. If LMW heparin has been used, it should be stopped 24 hours before surgery. (See
'Cessation and resumption of the heparins' above.)

We suggest that heparin or LMW heparin in therapeutic doses should not be restarted
postoperatively until at least 24 hours after surgery and delayed longer if there is any evidence
of bleeding (Grade 2C). (See 'Cessation and resumption of the heparins' above.)

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GRAPHICS

ASGE recommendations for adjusting warfarin prior to elective endoscopic

procedures

Low-risk procedure
No adjustments in anticoagulation need to be made irrespective of the underlying condition.
However, elective procedures should be avoided when the level of anticoagulation is above the
therapeutic range.

High-risk procedures in patients with low-risk conditions

Warfarin therapy should be discontinued 3 to 5 days before the scheduled procedure. The decision to
obtain a preprocedure prothrombin time should be individualized.

High-risk procedures in patients with high-risk conditions

Warfarin therapy should be discontinued 3 to 5 days before the procedure. The decision to administer
intravenous heparin once the INR falls below the therapeutic level should be individualized.
Preliminary experience suggest there may be a role for monitored reduction in the INR without the
use of heparin. Heparin, if used, should be discontinued 4 to 6 hours before the scheduled procedure
and may be resumed 2 to 6 hours after the procedure. Warfarin therapy may generally be resumed
the night of the procedure. Heparin infusion and warfarin should overlap for a period of 4 to 5 days or
until the INR has achieved the target therapeutic range for 2 to 3 days. However, the risk of major
hemorrhage after sphincterotomy is between 10 and 15 percent if anticoagulation is reinstituted
within three days of the sphincterotomy. Therefore, the benefits of immediate anticoagulation should
be carefully weighed against the risks and would be advisable only in a situation where the risk of
thromboembolic events significantly exceeds the risk of hemorrhage from sphincterotomy.

Data from: Eisen, GM, Baron, TH, Dominitz, JA, et al. Guideline on the management of anticoagulation and
antiplatelet therapy for endoscopic procedures. Gastrointest Endosc 2002; 55:775.

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Procedure-related bleeding risk from gastrointestinal procedures

High-risk procedures
Polypectomy or endoscopic resection

Argon plasma coagulation and thermal ablative therapy

Endoscopic sphincterotomy

Pneumatic or bougie dilation of benign or malignant strictures

Percutaneous endoscopic gastrostomy tube placement

Endoscopic ultrasound (EUS)-guided fine-needle aspiration

Endoscopic hemostasis

Therapeutic balloon assisted enteroscopy

Tissue ablation by any technique

Cystgastrostomy

Treatment of varices

Low-risk procedures
Diagnostic upper endoscopy, flexible sigmoidoscopy, and colonoscopy (including biopsies)

Diagnostic endoscopic retrograde cholangiopancreatography (ERCP)

Biliary stent insertion without endoscopic sphincterotomy

Endosonography

Push enteroscopy and diagnostic balloon assisted enteroscopy

Enteral stent deployment without dilation

Capsule endoscopy

Original figure modified for this publication. Anderson, MA, Ben-Menachem, T, Gan, SI, et al. Management of
antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70:1060. Illustration used with
the permission of Elsevier Inc. All rights reserved.

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Condition-related risk of thromboembolic complications

High-risk conditions
Atrial fibrillation associated with valvular heart disease (including the presence of a mechanical valve)

Atrial fibrillation associated with congestive heart failure or a left ventricular ejection fraction of <35
percent

Atrial fibrillation associated with a history of a thromboembolic event

Atrial fibrillation associated with hypertension, diabetes, or age >75 years

Mechanical valves in the mitral position

Mechanical valves in patients who have had a prior thromboembolic event

Coronary stents placed within one year

Acute coronary syndrome

Nonstented percutaneous coronary intervention after myocardial infarction

Low-risk conditions
Deep vein thrombosis

Chronic or paroxysmal atrial fibrillation that is not associated with valvular disease

Bioprosthetic valves

Mechanical valves in the aortic position

Original figure modified for this publication. Anderson, MA, Ben-Menachem, T, Gan, SI, et al. Management of
antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70:1060. Illustration used with
the permission of Elsevier Inc. All rights reserved.

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Increased stroke risk with low dose warfarin plus
aspirin in AF

Results from the SPAF III trial of high-risk patients showing

significantly higher event rates for intracranial hemorrhage and
ischemic stroke in patients treated with fixed low dose warfarin
plus aspirin compared with standard adjusted-dose warfarin. The
risk was greater in those with a previous thromboembolic event.
Data from Stroke Prevention in Atrial Fibrillation Investigators. Lancet 1996;
348:633.

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Low-dose warfarin plus aspirin is not optimal in
high risk AF

Cumulative event rate of patients with atrial fibrillation (AF) at

high risk for thromboembolism in the SPAF III trial. High risk was
defined as the presence of at least one of the following: previous
thromboembolism, female older than 75 years of age, heart
failure or severe left ventricular systolic dysfunction, and systolic
pressure >160 mmHg. There was a much lower incidence of
events with standard adjusted-dose warfarin therapy (INR 2 to 3)
compared to treatment with aspirin and low-dose warfarin (INR
1.2 to 1.5) (p<0.0001). Data from Stroke Prevention in Atrial Fibrillation
Investigators. Lancet 1996; 348:633.

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Recommendations for preoperative and postoperative anticoagulation in
patients on oral anticoagulation therapy

Indication Before surgery After surgery

Venous thromboembolism
Within first month IV heparin or SQ IV heparin or SQ LMWH
LMWH

Second/third month No change* IV heparin or SQ LMWH

≥3 months No change* SQ heparin or LWMH

Arterial thromboembolism
Recent, within one month IV heparin or SQ IV heparin or SQ LMWH
LMWH

Prophylaxis (non valvular AF, mechanical No change* Resume oral

valves) anticoagulation•

NOTE: Warfarin should be withheld to allow the INR to fall spontaneously to 1.5 to 2 before
surgery is performed. LMWH: low molecular weight heparin.
* If the patient is hospitalized, subcutaneous (SQ) heparin or LMWH should be administered, but
hospitalization is not recommended solely for this purpose.
• Can use SQ heparin or SQ LMWH if the surgery carries a high risk of postoperative thromboembolism.

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