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The cardiac consult
Perioperative management of anticoagulant and antiplatelet therapy
  1. Alfonso Tafur1,2,
  2. James Douketis2
  1. 1 Department of Medicine, Vascular Medicine, Northshore University Health System. University of Chicago, Chicago, Illinois, USA
  2. 2 Department of Medicine, St Joseph’s Healthcare Hamilton, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to Dr James Douketis, St Joseph’s Healthcare Hamilton, 50 Charlton Ave East, Hamilton, ON L8N 4A6, Canada; jdouket{at}

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Learning objectives

  • To underscore clinical scenarios when anticoagulation interruption is not needed.

  • To explain the how to bridge Coumadin when interruptions are needed.

  • To present a pharmacodynamic strategy to the interruption of direct oral anticoagulants.


Long-term oral anticoagulant therapy is often used in patients with atrial fibrillation (AF), a mechanical heart valve (MHV) or venous thromboembolism. The perioperative management of patients who are receiving anticoagulant therapy is already a frequently encountered clinical scenario, likely to increase due to an ageing population. Older people are both more likely to need anticoagulation and to require more surgeries or procedures than younger people. Moreover, anticoagulant use is also increasing due to the availability of the direct oral anticoagulants (DOACs),1 which are easier to administer than vitamin K antagonists (VKA) such as warfarin. Thus, it is estimated that in patients with AF, which is the dominant clinical indication for long-term anticoagulant therapy, 10%–15% will require treatment interruption annually for an elective surgery/procedure based on data from recent randomised trials of patients with AF.2 3

In warfarin-treated patients who need periprocedural treatment interruption, warfarin is typically stopped 5 days prior to a surgery/procedure to allow its anticoagulant effect to dissipate and is resumed within 24 hours postprocedure. During this periprocedural period, patients will have subtherapeutic anticoagulation for 10–15 days, raising the question of whether pre and postprocedure bridging anticoagulation is warranted to shorten the subtherapeutic anticoagulation interval with the intent of mitigating the risk for perioperative thromboembolism. However, there has been uncertainty as regards the putative therapeutic benefits of heparin bridging when weighed against the potential bleeding risks.4 5 Recently completed and ongoing randomised trials have assessed the therapeutic benefits and risks of heparin bridging and have helped to inform best practices regarding ‘how to bridge’ and, perhaps, more importantly ‘whether or not to bridge’.6 …

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  • AT and JD contributed equally.

  • Contributors Both authors were involved in drafting the work and revising it critically for important intellectual content.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note References which include a * in the reference listhave been identified as a key reference.