Clin Geriatr Med 22 (2006) 199 213

Perioperative Management of
Oral Anticoagulation
Martin ODonnell, MB, Clive Kearon, MB, PhDT
McMaster University and Henderson Research Centre, 711 Concession Street,
Hamilton, ON L8V 1C3, Canada

Chronic anticoagulant therapy with vitamin K antagonists (eg, warfarin) requires temporary interruption before surgery because anticoagulation is associated with excessive operative bleeding [14]. Warfarins antithrombotic effect
takes days to recede after it is stopped and a similar length of time to re-establish
after it is restarted [5]. During the period of anticoagulation cessation, patients are
at increased risk of thromboembolism [14]. Elderly patients constitute a large
proportion of patients who are treated with oral anticoagulants and present a
greater than average risk of both thromboembolism and bleeding during this
period [6]. Consequently, there is considerable uncertainty about the optimal
approach to perioperative management of anticoagulation that maximizes patient
safety with efficient health care delivery. Developing a rational approach requires
the clinician to estimate the risks of thrombosis and bleeding that are associated
with different approaches to management (Box 1) [1]. The risk of venous and
arterial thromboembolism associated with different conditions, and the relative risk reduction for thromboembolism achieved by anticoagulation, are summarized in Table 1 [1]. In general, arterial thromboembolism is associated with
far greater mortality (about 40% of events) and major disability (about 20% of
events) [1] than recurrent venous thromboembolism, which has an estimated
mortality of approximately 6% [7] and major disability of approximately 5% or
less in treated patients. In addition, because the risk of thromboembolism and
bleeding are often influenced by the surgical procedure, it is helpful to consider anticoagulant management separately for the preoperative and postoperative periods.

T Corresponding author.
E-mail address: [email protected] (C. Kearon).
0749-0690/06/$ see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.cger.2005.09.008
geriatric.theclinics.com

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Box 1. Factors influencing perioperative anticoagulant

management
Risk of thromboembolism without anticoagulation
During the preoperative period
During the postoperative period
Risk reduction for thromboembolism with
Oral anticoagulation
Unfractionated or low-molecular-weight heparin
Incremental risk of bleeding with unfractionated heparin or
low-molecular-weight heparin bridging therapy
During the preoperative period
During the intraoperative period
During the postoperative period
Consequences of thromboembolism (venous or arterial)
Consequences of bleeding
Patient preference (eg, fear of thromboembolism or bleeding)
Cost of unfractionated heparin or low-molecular-weight
heparin bridging therapy

Accordingly, based on an individual assessment of risk factors for arterial or

venous thrombosis and the risk of postoperative bleeding, this article outlines the
preoperative and postoperative approach to anticoagulant management, following
a brief description of the therapies most commonly used in the perioperative
period. Furthermore, the prevention of arterial thromboembolism is considered
separately from those whose indication is the prevention of venous thrombosis
(Fig. 1).

Perioperative bridging therapy

In this article, the term bridging therapy refers to the use of therapeuticdose unfractionated heparin (UFH) or low-molecular-weight-heparin (LMWH)
and does not include lower doses of UFH and LMWH that are used to prevent
venous thromboembolism [8]. Based on the predicted decline in the international
normalized ratio (INR) (starts to fall at approximately 29 hours after the last dose
of warfarin, and then decreases with a half-life of approximately 22 hours) it is
reasonable to start bridging therapy approximately 60 hours after the last dose of
warfarin (eg, third morning after last evening dose) [912]. Historically, intravenous UFH was used as bridging therapy because it has a short half-life
(60 minutes) and is readily reversed [8]. Intravenous administration necessitates
hospitalization before surgery, however, making intravenous UFH inconvenient
and expensive. More recently, the use of subcutaneous LMWH has allowed

perioperative management of oral anticoagulation

201

Table 1
Rates of thromboembolism associated with different indications for oral anticoagulation and risk
reduction with anticoagulation
Indication

