Updated October 2025

Perioperative Antithrombotic Management

Perioperative Management of Antiplatelet and Anticoagulant Therapy

Evidence-based, procedure-risk–stratified guidance to stop, bridge, and restart antiplatelet and anticoagulant agents around surgery. Key points: avoid LMWH bridging for antiplatelet interruption due to increased bleeding, use standardized DOAC hold/restart windows (PAUSE paradigm), and individualize based on thrombotic risk (e.g., recent stent, mechanical valve) and surgical bleeding risk.

Clinical question

How should antiplatelet and anticoagulant therapies be interrupted, bridged, and restarted for adults undergoing elective noncardiac surgery to balance bleeding and thrombotic risks?

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Key points

Do not bridge antiplatelet interruption with LMWH

Bridging during antiplatelet interruption increases major bleeding without clear thrombotic benefit (RR 1.86, 95% CI 1.24–2.79) ^[1].

Apply standardized DOAC interruption windows

Use procedure bleeding-risk and renal function to time last dose and restart; PAUSE-style protocols reduce bleeding and thromboembolism without heparin bridging ^[2].

Prioritize stent and valve considerations

Recent PCI (especially <30 days for BMS, <3 months for DES) or mechanical valves often necessitate continuation or minimal interruption with multidisciplinary planning ^[2], ^[3].

Restart early when hemostasis secured

For most procedures: resume antiplatelets within 24 hours and DOACs at 24–72 hours depending on bleeding risk; earlier resumption reduces thrombotic events ^[4], ^[5].

Avoid routine VKA bridging

Most VKA-treated patients do not need perioperative heparin bridging; reserve for very high thrombotic risk (e.g., select mechanical valves) per CHEST ^[4], ^[5].

Evidence highlights

↑ major bleeding: RR 1.86 (95% CI 1.24–2.79)

LMWH bridging during antiplatelet interruption

CHEST: 44 recommendations across VKAs, DOACs, antiplatelets

Guideline scope

Clinical Framework

Risk-Stratified Perioperative Plan

Integrate procedure bleeding risk, thrombotic risk, and drug pharmacology to guide interruption, bridging, and resumption.

Classify procedural bleeding risk

Low: superficial, dental, cataract. Intermediate: laparoscopic cholecystectomy, hernia. High: major cancer surgery, neuraxial, intracranial. This determines stop and restart timing ^[4], ^[5].

Define patient thrombotic risk

Very high: recent (<3 months) VTE, mechanical mitral valve, CHA2DS2-VASc ≥7, recent PCI (DES <3 months, BMS <30 days). Moderate/low: remote VTE or nonvalvular AF without recent stroke ^[4], ^[2], ^[3].

Map drug-specific timing

Antiplatelets (aspirin, P2Y12), VKAs (warfarin), DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) have distinct half-lives and reversal strategies. Use standardized windows and avoid unnecessary bridging ^[1], ^[4], ^[5].

Coordinate multidisciplinary decisions

Involve cardiology for recent stents or high-risk CAD, hematology for complex thrombophilia, anesthesia/surgery for neuraxial implications and hemostasis thresholds ^[2], ^[6], ^[3].

Medication-Specific Actions

What to Stop, Bridge, and When to Restart

Use these quick-reference cards to operationalize guideline-concordant care.

Aspirin (ASA) for Primary vs Secondary Prevention

Primary prevention: for high-bleeding-risk surgery, stop 5–7 days prior; usually no bridging; restart 24 hours after hemostasis ^[4], ^[5].

Secondary prevention (CAD, prior MI, stroke): often continue for low–moderate bleeding risk; for high risk (intracranial, posterior eye, neuraxial), consider stop 5–7 days after specialist input ^[4], ^[5], ^[6].

Recent PCI: prioritize continuation; if absolutely necessary to interrupt, minimize gap and resume early ^[2], ^[3].

P2Y12 Inhibitors (Clopidogrel, Prasugrel, Ticagrelor)

Standard stop times: clopidogrel 5 days, prasugrel 7 days, ticagrelor 3–5 days pre-op; no LMWH bridging (↑ bleeding: RR 1.86, 95% CI 1.24–2.79) ^[1].

