What are the key considerations for managing patients on anticoagulants in the perioperative period?

For patients on anticoagulants during the perioperative period, key considerations involve a careful balance of thromboembolic and bleeding risks, specific management of anticoagulant medications, and appropriate prophylaxis measures ³.

• Risk Assessment: All patients should be assessed for their risk of venous thromboembolism (VTE) and bleeding as soon as possible after hospital admission or by the first consultant review, using a national UK tool ³. Decisions to stop anticoagulation should be based on a reassessment of stroke and bleeding risk using CHA2DS2-VASc and ORBIT scores, alongside a discussion of the person's preferences ¹.
• Anticoagulant Interruption:
  • For most minor surgical procedures where bleeding is easily controllable, oral anticoagulation should generally not be interrupted ².
  • For procedures with a low bleeding risk, specific direct oral anticoagulant (DOAC) interruption times apply:
    • Dabigatran: The last dose should be taken 24 hours before the procedure for people with normal renal function. For those with creatinine clearance (CrCl) 50–79 mL/minute, an interruption of at least 36 hours is recommended; if CrCl is 30–49 mL/minute, at least 48 hours (European Heart Rhythm Association) or 48–72 hours (manufacturer) ².
    • Edoxaban: Discontinue at least 24 hours before for most people, and at least 36 hours if CrCl is 15–29 mL/minute ².
    • Rivaroxaban: Discontinue at least 24 hours before for most people, and at least 36 hours if CrCl is 15–29 mL/minute ².
  • For procedures with a high bleeding risk, the last DOAC dose is generally recommended 3 days before the procedure (British Society of Gastroenterology/European Society of Gastrointestinal Endoscopy) ². For rivaroxaban, this interruption may be 48 hours or longer ². Longer interruption is required for impaired renal function, particularly with dabigatran ². The decision to halt treatment for longer should consider the person’s thromboembolic risk versus bleeding risk, and concurrent antiarrhythmic drugs ².
• Continuation of Other Medications:
  • In people having cardiothoracic surgery, continue beta-blocker therapy unless contraindications develop (e.g., postoperative bradycardia or hypotension) ¹.
  • Continue statins in people having cardiothoracic surgery if they are already on them; do not start statins solely to prevent postoperative atrial fibrillation ¹.
  • Advise people to consider stopping oestrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery, providing advice on alternative contraceptive methods if stopped ³.
  • For people on antiplatelet agents, consider VTE prophylaxis if their VTE risk outweighs their bleeding risk, taking into account comorbidities like arterial thrombosis ³.
• Venous Thromboembolism (VTE) Prophylaxis:
  • Consider pharmacological VTE prophylaxis with low-molecular-weight heparin (LMWH) for a minimum of 7 days for people undergoing oral or maxillofacial surgery, ENT surgery, cardiac surgery (if not on other anticoagulation), open vascular surgery, or major endovascular procedures, where the VTE risk outweighs the bleeding risk ³.
  • Consider mechanical VTE prophylaxis (anti-embolism stockings or intermittent pneumatic compression) on admission for people undergoing oral or maxillofacial, ENT, cardiac, open vascular, or major endovascular surgery who are at increased VTE risk and/or high bleeding risk, or if pharmacological prophylaxis is contraindicated ³. Continue until the person no longer has significantly reduced mobility ³.
  • Ensure anti-embolism stockings are refitted if oedema or postoperative swelling develops ³. Seek expert opinion if arterial disease is suspected before fitting anti-embolism stockings ³. Monitor their use and stop if skin issues or discomfort occur, offering intermittent pneumatic compression as an alternative ³.
• Postoperative Management:
  • Do not stop anticoagulation solely because atrial fibrillation is no longer detectable ¹.
  • Manage new-onset postoperative atrial fibrillation after non-cardiothoracic surgery in the same way as new-onset atrial fibrillation with any other cause ¹. For postoperative atrial fibrillation after cardiothoracic surgery, consider either a rhythm-control or rate-control strategy ¹.
  • In the prophylaxis and management of postoperative atrial fibrillation, use appropriate antithrombotic therapy and correct identifiable causes (such as electrolyte imbalance or hypoxia) ¹.
  • Encourage people to mobilise as soon as possible and do not allow them to become dehydrated unless clinically indicated ³.
• Monitoring and Patient Advice: Regular follow-up and monitoring are recommended for people taking DOACs ². Baseline clotting screen, renal and liver function tests, and a full blood count should be performed at the start of treatment ². Review the person regularly, initially after 1 month, with intervals adjusted based on factors like renal function, age, and comorbidities ². During reviews, assess adherence, look for signs of bleeding or anaemia, ask about adverse effects and other medications (to identify drug interactions), and assess/minimize modifiable bleeding risk factors ². Repeat full blood count, renal and liver function tests yearly for most people ². Advise patients on their treatment and the importance of carrying an 'anticoagulant alert card' ²,⁴.