What is the general approach to anticoagulant management preoperatively for patients with atrial fibrillation or mechanical valves?

• A. Hold or adjust DOACs/warfarin per thromboembolism and bleeding risk; bridging may be considered for high-risk patients
• B. Continue anticoagulants unchanged
• C. Stop all anticoagulants permanently
• D. Switch to antiplatelet-only therapy

Answer: (A)

Managing anticoagulation before surgery in patients with atrial fibrillation or mechanical valves is about balancing two risks: the chance of a thromboembolism if protection is paused, and the risk of excessive bleeding during the operation. The best approach is to hold or adjust the anticoagulant based on how high the patient’s risk of clotting is and how high the bleeding risk of the planned procedure is, with bridging considered for those at particularly high thromboembolism risk. For warfarin, this often means stopping several days prior to a high-bleeding-risk surgery and using a short-acting agent like LMWH or UFH to cover the interval if the thromboembolism risk is significant. Direct oral anticoagulants, having shorter half-lives, are usually stopped for a shorter window and are resumed after procedure hemostasis is secured, with bridging not routinely needed. This strategy protects the patient from stroke or valve thrombosis during the perioperative period while minimizing bleeding during surgery. Continuing anticoagulation unchanged would raise bleeding risk, stopping all anticoagulants permanently would expose the patient to stroke or valve thrombosis, and switching to antiplatelet therapy alone generally fails to provide adequate protection for AF or mechanical valve scenarios.