PERIPROCEDURAL ANTITHROMBOTIC RECS












ACCP 2012 periprocedural aspirin recommendations
Patients taking aspirin for the PRIMARY prevention of any condition
  • Stop aspirin 7 days before the procedure [2]
Patients taking aspirin for the SECONDARY prevention of cardiovascular disease
  • Minor dental procedures, minor dermatological procedures, and cataract surgery
    • Continue aspirin [1]

  • Noncardiac surgery
    • Patients at moderate to high risk for cardiovascular events
      • Continue aspirin
      • NOTE: A large, randomized controlled trial published in 2014 found that aspirin had no benefit in high-risk patients undergoing noncardiac surgery. See POISE-2 study for more.
        • Moderate to high risk defined as one or more of the following:
          • Patients with ischemic heart disease
          • Compensated or prior congestive heart failure
          • Diabetes mellitus
          • Kidney disease
          • Cerebrovascular disease
        • Other considerations:
          • If the surgery is associated with an increased risk for perioperative cardiovascular events, such as carotid endarterectomy and peripheral artery bypass surgery, then continuing aspirin may be beneficial
          • For surgeries that are associated with an increased risk of bleeding (ex. prostate and intracranial surgery), then the risk/benefit ratio of continuing aspirin should be considered
    • Patients at low risk for cardiovascular events
      • Stop aspirin 7 - 10 days before surgery [1]

  • Coronary artery bypass graft surgery (CABG)
    • Continue aspirin [1]
    • NOTE: A large, randomized controlled trial published in 2016 found that preoperative aspirin had no benefit in high-risk patients who were undergoing CABG. See ATACAS trial for more.

  • The ACCP 2012 guidelines did not give recommendations for Factor Xa inhibitors or dabigatran
ACCP 2012 periprocedural warfarin recommendations
Minor dental procedures
  • Two options
    • 1. Continue warfarin and administer oral prohemostatic agent (ex. tranexamic acid)
    • 2. Stop warfarin 2-3 days before the procedure (if INR is between 2 - 3, it should drop to 1.6 - 1.9 at time of procedure)

Minor dermatological procedures and cataract surgery
  • Continue warfarin and optimize local hemostasis

Other surgeries
  • Patients at high risk for thromboembolism (see risk categories below)
    • Stop warfarin 5 days before surgery
    • Administer bridging therapy (typically with SQ Low Molecular Weight Heparin (LMWH), ex. Lovenox®)
    • Restart warfarin 12 - 24 hours after surgery and when there is adequate hemostasis

  • Patients at moderate risk for thromboembolism (see risk categories below)
    • The decision to administer bridging therapy should be made on an individual basis

  • Patients at low risk for thromboembolism (see risk categories below)
    • Stop warfarin 5 days before surgery
    • Do not administer bridging anticoagulation therapy
    • Restart warfarin 12 - 24 hours after surgery and when there is adequate hemostasis [1]

ACCP 2012 thromboembolism risk categories
Atrial fibrillation
  • High risk
    • CHADS₂ score of 5 or 6
    • Recent (within 3 months) stroke or TIA
    • Rheumatic valvular heart disease
  • Moderate risk
    • CHADS₂ score of 3 or 4
  • Low risk
    • CHADS₂ score of 0 - 2, assuming no prior stroke or TIA
    • NOTE: A recent study found no benefit of bridging therapy in patients with an average CHADS2 score of 2.3 (see BRIDGE study for more)
  • Other considerations (these factors may affect decision for bridging therapy)
    • High risk surgeries - certain surgeries carry a higher risk for stroke and thromboembolism (ex. heart valve replacement, carotid endarterectomy, and major vascular surgery)
    • Prior thromboembolism during warfarin interruption
    • Any history of stroke or TIA [1]
Venous thromboembolism
  • High risk
    • Recent (within 3 months) DVT or PE
    • Severe hypercoagulable disorder (Protein C and S deficiency, antithrombin deficiency, antiphospholipid antibodies, multiple abnormalities)
  • Moderate risk
    • DVT or PE within past 3 - 12 months
    • Non-severe hypercoagulable disorder (heterozygous Factor V Leiden or prothrombin gene mutation)
    • Recurrent DVT or PE
    • Active cancer (treated within 6 months or palliative)
  • Low risk
    • DVT or PE greater than 12 months ago and no other risk factors
  • Other considerations (these factors may affect decision for bridging therapy)
    • High risk surgeries - certain surgeries carry a higher risk for stroke and thromboembolism (ex. heart valve replacement, carotid endarterectomy, and major vascular surgery)
    • Prior thromboembolism during warfarin interruption
    • Any history of stroke or TIA [1]
Mechanical heart valve
  • High risk
    • Any mitral valve prosthesis
    • Any caged-ball or tilting disc aortic valve prosthesis
    • Recent (within 6 months) stroke or TIA
  • Moderate risk
    • Bileaflet aortic valve prosthesis and one or more of the following risk factors:
      • Atrial fibrillation
      • Prior stroke or TIA
      • Hypertension
      • Diabetes
      • Congestive heart failure
      • Age > 75 years
  • Low risk
    • Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke
  • Other considerations (these factors may affect decision for bridging therapy)
    • High risk surgeries - certain surgeries carry a higher risk for stroke and thromboembolism (ex. heart valve replacement, carotid endarterectomy, and major vascular surgery)
    • Prior thromboembolism during warfarin interruption
    • Any history of stroke or TIA [1]



