Abstract
During the perioperative period, each patient receiving the anticoagulant, the ratio between the risk of bleeding and the risk of a thromboembolic event resulting from it itself surgery should be evaluated. Results from the large randomized trials that have been dealt with optimal perioperative regime are limited.
Current recommendations for perioperative procedure are based on the expected risk of bleeding. In case of elective surgery intervention associated with high risk of bleeding, oral anticoagulant therapy may be discontinued without bridging.
In case of low risk of bleeding, after discontinuation of oral anticoagulants, bridging therapy with unfractionated or low molecular weight heparin is started. The discontinuation time of warfarin required prior to surgery is based on its longer half-life.
Two to three days are required for INR to drop below 2.0 is and five days are needed to normalize INR. For direct oral anticoagulants, due to their pharmacokinetic and pharmacodynamic profile, the duration of the necessary discontinuation of anticoagulant therapy is shorter compared to warfarin.
In patients with normal renal function, dabigatran should be discontinued two days before surgery, rivaroxaban for at least 24 hours and for apixaban 48 hours in advance. New oral anticoagulants are not intended to bridge the treatment with other anticoagulants or antiaggregants.
This review article presents the practical procedure of optimal perioperative strategies in patients with oral anticoagulant therapy.