Control rate

% Risk reduction

Venous thromboembolism
Acute venous thromboembolism
01 month
13 month
Recurrent venous thromboembolismb

40%/montha
10%/2 montha
15%/ya

80
90
90

4.5%/y
12%/y
8%/y

75c
75c
75c

15%/month

75c

Arterial thromboembolism
NVAF
NVAF and previous embolism
Mechanical heart valve
Acute arterial embolism
01 month

Abbreviation: NVAF, nonvalvular atrial fibrillation.

a
An increase in the risk of venous thromboembolism associated with surgery (estimated to be
100-fold) is not included in these rates.
b
Last episode of venous thromboembolism more than 3 months previously, but require longterm anticoagulation because of high risk of recurrence.
c
Risk reduction with oral anticoagulation; risk reduction with bridging therapy is uncertain but
expected to be less (see discussion).
Adapted from Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery.
N Engl J Med 1997;336:150611; with permission.

bridging therapy to be administered to outpatients. Outpatient therapy seems to

be feasible and safe in elderly patients provided they have no contraindication,
such as significant renal impairment [13]. With this approach, doses of LMWH
that are recommended for treatment of venous thromboembolism are administered once [10,14] or twice [12,15] daily, generally for 3 days before surgery.
The authors group recently completed a prospective cohort study (N = 102) that
measured anti-Xa LMWH levels shortly before surgery or invasive procedure in
consecutive patients receiving a standardized regimen of preoperative LMWH
(enoxaparin, 1 mg/Kg twice-daily, last dose given 12 hours before surgery).
It was observed that residual anticoagulant activity was present in most patients. Importantly, in two thirds the anti-Xa level was 0.5 IU/mL [16]. Based
on this observation and others [17,18], the authors practice is to administer a
twice-daily regimen with the last dose (eg, approximately 100 U/kg of LMWH)
given more than 24 hours before surgery or invasive procedure.
Perioperative bridging LMWH therapy has not been evaluated in randomized
trials. Two large cohort studies, however, have studied the safety and feasibility
of bridging therapy with LMWH [11,12]. Kovacs and coworkers [11] recruited
224 patients at risk of arterial embolism (112 with prosthetic valves and 112 with
atrial fibrillation, mean age 70 years), who required temporary interruption of
warfarin, to receive a standardized regimen of perioperative LMWH. In this
prospective cohort study, LMWH was started 3 days before surgery (dalteparin,

IVC Filter

Yes

Last VTE 2-4 weeks

No IVC filter

Minor Surgery

Last VTE <2 weeks

Stop warfarin 4 days preop

Bridging when INR <2.0

No

Bridging
when INR <2

Yes

No Bridging

No

Immobilized preop

Stop warfarin
4 days preop

>3 months

Stop warfarin 5 days preop

No bridging

Last event

Venous

&

Major Surgery

Stop warfarin
5 days pre-op
No bridging

Stop warfarin
4 days pre-op
Consider bridging

1-3 months

Non-High
Embolic Risk

High
Embolic Risk

Target INR 2.5

Indication for warfarin

odonnell

Can defer surgery until >1 or >3 months

<1 month

Stop warfarin 5 days pre-op

Consider bridging

Target INR 3.0

Arterial

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perioperative management of oral anticoagulation

