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Managing patients taking anticoagulants and antiplatelets prior to minor procedures and surgery

Response from the bpac^nz editorial team:

As the correspondent suggests, the planned procedure and the patient’s medical condition(s) heavily influence whether an antithrombotic should be stopped prior to surgery. Ultimately, this decision should be individualised; weighing the added risk and consequences of bleeding (Table 1) against the risk of experiencing a thromboembolic event if treatment is stopped, and taking into consideration the patient’s medical history.^1,2 In clinical scenarios involving patients with a significant cardiac history or high-risk procedures, consultation with the cardiologist, surgeon and anaesthesiologist is also likely to be necessary.²

Table 1. Risk of bleeding associated with invasive surgical procedures¹

Publications by Keeling et al³ and Armstrong et al⁴ provide recommendations based on the bleeding risk of a procedure and type of antithrombotic used. Overall, evidence suggests that many minor procedures can be performed in primary care without stopping the patient’s normal regimen (e.g. most minor dermatological procedures).^3,4 In addition, continued treatment is likely suitable during some minimally invasive surgeries performed in secondary care, such as cataracts, joint injections and pacemaker insertion.⁴ For other procedures, however, the guidance is not as clear cut. For example, in hip fracture surgery patients may continue an antiplatelet, although anticoagulation should generally be stopped.⁵

The American Dental Association (ADA)⁶ provides guidance specific to dental procedures and indicates there is strong evidence for continuing “older” anticoagulants (e.g. warfarin) and antiplatelets (e.g. aspirin, clopidogrel, ticagrelor) during both minor procedures and invasive dental surgeries (e.g. oral tumour removal). There is also limited evidence that direct oral anticoagulants (DOACs; e.g. dabigatran, rivaroxaban) can be continued, however, the ADA acknowledges that there is “no direct evidence from prospective trials comparing different periprocedural management strategies” for these medicines.⁶

If the risk of bleeding is considered too great and a decision for withdrawal is made, the timing of the last dose depends on the half-life of the medicine and, for DOACs, the patient’s renal function.^1,2 Table 2 provides recommendations on when to stop various antithrombotics before surgery based on information from Hornor et al² and PHARMAC/bpac^nz bleeding management guidelines.¹ Following surgery, the decision on when to restart treatment should be patient-specific and only considered once the risk of bleeding is minimal.²

Table 2. Recommendations for stopping antithrombotics prior to surgery^1,2

^* In patients who stop warfarin for a procedure and remain at high thrombotic risk, “bridging” treatment with a low molecular weight heparin or unfractionated heparin may be necessary.²