← Interactive tools
Hematology · Planner

Peri-procedural anticoagulation

Elective procedure on warfarin, a DOAC, LMWH, UFH, aspirin or a P2Y12 inhibitor: when to give the last dose, whether to bridge, what to do about the INR, and when to restart, set by the procedure’s bleeding risk.

CHEST 2022 rec numbersPAUSE DOAC schedulesBridging only when it helpsReviewed Oct 2026

1What the patient takes

2Procedure

Examples of each class
  • High (30-day major bleeding 2% or more): any operation over 45 minutes; cardiac, intracranial or spinal surgery; major orthopedic, thoracic or reconstructive plastic surgery; most cancer surgery; GI or urologic surgery, especially with an anastomosis; TURP, bladder resection or tumor ablation; nephrectomy or kidney biopsy; surgery on highly vascular organs (kidney, liver, spleen); colonic polyp resection; PEG placement; ERCP; neuraxial anesthesia or epidural injection.
  • Low to moderate (under 2%): arthroscopy; GI endoscopy or colonoscopy with or without biopsy, when none of the high-risk steps above is planned; coronary angiography; laparoscopic cholecystectomy; abdominal hysterectomy; hernia repair; hemorrhoidal surgery; bronchoscopy; skin or lymph node biopsy; foot or hand surgery.
  • Minimal (about 0%): minor dental, minor skin procedures, cataract surgery, pacemaker or ICD implantation.
  • Vitreoretinal, oculoplastic or other non-cataract eye surgery is not in the minimal class: pick its bleed-risk class with the surgeon.

How it works

Schedules used

Day 0 is the procedure. “Dose-free days” are whole days with no dose before Day 0, so the last dose falls the day before the first dose-free day. LM = low to moderate bleed risk; H = high.

AgentLast dose · restart
Apixaban, rivaroxaban, edoxabanLM: Day −2 · Day +1. H: Day −3 · Day +2 to +3 (PAUSE; CHEST #22, #24, #25, #27). Edoxaban was not in PAUSE.
Dabigatran, CrCl 50 or moreLM: Day −2. H: Day −3. Restart as above (PAUSE; CHEST #23).
Dabigatran, CrCl 30 to under 50LM: Day −3. H: Day −5. Restart as above (PAUSE Table 2).
WarfarinDay −6 (#1) · evening of Day 0 or Day +1 at the usual dose (#2, #3).
LMWH, treatment doseMorning of Day −1 at half the daily dose (#18, #20) · 24 h or more (#19); after high-bleed-risk surgery, 48 to 72 h.
UFH infusionStop 4 h or more before (#16) · 24 h or more after (#17); after high-bleed-risk surgery, 48 to 72 h (AAFP 2023).
Clopidogrel, ticagrelor, prasugrel5, 3 to 5, and 7 dose-free days (#30–#32) · within 24 h (#33). Before CABG, #34 says interrupt but gives no day count; before other cardiac surgery the cardiac surgery team decides.
AspirinContinue for non-cardiac surgery (#29a) and CABG (#34); if held, 7 days or less before (#29b) · within 24 h (#33).

PAUSE excluded CrCl under 25 for apixaban and under 30 for dabigatran and rivaroxaban; below those, the tool gives no standard plan. Edoxaban was not studied in PAUSE, so the tool applies the rivaroxaban cutoff (30) to it as a caution, not a guideline threshold. LMWH and UFH timings come from CHEST’s recommendations for heparin given during warfarin interruption; the tool applies them to patients on long-term treatment-dose LMWH or a UFH infusion and says so.

Bridging warfarin

CHEST 2022 suggests bridging for patients at high thromboembolic risk (#8) and against it at low to moderate risk (#9). By indication: atrial fibrillation, recommend against (#6, strong); mechanical valve, suggest against (#5); VTE as the only indication, suggest against (#7); colonoscopy with polypectomy, suggest against (#15). ACG–CAG 2022 suggests against bridging for elective endoscopy “unless the patient has a mechanical heart valve”; its remarks keep it for mechanical valves, atrial fibrillation with CHADS₂ above 5 and prior thromboembolism during interruption, with cardiology and hematology input. The 2024 AHA/ACC perioperative guideline agrees: routine bridging Class 3 (harm), bridging at high thrombotic risk Class 2a.

BRIDGE (atrial fibrillation on warfarin, no mechanical valves): arterial thromboembolism 0.4% without bridging vs 0.3% with dalteparin; major bleeding 1.3% vs 3.2%.

Antiplatelets and coronary stents

Aspirin: continue through elective non-cardiac surgery (#29a, moderate certainty) and through CABG (#34). Minor dental, skin and eye procedures: continue aspirin or a P2Y12 inhibitor (#41–#43).

Coronary stent in the last 12 months: this tool does not set DAPT timing. CHEST context: stents placed 6 to 12 weeks earlier, continue both drugs or stop one within 7 to 10 days of surgery (#37); 3 to 12 months, stop the P2Y12 inhibitor (#38); if DAPT must continue, delay elective surgery (#40); no routine bridging with a GP IIb/IIIa inhibitor, cangrelor or LMWH (#39). The decision is cardiology’s.