AHA 2016 periprocedural recommendations for dual antiplatelet therapy
Elective, noncardiac surgery
  • Drug-eluting stents (DES)
    • < 3 months since DES implantation
      • Delay surgery
    • 3 - 6 months since DES implantation
      • Proceeding with surgery may be considered
      • If having surgery, discontinue DAPT before surgery (aspirin should be continued if possible)
      • After surgery, restart DAPT as soon as possible if still indicated
      • There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial
    • ≥ 6 months since DES implantation
      • Proceed with surgery
      • Discontinue DAPT before surgery (aspirin should be continued if possible)
      • After surgery, restart DAPT as soon as possible if still indicated
      • There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial [11]

  • Bare metal stents (BMS)
    • < 30 days since BMS implantation
      • Delay surgery
    • ≥ 30 days since BMS implantation
      • Proceed with surgery
      • If having surgery, discontinue DAPT before surgery (aspirin should be continued if possible)
      • After surgery, restart DAPT as soon as possible if still indicated
      • There is no convincing evidence that "bridging therapy" with parenteral antiplatelet/anticoagulant agents is beneficial [11]
Coronary artery bypass graft surgery (CABG)
  • Urgent on-pump CABG
    • Aspirin - do not stop aspirin before surgery
    • P2Y12 inhibitor:
      • Clopidogrel - stop clopidogrel 24 hours before surgery if possible
      • Ticagrelor - stop ticagrelor 24 hours before surgery if possible [7]

  • Elective CABG
    • Aspirin
      • Do not stop aspirin before surgery
    • P2Y12 inhibitor:
      • Clopidogrel - stop clopidogrel 5 days before surgery
      • Ticagrelor - stop ticagrelor 5 days before surgery
      • Prasugrel - stop prasugrel 7 days before surgery [3]

AHA 2017 periprocedural recommendations for patients with mechanical heart valves
Minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled
  • Continue warfarin [6]

Other invasive or surgical procedures
  • Patients with bileaflet mechanical aortic valve replacement (AVR) and no other risk factors for thrombosis
    • Temporary interruption of warfarin without bridging agents while the INR is subtherapeutic - warfarin is stopped 2 to 4 days before the procedure (so the INR falls to < 1.5 for major surgical procedures) and restarted as soon as bleeding risk allows, typically 12 to 24 hours after surgery [6]

  • Patients with 1) mechanical AVR and any thromboembolic risk factor, 2) older-generation mechanical AVR, or 3) mechanical mitral valve replacement
    • Bridging therapy is reasonable. Risks of bleeding should be weighed against the benefits of thromboembolism prevention.
    • NOTE: Bridging therapy has not been found to be of benefit in A fib trials (see BRIDGE study). This may have implications for bridging anticoagulation in patients with prosthetic valves. [12]






