Peri‐operative management of anticoagulation and
antiplatelet therapy
• Depending on the invasiveness of the procedures or surgery, patients taking anticoagulation or antiplatelet
therapy may require interruption of anticoagulation or antiplatelet
• During interruption of anticoagulation, depending on the thromboembolic risk, bridging treatment with
shorter acting anticoagulation may sometimes be required.
Table 1. Suggested Risk Stratification for Procedural Bleed Risk Based on ISTH Guidance Statements
Minimal bleeding risk Low bleeding risk procedure* High bleeding risk procedure *
procedure* (30-d risk of major bleed 0%-2%) (30-d risk of major bleed ≥2%)
• Skin excisional biopsy • Arthroscopy • TKR or THR
• Cataract surgery • Bladder, prostate, thyroid, • Laminectomy
• Minor dental procedures i.e. breast, and lymph node biopsies • Foot, hand and shoulder surgery
simple extractions, • Cholecystectomy • Cancer surgery
prosthetics, endodontics, • Abdominal hysterectomy or • CABG
filling, scaling & polishing hernioraphy • Heart valve surgery
• PPM or ICD installation • Haemorrhoidal surgery • Vascular surgery
• Dilatation and curettage • Kidney biopsy
• Bronchoscopy +/- biopsy • Polypectomy
• Endoscopy +/- biopsy • PEG insertion
• Coronary angiography • ERCP + sphincterectomy
• TURP
• Any major operation of duration
>45 minutes
• Neuraxial anesthesia (will need
anesthetist’s inputs)
*not an exhaustive list
• Epidural injections
Table 2. Risk of thromboembolic risk
Low (< 4%/y risk of ATE or Moderate (4%-10%/y risk of High (> 10%/y risk of ATE or >
< 2%/mo risk of VTE) ATE or 4%-10%/mo risk of 10%/mo risk of VTE)
VTE)
Heart Valves Bi-leaflet AVR without • Bi-leaflet AVR with major • Mitral valve with major risk
major risk factors risk factors (1 or more of factors for stroke
the following) • Caged ball or tilting-disc
a. AF valve in mitral/aortic
b. Stroke/TIA position
c. Hypertension • Recent (< 3 mo) stroke or
d. DM TIA or other high risk
e. CCF stroke situations
f. Age >75 years
AF • CHA2DS2VASc score of • CHA2DS2VASc score of 5 or • CHA2DS2VASc score of ≥7
1-4 6 or CHADS2 score of 5 or 6
• or CHADS2 score of 0-2 • or CHADS2 score of 3 or 4 • Recent (< 3 mo) stroke or
• (and no prior stroke or TIA
• TIA) • Rheumatic valvular heart
disease
VTE VTE > 12 m ago • VTE (3-12 m) • VTE (<3 m)
• Recurrent VTE • Protein C def, protein S
• Active cancer def, ATIII def, multiple
• Heterozygous factor V thrombophilia
Leiden, or prothrombin • Antiphospholipid
gene mutation) antibodies
• Active cancer associated
with high VTE risk
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antiplatelet therapy
• Depending on the invasiveness of the procedures or surgery, patients taking anticoagulation or antiplatelet
therapy may require interruption of anticoagulation or antiplatelet
• During interruption of anticoagulation, depending on the thromboembolic risk, bridging treatment with
shorter acting anticoagulation may sometimes be required.
Table 1. Suggested Risk Stratification for Procedural Bleed Risk Based on ISTH Guidance Statements
Minimal bleeding risk Low bleeding risk procedure* High bleeding risk procedure *
procedure* (30-d risk of major bleed 0%-2%) (30-d risk of major bleed ≥2%)
• Skin excisional biopsy • Arthroscopy • TKR or THR
• Cataract surgery • Bladder, prostate, thyroid, • Laminectomy
• Minor dental procedures i.e. breast, and lymph node biopsies • Foot, hand and shoulder surgery
simple extractions, • Cholecystectomy • Cancer surgery
prosthetics, endodontics, • Abdominal hysterectomy or • CABG
filling, scaling & polishing hernioraphy • Heart valve surgery
• PPM or ICD installation • Haemorrhoidal surgery • Vascular surgery
• Dilatation and curettage • Kidney biopsy
• Bronchoscopy +/- biopsy • Polypectomy
• Endoscopy +/- biopsy • PEG insertion
• Coronary angiography • ERCP + sphincterectomy
• TURP
• Any major operation of duration
>45 minutes
• Neuraxial anesthesia (will need
anesthetist’s inputs)
*not an exhaustive list
• Epidural injections
Table 2. Risk of thromboembolic risk
Low (< 4%/y risk of ATE or Moderate (4%-10%/y risk of High (> 10%/y risk of ATE or >
< 2%/mo risk of VTE) ATE or 4%-10%/mo risk of 10%/mo risk of VTE)
VTE)
Heart Valves Bi-leaflet AVR without • Bi-leaflet AVR with major • Mitral valve with major risk
major risk factors risk factors (1 or more of factors for stroke
the following) • Caged ball or tilting-disc
a. AF valve in mitral/aortic
b. Stroke/TIA position
c. Hypertension • Recent (< 3 mo) stroke or
d. DM TIA or other high risk
e. CCF stroke situations
f. Age >75 years
AF • CHA2DS2VASc score of • CHA2DS2VASc score of 5 or • CHA2DS2VASc score of ≥7
1-4 6 or CHADS2 score of 5 or 6
• or CHADS2 score of 0-2 • or CHADS2 score of 3 or 4 • Recent (< 3 mo) stroke or
• (and no prior stroke or TIA
• TIA) • Rheumatic valvular heart
disease
VTE VTE > 12 m ago • VTE (3-12 m) • VTE (<3 m)
• Recurrent VTE • Protein C def, protein S
• Active cancer def, ATIII def, multiple
• Heterozygous factor V thrombophilia
Leiden, or prothrombin • Antiphospholipid
gene mutation) antibodies
• Active cancer associated
with high VTE risk
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