203

200 U/kg once-daily on the third and second days before surgery and 100 U/kg
on the morning before surgery); was not given on the day of surgery; and was
restarted the day after surgery (dalteparin, 200 U/kg daily or fixed low-dose
5000 U daily if patient were judged to be at high-risk of postoperative bleeding)
and was given for at least 4 days postoperatively and until the INR N1.9. During
the 5-day preoperative and 90-day postoperative periods, there were eight episodes of thromboembolism, of which two were considered cardioembolic and
occurred on postoperative days 14 (transient ischemic attack) and 42 (ischemic
stroke). Importantly, six of the eight episodes occurred in patients who had postoperative warfarin therapy withheld or deferred because of bleeding. Fifteen
episodes of major bleeding were reported, of which eight occurred during or
within 6 hours after surgery. There were no episodes of thromboembolism or
major bleeding preoperatively [11].
Douketis and colleagues [12] reported the frequency of thromboembolism
and major bleeding in a registry of 650 consecutive patients at risk of arterial
embolism (215 with mechanical valves, 346 with atrial fibrillation, 89 with other
indication; mean age 68 years) who required temporary interruption of warfarin.
Warfarin was discontinued 5 days (INR target 23) or 6 days (INR target 2.53.5)
before surgery. The INR was measured on the third or fourth day before
the procedure and preoperative LMWH (dalteparin, 100 U/kg twice-daily) was
started if the INR was less than 2.5, with last dose given 12 hours before surgery.
LMWH was restarted the day after surgery (dalteparin, 100 U/kg twice-daily) in
those considered not to be at high-risk of postoperative bleeding (surgical procedure considered to be associated with a low risk of bleeding and primary hemostasis established postoperatively). During the study period (5 days preoperatively
and approximately 2 weeks after surgery) there were four episodes of thromboembolism, of which two were cardiac arrests, one was a systemic embolism, and
one was a transient ischemic attack; all occurred in the postoperative period.
Six episodes of major bleeding occurred, all in the postoperative period [12].
Although these studies [11,12] support the feasibility of bridging therapy
with LMWH, clinical trials are required to determine whether the benefit of
bridging therapy outweighs the associated risks of bleeding. Currently, it is
generally recommended that patients with the highest risk of arterial or venous
thromboembolism, who require interruption of oral anticoagulant therapy for
surgery, should receive therapeutic-dose heparin therapy (UFH or LMWH) during much of the interval when the INR is subtherapeutic [25].

Preoperative management of anticoagulation

Certain surgical procedures are associated with a low risk of bleeding. Consequently, there is uncertainty about the need to reverse anticoagulation for some
Fig. 1. Algorithm outlining an approach to the management of anticoagulation before elective surgery.
INR, international normalized ratio; IVC, inferior vena cava; VTE, venous thromboembolism.

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invasive procedures. For example, it does not seem to be necessary for dental
extractions [5,19] (a local hemostatic agent may be used with more extensive
dental surgery [20]) or for extracapsular cataract removal under local anaesthetic
[21]. Similarly, the American Society for Gastrointestinal Endoscopy recommends that, because of a low associated risk of bleeding, diagnostic endoscopy
(upper endoscopy, colonoscopy, and flexible sigmoidoscopy) with or without
biopsy (but not polypectomy), diagnostic endoscopic retrograde cholangiopancreatography, and biliary stent implantation (without sphincterotomy) can be
performed with an INR of up to 2.5 [22]. In general, it is more acceptable to
perform surgical procedures while on anticoagulant therapy if the site of potential
bleeding is accessible (eg, mouth or skin) rather than remote (eg, percutaneous
biopsy of internal organs).
For surgery and invasive procedures associated with a moderate or high risk of
bleeding, vitamin K antagonists are stopped 4 to 5 days before surgery, depending on the targeted anticoagulant intensity (see Fig. 1). In patients whose INR is
2 to 3 (ie, target INR of 2.5), it takes about 4 days for the INR spontaneously to
fall to 1.5 or less in most (approximately 95%) patients [9], an intensity of anticoagulation that is not expected to be associated with an increase in intraoperative
bleeding [9,2327]. If the INR is 2.5 to 3.5 (ie, target INR of 3), this is expected
to take 5 days. There is evidence that the rate of decline in INR is slower in
elderly patients [28]. Although the authors usually recommend that the INR be
measured on the day before surgery, they take particular care to ensure it is
measured in elderly patients (75 years) to determine if it has decreased
adequately. If on the morning before surgery the INR is 1.6 or 1.7, they generally
give 1 mg, and if the INR is 1.8 or higher, they generally give 2 mg of vitamin K
orally to accelerate reversal of anticoagulation and then repeat the INR the day
of surgery [29]. In general, fresh frozen plasma should be avoided for elective surgery.
Another approach to management in this setting is to shorten the interval when
the INR is subtherapeutic by withholding fewer dose of warfarin preoperatively
while giving a small dose of oral vitamin K (eg, 1 mg) to accelerate reversal of
anticoagulation. The safety of this approach is not known, and although it seems
reasonable for most patients if surgery needs to be performed before the INR can
spontaneously decrease to an acceptable level, unless accompanied by bridging
therapy, this practice is discouraged for patients with mechanical heart valves
[30,31].