  • Reference [4]
ASGE 2016 ANTITHROMBOTIC RECOMMENDATIONS FOR ELECTIVE GI ENDOSCOPY
ANTIPLATELET THERAPY
TE risk Procedure bleed risk Recommendation
Low Low
  • Continue ASA/NSAIDs
  • Continue P2Y12 inhibitor
Low High
  • Continue ASA/NSAIDs
  • Discontinue P2Y12 inhibitors at least 5 days before endoscopy or switch to ASA
  • For patients taking dual antiplatelet therapy, hold P2Y12 inhibitors for at least 5 days and continue ASA
High Low
  • Continue ASA/NSAIDs
  • Continue P2Y12 inhibitors
High High
  • Continue ASA/NSAIDs
  • Discontinue P2Y12 inhibitors at least 5 days before endoscopy or switch to ASA
  • For patients taking dual antiplatelet therapy, hold P2Y12 inhibitors for at least 5 days and continue ASA
Ticagrelor should be held for 3-5 days, and all other P2Y12 inhibitors should be held for 5-7 days
ANTICOAGULATION THERAPY
TE risk Procedure bleed risk Recommendation
Low Low
  • Continue anticoagulation
Low High
  • Discontinue anticoagulation
  • Restart warfarin on same day as procedure
  • Restart Factor Xa inhibitors and direct thrombin inhibitors once adequate hemostasis is achieved
High Low
  • Continue anticoagulation
High High
  • Discontinue anticoagulation
  • Bridging therapy
  • Restart warfarin on same day as procedure
  • Restart Factor Xa inhibitors and direct thrombin inhibitors once adequate hemostasis is achieved

  • Reference [4]
ASGE THROMBOEMBOLISM RISK CATEGORIES
Nonvalvular atrial fibrillation
Mechanical heart valve
  • High risk
    • Any mitral valve prosthesis
    • Any caged-ball or tilting disc aortic valve prosthesis
    • Recent (within 6 months) CVA or TIA

  • Medium risk
    • Bileaflet aortic valve prosthesis and one or more of the following risk factors: A fib, prior CVA or TIA, hypertension, diabetes, congestive heart failure, age ≥ 75 years

  • Low risk
    • Bileaflet aortic valve prosthesis without A fib and no other risk factors for CVA
Venous thromboembolism (VTE)
  • High risk
    • Recent (within 3 months) VTE
    • Severe thrombophilia (deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)

  • Medium risk
    • VTE within the past 3 - 12 months
    • Nonsevere thrombophilia (heterozygous factor V Leiden or prothrombin gene mutation)
    • Recurrent VTE
    • Active cancer (treated within 6 months or palliative)

  • Low risk
    • VTE > 12 months previous and no other risk factors
Recent cardiac stent (antiplatelet therapy)
  • High risk
    • Placement of drug-eluting stent ≤ 12 months
    • Placement of bare metal stent ≤ 1 month
    • Placement of bare metal stent after acute coronary syndrome ≤ 12 months

  • Other conditions that can raise cardiovascular risk include:
    • Prior history of stent occlusion
    • History of acute coronary syndrome or ST-elevation MI
    • Multivessel PCI
    • Diabetes
    • Kidney failure

  • Reference [4]
ASGE PROCEDURE BLEEDING RISK CATEGORIES
High bleeding risk
  • Polypectomy
  • Biliary or pancreatic sphincterotomy
  • Treatment of varices
  • PEG placement (PEG on aspirin or clopidogrel is low risk. DAPT is high risk)
  • Therapeutic balloon-assisted enteroscopy
  • Endoscopic ultrasound (EUS) with FNA (EUS-FNA of solid masses on ASA/NSAIDs is low risk)
  • Endoscopic hemostasis
  • Tumor ablation
  • Cystogastrostomy
  • Ampullary resection
  • Endoscopic mucosal resection (EMR)
  • Endoscopic submucosal dissection
  • Pneumatic or bougie dilation
  • Percutaneous endoscopic jejunostomy
Low bleeding risk
  • Diagnostic (EGD, colonoscopy, flexible sigmoidoscopy) including mucosal biopsy
  • ERCP with stent (biliary or pancreatic) placement or papillary balloon dilation without sphincterotomy
  • Push enteroscopy and diagnostic balloon-assisted enteroscopy
  • Capsule endoscopy
  • Enteral stent deployment (Controversial)
  • Endoscopic ultrasound (EUS) without FNA
  • Argon plasma coagulation
  • Barrett’s ablation


