It is estimated that 6 million patients with atrial fibrillation worldwide will require anticoagulation interruption per year for an invasive procedure, or about one in six patients annually,1 and this number is increased when patients with mechanical valves and venous thromboembolism (VTE) are included. Periprocedural interruption of anticoagulation has several components: a) need for interruption; b) pre-procedure interruption timing; c) timing of post-procedure resumption; d) need for parenteral bridging anticoagulation; and e) urgent reversal for emergent procedures. Four primary guidelines help inform periprocedural anticoagulation interruption: the 2012 American College of Chest Physicians (ACCP) guidelines,2 the 2017 American College of Cardiology (ACC) Expert Consensus Decision Pathway which offers guidance for patients with atrial fibrillation only,3 the 2018 American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines,4 and the 2018 American Society of Hematology guidelines for VTE.5
LOW-RISK PROCEDURES THAT DO NOT NEED ORAL ANTICOAGULATION INTERUPTION
The ACCP guidelines suggest patients undergoing most dental procedures, minor dermatologic procedures, and cataract surgery do not require interruption of warfarin2 but these guidelines do not address patients who are receiving direct oral anticoagulants (DOAC). The ACC consensus pathway recommends not interrupting warfarin for patients with no clinically important or low bleeding risk and includes a series of tables in the appendix listing procedural bleeding risks from multiple specialty societies.3 The PAUSE management study, which assessed the periprocedural management of DOAC-treated patients, only assessed procedures that required anticoagulant interruption and was published after the ACCP and ACC guidelines.1 Based on expert opinion, in DOAC-treated patients who require a minor dental, skin, or cataract procedure, it is likely safe to continue DOACs without interruption.
PRE-PROCEDURE INTERRUPTION TIMING
An international normalized ratio (INR) should be checked about 7 days prior to invasive procedures and warfarin should be held about 5 days before if the INR is between 2 and 3 with longer or shorter hold time for higher and lower INRs.2,3 Checking an INR 1 day before procedures can detect elevated values and most can be corrected with 1 mg of oral vitamin K.6 For patients undergoing neuraxial blockade, ASRA recommends holding warfarin for 5 days, and the INR normalized prior to a block.4
Direct Oral Anticoagulants (DOAC)
The ACC consensus pathway recommends timing based on creatinine clearance (CrCl) and bleeding risk.3 For low bleeding risk procedures and Xa inhibitors, hold > 24 hours, > 36 hours, and > 48 hours (or check DOAC level using an agent specific test) for CrCl of > 30, 15–29, or < 15 mL/min, respectively. For uncertain, intermediate, or high-risk bleeding procedures and Xa inhibitors, hold > 48 hours for CrCl > 30 mL/min and > 72 hours (or measure DOAC level) for CrCl < 30 mL/min.3 For dabigatran and low-risk bleeding procedures, hold for > 24 ...