Arterial thromboembolism
Prevention of systemic embolism with oral anticoagulation (vitamin K antagonists) is most commonly used in patients with atrial fibrillation or another cardiac source of arterial thromboembolism (eg, valvular heart disease [native or
prosthetic]) [5]. Patients with nonvalvular atrial fibrillation have an average risk
of systemic embolism of about 4.5% per year in the absence of antithrombotic

perioperative management of oral anticoagulation

205

therapy [32]. In individual patients, this risk varies from about 1% to 20%,
depending on the prevalence of risk factors (ie, previous embolism, hypertension,
age 75 years, left ventricular dysfunction, diabetes, mitral stenosis) [3235].
The average rate of major thromboembolism in nonanticoagulated patients
with mechanical heart valves is estimated to be 8%, with the risk in individuals
also varying widely according to the prevalence of risk factors (ie, caged ball or
disk valves, mitral position, atrial fibrillation, previous embolism, age 70 years)
[3639]. Previous thromboembolism is the single most important risk factor for
ischemic stroke in patients with atrial fibrillation [32,34,35,40] and it is also an
important risk factor in patients with prosthetic heart valves [38,39]. Consequently, the period of subtherapeutic oral anticoagulation should be kept to a
minimum in patients with previous embolism, and in others who are at highest
risk for embolism (see Fig. 1).

Efficacy of heparin in prevention of systemic thromboembolism

Although there is good evidence that UFH and LMWH are effective at
preventing venous thromboembolism [8,41], this is less certain for the prevention of cardioembolism, particularly with the use of LMWH. In the only trial to
evaluate the efficacy of LMWH for the reduction of early recurrent stroke in
patients with atrial fibrillation exclusively, dalteparin, 100 IU/kg twice-daily, was
not shown to be superior to aspirin therapy (odds ratio = 1.1 in favor of aspirin,
95% confidence interval 0.62.2) [42]. Similarly, subgroup analyses of other
studies that have evaluated LMWH in acute ischemic stroke and subsequent
meta-analyses have also failed to demonstrate a benefit in reduction of systemic embolism over aspirin [4345]. In the International Stroke Trial, however,
UFH (5000 or 12,500 IU subcutaneously twice-daily) was more effective than
aspirin at preventing early recurrent stroke (within 14 days) in the subgroup of
patients with atrial fibrillation (N = 3169) [46]. Rates of recurrent ischemic stroke
were 4.9%, 3.4%, and 2.3% in the non-UFH, UFH 5000-IU, and UFH 12,500-IU
groups, respectively (P = .001) [46]. In addition, therapeutic or near-therapeutic
doses of UFH approximately halves the frequency of stroke associated with acute
myocardial infarction in the absence of treatment with thrombolytic therapy and
aspirin (but not with such therapy), supporting that UFH can reduce cardioembolism [47].
There are less data relating to the efficacy of UFH and LMWH for the prevention of embolism in patients with mechanical heart valves. Indirect comparisons suggest that subcutaneous UFH is substantially less effective than oral
anticoagulants at preventing thromboembolic complications in pregnant women
with mechanical heart valves; however, less than currently recommended therapeutic doses of UFH were often used in these patients [48,49]. Although it cannot
be concluded that LMWH does not reduce the risk of thromboembolism in patients with mechanical heart valves when oral anticoagulation is interrupted [50],
taken together these data suggest that UFH, and particularly LMWH, are less
effective than warfarin at preventing cardioembolism.