  • Reference [12]
SEC RECOMMENDATIONS FOR ANTITHROMBOTIC THERAPY
ANTIPLATELET THERAPY
TE risk Procedure bleed risk Recommendation
Low Low / Moderate
  • Continue ASA
  • Stop P2Y12 inhibitor and replace with ASA if possible
Low High
  • Continue ASA except when contraindicated (e.g. neurosurgery)*
  • Stop P2Y12 inhibitor and replace with ASA if possible
Moderate / High Low
  • Continue ASA
  • Continue P2Y12 inhibitors
Moderate / High Moderate
  • Individualize therapy based on patient risk factors
  • Continue ASA
  • Assess withdrawal of P2Y12 inhibitor
Moderate / High High
  • Individualize therapy based on patient risk factors
  • Continue ASA unless contraindicated*
  • Stop P2Y12 inhibitor and replace with ASA if possible
  • Assess bridging therapy
  • Stop clopidogrel 5 days before surgery; Stop ticagrelor 3 - 5 days before surgery; Stop prasugrel 7 days before surgery
  • *If necessary, withdraw ASA 3 days before surgery
  • Restart antiplatelet therapy within 24 hours of surgery if bleeding risk is low or moderate. Restart 48 - 72 hours when bleeding risk is high
  • NOTE: A large, randomized controlled trial published in 2014 found that aspirin had no benefit in high-risk patients undergoing noncardiac surgery. (see POISE-2 study). Also, a large, randomized controlled trial published in 2016 found that preoperative aspirin had no benefit in high-risk patients who were undergoing CABG (see ATACAS trial for more).
ANTICOAGULATION THERAPY
TE risk Procedure bleed risk Recommendation
Low / Moderate / High Low
  • Continue anticoagulation
Low / Moderate Low / Moderate / High
  • Discontinue anticoagulation
  • Do not use bridging therapy
High Low / Moderate / High
  • Guidelines do not state specifically which procedures are okay to continue anticoagulation. Other guidelines state minor procedures such as dental extractions, minor derm procedures, and cataract surgery are okay for continued anticoagulation.
  • For procedures with a low or moderate bleeding risk, restart anticoagulation 24 hours after surgery and consider bridging therapy in patients taking warfarin with high thromboembolic risk
  • For procedures with a high bleeding risk, restart anticoagulation 48 - 72 hours after surgery without bridge therapy

  • Reference [12]
SEC THROMBOEMBOLISM RISK CATEGORIES FOR PATIENTS ON ANTICOAGULANT THERAPY
Atrial fibrillation
Mechanical heart valve
  • High risk
    • Mitral valve
    • Tricuspid valve (including biological valve)
    • Aortic valve (monoleaflet)
    • Stroke/TIA in last 6 months

  • Moderate risk
    • Aortic valve + any of the following risk factors:
      • Atrial fib
      • Stroke/TIA > 6 months ago
      • Diabetes
      • Heart failure
      • Age > 75 years

  • Low risk
    • Aortic valve without other risk factors
Venous thromboembolism (VTE)
  • High risk
    • Recent (within 3 months) VTE
    • Severe thrombophilia (homozygous factor V Leiden, prothrombin 20210A, protein C, protein S, or antithrombin deficiency, multiple defects, antiphospholipid syndrome)

  • Moderate risk
    • VTE within the past 3 - 12 months
    • Nonsevere thrombophilia (heterozygous factor V Leiden or prothrombin 20210A gene mutation)
    • Recurrent VTE
    • VTE + active cancer

  • Low risk
    • VTE > 12 months

  • Reference [12]
SEC THROMBOEMBOLISM RISK CATEGORIES FOR PATIENTS ON ANTIPLATELET THERAPY
Heart disease
  • The SEC risk categories for patients with heart disease are broken down into a large number of subgroups based on numerous variables. Those categories are detailed at the link below on page 4 of the pdf.
Cerebrovascular disease
  • High risk
    • Ischemic stroke within 3 months
    • Carotid stent placement within 3 months

  • Moderate risk
    • Ischemic stroke within 3 - 6 months
    • Carotid stent placement within 3 - 6 months

  • Low risk
    • Ischemic stroke > 6 months ago
    • Carotid stent placement > 6 months ago
Peripheral vascular disease
  • High risk
    • Within 3 months of acute peripheral vascular event + revascularization with DES or stents used in chronic occlusions

  • Moderate risk
    • Within 3 - 6 months of acute peripheral vascular event + revascularization with DES or stents used in chronic occlusions

  • Low risk
    • > 6 months since acute peripheral vascular event + revascularization with DES or stents used in chronic occlusions





When to hold P2Y12 inhibitors before procedures
Drug ASGE / SEC Manufacturer
Clopidogrel 5 days 5 days
Prasugrel 7 days 7 days
Ticagrelor 3 - 5 days 5 days
Ticlopidine N/A 10 - 14 days


  • Reference [12]
SEC recommendations on holding warfarin before procedures
INR 7 days before procedure Hold warfarin
> 3 7 days
2 - 3 6 days
< 2 5 days