Recent stent: favor continuation of at least one agent (often ASA) and minimize P2Y12 interruption; discuss with cardiology ^[2], ^[3].

Restart: resume within 24 hours post-op when hemostasis secured; consider loading dose if prolonged interruption and high thrombotic risk ^[4], ^[5].

Warfarin (VKA)

Stop 5 days pre-op; check INR day −1; give vitamin K 1–2 mg PO if INR >1.5 to avoid delay ^[4], ^[5].

Bridging: avoid routine LMWH/UFH bridging; consider only for very high thrombotic risk (e.g., mechanical mitral valve, recent stroke/VTE) ^[4], ^[5].

Restart: evening of surgery or next day if hemostasis; full anticoagulation delayed ~5 days—assess need for prophylactic-dose heparin during lag in high-risk cases ^[4], ^[5].

DOACs (Apixaban, Rivaroxaban, Edoxaban, Dabigatran)

Low-bleeding-risk procedures: last dose 24 hours prior (CrCl ≥50 mL/min); high-bleeding-risk: last dose 48–72 hours prior; dabigatran requires longer if CrCl <50 (up to 96 hours) ^[4], ^[2], ^[5].

No bridging: heparin bridging is not recommended; use pharmacologic or mechanical VTE prophylaxis post-op as indicated ^[4], ^[5].

Restart: 24 hours after low-risk procedures; 48–72 hours after high-risk when hemostasis achieved; consider 72–96 hours with neuraxial or ongoing oozing ^[4], ^[2], ^[5].

Neuraxial Anesthesia Considerations

Adhere to drug-specific ASRA-compatible intervals; for P2Y12 inhibitors and DOACs, ensure adequate hold time before neuraxial puncture and catheter removal; restart only after catheter removal and hemostasis ^[2], ^[6].

Coronary Stents and Dual Antiplatelet Therapy (DAPT)

Elective surgery: defer until completion of critical DAPT window when possible (BMS ≥30 days, DES ≥3–6 months) ^[2], ^[3].

If surgery cannot be delayed: continue ASA; minimize P2Y12 interruption; schedule early-day surgery, meticulous hemostasis, and early restart (often within 24 hours) ^[2], ^[3].

Avoid LMWH “bridging” during DAPT interruption due to bleeding risk and lack of benefit ^[1].

Evidence Signals

What the Data Say

Effect sizes and certainty to inform shared decision-making.

Antiplatelet Interruption and Bridging

Short vs longer antiplatelet interruption: no significant difference in major bleeding (low certainty) ^[1], ^[7].

LMWH bridging during antiplatelet interruption: RR 1.86 for major bleeding (95% CI 1.24–2.79; very low certainty) ^[1].

Guideline Consensus

CHEST panel produced 44 perioperative recommendations spanning VKAs, DOACs, and antiplatelets; emphasizes no routine bridging and standardized DOAC holds/restarts ^[4], ^[5].

DOAC Protocols

PAUSE study-informed strategies support simple, non-bridged DOAC interruption with low rates of major bleeding and arterial thromboembolism across procedure risks ^[2].

Operational Playbook

Day-by-Day Timing Guide

Illustrative schedule for common scenarios; adjust for renal function and specific procedure risks.

Warfarin elective surgery (moderate bleeding risk, nonvalvular AF)

Day −5: stop warfarin. Day −1: ensure INR ≤1.5; give low-dose vitamin K if needed. Day 0: surgery; no heparin bridging. Post-op day 0–1: restart warfarin; consider mechanical VTE prophylaxis and escalate to pharmacologic prophylaxis per surgical protocol ^[4], ^[5].

Apixaban elective high-bleeding-risk surgery (CrCl 60 mL/min)

Last dose 48–72 hours pre-op. No bridging. Resume 48–72 hours post-op when hemostasis assured; consider prophylactic-dose heparin 6–12 hours post-op if indicated ^[4], ^[2], ^[5].

Clopidogrel with prior DES placed 4 months ago, moderate-bleeding-risk surgery

Continue ASA. Hold clopidogrel 5 days only if procedural bleeding risk necessitates; schedule early restart (within 24 hours) with hemostasis; discuss with cardiology regarding loading dose if interruption exceeds 5–7 days ^[2], ^[3].

References

Source material

Primary literature that informs this article.