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Bridging therapy with heparin

Despite uncertainty about efficacy, most authorities recommend use of bridging therapy for patients with the highest risk of embolism [24,8,5153]. With
mechanical heart valves, this includes those for which a higher (eg, target INR 3;
range 2.53.5) intensity of anticoagulation is recommended (ie, tilting disk and
bileaflet mitral valves, bileaflet aortic valves with atrial fibrillation, caged ball or
caged disk valves, any valve with previous embolism) [39]. With atrial fibrillation, this includes those with a history of embolism or multiple risk factors
[32,34,35,40]. Because current evidence suggests that therapeutic dose LMWH
is not effective at preventing ischemic stroke in patients with atrial fibrillation
[42,43], the authors rarely use bridging LMWH therapy in such patients.
Patient and physician preference
After a discussion of the risk and benefits of bridging therapy in patients
with mechanical heart valve or atrial fibrillation, some patients express a preference either to receive or not to receive such therapy. Their decision may be
influenced by previous good or bad experience with bridging therapy; aversion to
subcutaneous injections (self-administered, or by another); fear of stroke; or cost
implications. Similarly, referring physicians (eg, cardiologists, cardiac surgeons)
may have a strong preference that their patients receive bridging therapy. Because preoperative bridging therapy may reduce embolism and is associated
with a low risk of major bleeding, the authors do not discourage its use, particularly in patients with prosthetic heart valves where there is less evidence
challenging the efficacy of bridging therapy than there is for those with atrial
fibrillation [42,43,54].
Venous thromboembolism
Oral anticoagulation with vitamin K antagonists is indicated for the prevention of recurrent venous thromboembolism, a risk that declines rapidly during
the 3 months after an acute episode [55,56]. It is estimated that stopping anticoagulation within 1 month of an acute event is associated with a very high
risk of recurrent venous thromboembolism (ie, 40% over a 1-month period) (see
Table 1) and that this risk is intermediate if anticoagulants are stopped during
the second and third months of treatment (ie, 10% over a 2-month period [1]).
If feasible, surgery should be deferred following an acute episode of venous
thromboembolism until patients have received at least 1 month, and preferably
3 months, of anticoagulation (see Fig. 1). If this is not feasible and surgery is
performed within 1 month of an acute event, bridging therapy should be used
while the INR is less than 2. If it is necessary to perform surgery within 2 weeks
of an acute episode of venous thromboembolism, the risk of pulmonary embolism is probably acceptable if bridging therapy is withheld for 18 hours or less
(eg, with intravenous UFH, 6 hours preoperatively and 12 hours postoperatively)
and the duration of surgery is short (eg, 1 hour or less). Consequently, patients
who do not have major surgery and do not have a high risk of postoperative

perioperative management of oral anticoagulation

207

bleeding can be managed with bridging therapy. Patients who have major surgery within 2 weeks of an acute episode of proximal deep vein thrombosis or
pulmonary embolism, however, should have a vena caval filter inserted preoperatively or intraoperatively [1]. Currently available temporary filters allow
removal of the filter in the postoperative period, when it becomes safe to reestablish oral anticoagulation.
If the most recent episode of venous thromboembolism occurred within
1 and 3 months previously, warfarin should only be withheld for four doses to
minimize the period of thrombotic risk; however, unless patients are immobilized (ie, already hospitalized) neither bridging therapy nor prophylactic doses
of UFH or LMWH are necessary preoperatively. If patients are immobilized
in hospital before surgery, they should receive prophylactic doses of UFH or
LMWH when the INR decreases to less than 1.6. The INR of outpatients can be
checked the day before surgery and, depending on its value, a single dose of
oral vitamin K or subcutaneous LMWH can be considered at that time. Three
months or greater of anticoagulation is usually reserved for patients with multiple episodes of venous thromboembolism; a single episode of unprovoked
thrombosis; or thrombosis in association with a persistent risk factor, such as
active malignancy. Interruption of warfarin therapy during this phase of treatment is estimated to be associated with a much lower risk of thromboembolism
than if it is stopped during the first 3 months of therapy (eg, 10%15% per year).
Consequently, it is reasonable to withhold five doses of warfarin before surgery in
patients who have already been treated with 3 or more months of anticoagulation and not use bridging therapy.