  • Recommendations are for apixaban, rivaroxaban, and edoxaban only
  • Recommendations are from the ACC. Other recommendations may vary.
  • Anti-Xa level is a lab that measures the concentration of Factor Xa inhibitors in the blood
  • References [13,14]
Recommendations for holding Factor Xa inhibitors (apixaban, rivaroxaban, edoxaban) before procedures
CrCl (ml/min) Procedure bleeding risk Hold before procedure
≥ 30 Low ≥ 24 hours
15 - 29 Low ≥ 36 hours
< 15 Low No data. Consider anti-Xa level and/or ≥ 48 hours.
≥ 30 Moderate / High ≥ 48 hours
< 30 Moderate / High No data. Consider anti-Xa level and/or ≥ 72 hours.


  • dTT - dilute thrombin time assay (not widely available). A normal aPTT usually excludes clinically relevant levels if a sensitive reagent is used. A normal thrombin time (TT) excludes clinically relevant levels.
  • Recommendations are from the ACC. Other recommendations may vary.
  • References [13,14]
Recommendations for holding dabigatran before procedures
CrCl (ml/min) Procedure bleeding risk Hold before procedure
≥ 80 Low ≥ 24 hours
50 - 79 Low ≥ 36 hours
30 - 49 Low ≥ 48 hours
15 - 29 Low ≥ 72 hours
< 15 Low No data. Consider dTT and/or ≥ 96 hours.
≥ 80 Moderate / High ≥ 48 hours
50 - 79 Moderate / High ≥ 72 hours
30 - 49 Moderate / High ≥ 96 hours
15 - 29 Moderate / High ≥ 120 hours
< 15 Moderate / High No data. Consider dTT.


  • Drugs are typically cleared after 4 - 5 half-lives
  • The manufacturer states that in trials, celecoxib had no effect on reduction of platelet aggregation or increase in bleeding time
  • *The manufacturer states that in trials, nabumetone had little effect on collagen-induced platelet aggregation and no effect on bleeding time
  • References [Manufacturer PI]
NSAID half-lives
Drug Half-life
Ibuprofen (Motrin®, Advil®) 2.2 hours
Naproxen (Aleve®, Anaprox®, etc.) 12 - 17 hours
Meloxicam (Mobic®) 15 - 20 hours
Celecoxib (Celebrex®) 11 hours
Indomethacin (Indocin®) 4.5 hours
Ketorolac (Toradol®) 5 - 6 hours
Nabumetone (Relafen®)* 24 hours







  • Reference [1,10,14]
BRIDGING THERAPY RECOMMENDATIONS
Pre-operative
  • Stop warfarin 5 days prior to scheduled surgery. When INR becomes subtherapeutic, start a bridging regimen.
  • If patient is receiving a Factor Xa inhibitor or dabigatran, start bridging regimen after omitting 2 - 3 doses of the drug

Bridging regimens
  • Enoxaparin (Lovenox®) 1 mg/kg twice a day OR 1.5 mg/kg once daily
  • Dalteparin (Fragmin®) 100 IU/kg twice a day OR 200 IU/kg once daily
  • IV unfractionated heparin to maintain aPTT 1.5 - 2 X the control aPTT
  • NOTE: When patient has a mechanical heart valve, twice daily LMWH regimens are recommended

Before procedure
  • LMWH
    • Twice daily regimen - withhold the last LMWH dose before surgery
    • Once daily regimens - give half the total daily dose the morning of the day before surgery
  • Unfractionated heparin (UFH)
    • Stop UFH 4 - 6 hours before surgery

Post-operative
  • Warfarin
    • Restart warfarin 12 - 24 hours after surgery when adequate hemostasis has been achieved
    • In patients who underwent surgery that has a high bleeding risk, resume LMWH or UFH (without bolus dose) 48 - 72 hours after surgery
    • In patients who underwent surgery that has a moderate or low bleeding risk, resume LMWH or UFH (without bolus dose) 24 hours after surgery
    • Continue bridging therapy until INR is therapeutic
  • Factor Xa inhibitors and dabigatran
    • Confirm that adequate hemostasis has been achieved
    • In patients who underwent surgery that has a high bleeding risk, resume medication 48 - 72 hours after surgery
    • In patients who underwent surgery that has a low bleeding risk, resume medication on the day following the procedure
    • Parenteral anticoagulation is generally not required