Neuraxial and deep blocks

CHEST 2022 classes neuraxial anesthesia and epidural injections as high bleed risk. With a neuraxial or deep block planned, the tool does not give firm stop or restart days for DOACs, P2Y12 inhibitors, LMWH or UFH: the anesthesia team sets them from the ASRA fifth edition (2025), which calls its times conservative. ASRA intervals are typically longer than CHEST/PAUSE; the fourth edition (2018), for example, used 72 hours for apixaban, rivaroxaban and edoxaban and 5 to 7 days for clopidogrel and ticagrelor. The CHEST/PAUSE schedule is shown only as a labelled minimum. Warfarin: the fourth edition asks for a normalized INR before a neuraxial block.

Prophylactic-dose LMWH or UFH around a block: the fifth edition frames doses as low or high; follow ASRA or the anesthesia team.

Not covered

Urgent or emergency surgery and reversal: see anticoagulant reversal. Also not covered: DOACs below the PAUSE CrCl cutoffs; DAPT timing after a recent stent (see preoperative cardiac evaluation); P2Y12 timing before cardiac surgery; ASRA intervals; prophylactic-dose LMWH or UFH (the ASRA fifth edition frames doses as low or high; follow ASRA or the anesthesia team); cilostazol, dipyridamole (including aspirin-dipyridamole), vorapaxar and NSAIDs, to which the aspirin rules here do not apply; VKAs other than warfarin; children. Bleed-risk class is the proceduralist’s call.

Sources

  1. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: an American College of Chest Physicians clinical practice guideline. Chest 2022;162(5):e207–e243. doi:10.1016/j.chest.2022.07.025. Recommendations 1–43 with strength and certainty (the guideline’s 44 statements; #29 has parts a and b). Executive summary: Chest 2022;162(5):1127–39. doi:10.1016/j.chest.2022.08.004. Recommendation wording checked against chestnet.org (key recommendations) and the full statement list reproduced by Prognia, accessed 2026-10-19.
  2. Douketis JD. Perioperative management of antithrombotic therapy: 2022 ACCP/CHEST guidelines. Canadian Society of Internal Medicine annual meeting, 11 Oct 2023 (first author’s slides). Source for the guideline’s implementation notes, Figure 1 (VKA and LMWH bridging) and Figure 2 (DOAC schedule) legends, the thromboembolic-risk table after its 2023 correction (slide 8) and the bleed-risk examples (slide 9).
  3. Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant (PAUSE). JAMA Intern Med 2019;179(11):1469–78. doi:10.1001/jamainternmed.2019.2431 (Methods; Table 2 interruption intervals; CrCl exclusions).
  4. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation (BRIDGE). N Engl J Med 2015;373(9):823–33. doi:10.1056/NEJMoa1501035
  5. Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology–Canadian Association of Gastroenterology clinical practice guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol 2022;117(4):542–58. doi:10.14309/ajg.0000000000001627 (abstract; PICO 12 and its remarks).
  6. Birnie DH, Healey JS, Wells GA, et al. Continued vs. interrupted direct oral anticoagulants at the time of device surgery (BRUISE CONTROL-2). Eur Heart J 2018;39(44):3973–9. doi:10.1093/eurheartj/ehy413
  7. ELIQUIS (apixaban) US prescribing information, Bristol-Myers Squibb, DailyMed setid e9481622-7cc6-418a-acb6-c5450daae9b0, effective 2025-04-17. Section 2.4.
  8. XARELTO (rivaroxaban) US prescribing information, Janssen, DailyMed setid 10db92f9-2300-4a80-836b-673e1ae91610, effective 2026-09-10. Section 2.4.
  9. SAVAYSA (edoxaban) US prescribing information, Daiichi Sankyo, DailyMed setid e77d3400-56ad-11e3-949a-0800200c9a66, effective 2025-07-10. Section 2.5.
  10. PRADAXA (dabigatran etexilate) US prescribing information, Boehringer Ingelheim, DailyMed setid ba74e3cd-b06f-4145-b284-5fd6b84ff3c9, effective 2025-06-25. Section 2.8.
  11. Kopp SL, Vandermeulen E, McBane RD, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (fifth edition). Reg Anesth Pain Med 2025. doi:10.1136/rapm-2024-105766
  12. Horlocker TT, Vandermeuelen E, Kopp SL, et al. ASRA evidence-based guidelines (fourth edition). Reg Anesth Pain Med 2018;43(3):263–309, as summarized by OpenAnesthesia, “Regional anesthesia in patients receiving antithrombotic or thrombolytic therapy: part 2” (updated 2023-04-06): warfarin and INR before neuraxial block, and example intervals. Superseded by the fifth edition.
  13. Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery. Circulation 2024;150(19):e351–e442. doi:10.1161/CIR.0000000000001285. Bridging statements as given in the ACC “Key Points” (23 Sep 2024).
  14. Lyons MD, Pope B, Alexander J. Perioperative management of antithrombotic therapy (JAMA Clinical Guidelines Synopsis). JAMA 2024;332(5):420–1. doi:10.1001/jama.2024.5880 (risk-category definitions).
  15. du Breuil AL. Perioperative management of antithrombotic medications: guidelines from the American College of Chest Physicians. Am Fam Physician 2023;108(2):208–11 (procedure examples by bleed risk; DOAC continuation for minimal-risk procedures; longer holds with severe renal or hepatic impairment or CYP3A4 inhibitors; heparin restart 48 to 72 hours after high-bleed-risk surgery; post-operative LMWH prophylaxis while anticoagulation is delayed).

Educational reference only — not a substitute for clinical judgment, institutional protocols, or specialist advice. Calculations run in your browser; nothing you enter is sent or stored.