Postoperative management of anticoagulation

Major surgery is associated with a marked increase in the risk of venous thromboembolism; in the short term, this is estimated to be a 100-fold increase in risk
[1]. Unlike venous thromboembolism, however, the increase in arterial embolism
associated with nonvascular surgery has not been adequately quantified.
Recent surgery is a major risk factor for anticoagulant-induced bleeding
[1]. Whereas bleeding is uncommon when warfarin is started after major surgery
[8,27,57,58], bleeding is expected to be substantial if therapeutic doses of UFH or
LMWH are administered within days of operation [57]. For example, when both
are started within 24 hours of major orthopedic surgery, prophylactic doses of
LMWH (ie, less than half the dose used for bridging therapy) are associated with
more bleeding than warfarin [8,5759]. Although the consequences of an episode of major bleeding in the postoperative period (eg, case-fatality estimated
at 3%) [60,61] are generally less severe than those of an episode of thromboembolism, because the absolute risk of thromboembolism before re-establishing
oral anticoagulation is often extremely low, administration of bridging therapy
has the potential to do more harm than good during this interval [1]. Because
there is a delay of about 12 to 24 hours after warfarin administration before

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Start warfarin day of surgery

Indication for warfarin
Arterial

Venous

Target INR 3.0 or other

High embolic risk

Yes

Minor
surgery

Previous thromboembolism
within 3 months

No

No

Yes
Has IVC filter

Major
surgery
Yes

Consider
Bridging
therapy

Prophylactic dose LMWH or UFH until INR 1.8

or until hospital discharge

No

Bridging
therapy

Fig. 2. Algorithm outlining an approach to the management of anticoagulation after elective surgery.
INR, international normalized ratio; IVC, inferior vena cava; LMWH, low-molecular-weight heparin;
UFH, unfractionated heparin.

the INR begins to increase, warfarin should be restarted as soon as possible after
surgery unless patients have additional invasive procedures planned or are actively bleeding (Fig. 2).
Arterial thromboembolism
In patients with the highest risk of arterial embolism, it is reasonable to
use bridging therapy after surgery provided the risk of bleeding is minimal
(eg, minor surgical or diagnostic procedures) (see Fig. 2).
If intravenous UFH is being used for postoperative bridging therapy, it
should be started without a loading bolus-dose, no sooner than 12 hours after
surgery, at a rate of no more than 18 U/kg/h [62]. In the absence of a loading
dose, the first activated partial thromboplastin time measurement should be
deferred for 12 hours for a stable anticoagulant response to have been attained.
Compared with therapeutic-dose subcutaneous LMWH, intravenous UFH has
the advantage that it is rapidly eliminated when stopped, and can be effectively
reversed by protamine sulfate if bleeding occurs [63]. If therapeutic-dose subcutaneous LMWH is being used, it should probably not be started until approximately 24 hours after surgery. With hospitalized patients, the LMWH dose
can be increased in a stepwise fashion over 36 hours, starting with a prophylactic dose within 12 hours of surgery. Twice-daily dosing may be preferable to once-daily dosing in the early postoperative period because lower
peaks of anticoagulant effect are induced, and the smaller twice-daily dose is

