How should perioperative anticoagulants and antiplatelet agents be managed for elective surgery?

• A. Continue all anticoagulants without interruption.
• B. Hold or adjust based on bleeding and thrombotic risk; manage DOACs 24–48 hours preop, warfarin with INR in acceptable range and possible bridging as indicated; restart after hemostasis.
• C. Discontinue all anticoagulants 2 weeks before surgery.
• D. Only DOACs are stopped; warfarin continues.

Answer: (B)

Balancing bleeding risk from the surgery with the risk of a thromboembolic event if anticoagulation is stopped is the main idea. Direct oral anticoagulants have shorter half-lives, so they’re typically held about 24–48 hours before elective procedures, with exact timing adjusted for kidney function and how much bleeding the procedure is likely to cause. Warfarin needs several days off to allow the INR to fall into a safer range for surgery, and for patients at high risk of clotting, bridging with a short-acting agent (such as heparin) is often considered. After the operation, anticoagulation is restarted once hemostasis is secure and the surgical site is stable.

This approach applies similarly to antiplatelet therapy, weighing the bleeding risk of the planned surgery against the patient’s risk of thrombosis and modifying the plan accordingly. The other strategies—continuing all anticoagulants, stopping everything two weeks before, or stopping only DOACs while warfarin continues—do not appropriately balance bleeding and thrombotic risks in most elective cases.