perioperative management of oral anticoagulation

209

expected to be eliminated sooner if bleeding occurs close to the time of injection; however, once-daily [10,11] and twice-daily [12,13] regimens have been
used postoperatively.
Bridging therapy is not recommended after surgery that is associated with a
moderate or higher risk for bleeding, even if patients are considered to have
a high risk of arterial embolism [1]. Instead, subcutaneous UFH or LMWH, in
doses recommended for thromboembolism prophylaxis of high-risk patients,
should be given to hospitalized patients until the INR reaches 1.8 [8].
Venous thromboembolism
Because surgery is a major risk factor for venous thromboembolism, the
need for antithrombotic prophylaxis is much greater postoperatively than it is
preoperatively. Patients who have had an episode of venous thromboembolism
within 3 months of surgery are expected to have a very high risk of recurrence postoperatively. Consequently, bridging therapy is recommended in this
setting until the INR is 2 or greater, provided the surgeon does not believe that
the patient is at high risk for bleeding [1]. Although patients who have a vena
caval filter remain at high risk of recurrent venous thrombosis, they are at least
partially protected from pulmonary embolism [64] and, consequently, bridging
therapy can be avoided in these patients in the early postoperative period.
Provided there have been no previous episodes of thromboembolism within
3 months before surgery, postoperative bridging therapy is not indicated. Subcutaneous UFH or LMWH is recommended in doses used for venous thromboembolism prophylaxis of high-risk patients while the INR is less than 1.8 and
patients are hospitalized. Because there is a concern that restarting warfarin may
induce a transient hypercoagulable state in patients with protein C or protein S
deficiency [65], patients with these conditions should restart warfarin slowly,
at no more than the expected maintenance dose, and should receive at least
prophylactic doses of UFH or LMWH until the INR is 2 for 2 days.

Qualifying remarks
The recommendations outlined previously are strongly influenced by a number of assumptions, some of which are considered in greater detail. It is proposed
that, for most patients, warfarin is withheld preoperatively long enough for the
INR spontaneously to fall to a value of 1.5 or lower before surgery without
the need for bridging therapy. Because the INR is prolonged to some extent for
much of this time, it is estimated that this interruption of warfarin exposes
patients to a small risk of thromboembolism preoperatively (ie, equivalent to the
thromboembolic risk associated with 1 day of no anticoagulation) [6668]. For
the same reason, provided warfarin is restarted the day of surgery, it is estimated
that patients are exposed to a similar small risk of thromboembolism postoperatively while oral anticoagulant therapy is being re-established. It has also

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been assumed that the risk of thromboembolism associated with a day without
anticoagulation is one 365th part of the risk associated with a year without
therapy. Hence, a 10% per year risk of thromboembolism translates to a daily risk
of approximately 0.03%, or a 1 in 3650 probability of an event. If stopping oral
anticoagulation induces a transient rebound hypercoagulable state [1,4,69], or
starting anticoagulation induces a transient paradoxical hypercoagulable state
[65], the daily risk of thromboembolism may be underestimated. There is no
convincing clinical evidence, however, to support either of these phenomena
in unselected patients [69].
It is concluded that warfarin should be interrupted for as short a time as
possible (usually 4 or 5 days) when it is necessary to reverse oral anticoagulant
therapy. Most patients can then have invasive procedures performed without
the need for bridging therapy and, because of the associated risk of bleeding,
bridging therapy should generally be avoided within 2 days of major surgery.
Because this assessment is based on an interpretation of mostly indirect data, and
these data are open to different interpretations, however, uncertainty as to the
optimal management of such patients is acknowledged.
Finally, perioperative management of anticoagulation can cause anxiety for
patients, surgeons, anesthetists, and those that manage long-term anticoagulant
therapy. Good communication between all of these parties is essential to ensure
that an optimal management strategy is identified, that this strategy is then
successfully executed, and that the potential for recrimination is minimized in
the unlikely event of a serious thrombotic or hemorrhagic complication.

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