Never give a naked hold instruction. Record the drug, indication, last dose, kidney function, procedure bleeding risk, thrombotic risk, exact restart condition, and named owner.
1 · IdentifyExact anticoagulant/antiplatelet, dose, last administration, adherence, interacting drugs, and indication.
3 · Write the planLast dose date/time, whether bridging applies, day-of-procedure checks, restart gate, and contact for delay/bleeding.
A
Representative elective interruption windows
verify local table
Drug
Low/moderate bleed-risk procedure
High bleed-risk procedure
Variables that lengthen hold
Apixaban / rivaroxaban / edoxaban
Usually omit 1 full day before plus no procedure-day dose
Usually omit 2 full days before plus no procedure-day dose
Kidney dysfunction, interacting drugs, neuraxial or exceptionally high-consequence bleeding
Dabigatran
Commonly 1–2 days
Commonly 2–4 days
CrCl is decisive. Use Cockcroft–Gault and the procedural table
Warfarin
Often stop about 5 days when interruption is needed. Check INR near procedure and use indication-specific target
High baseline INR, liver disease, interacting drugs
Full omitted days are not elapsed hours. Friday 20:00 final apixaban dose → Monday 08:00 surgery is 60 hours. PAUSE excluded CrCl <25 for apixaban and <30 for dabigatran/rivaroxaban. Edoxaban was not studied. Minimal-risk procedures may need less interruption. Neuraxial and specialty procedures need their own plan.
B
Bridging & antiplatelets
exceptions, not reflexes
DOACs generally need no therapeutic heparin bridge. Postoperative VTE prophylaxis is a separate decision.
AF on warfarin routine bridging is discouraged because bleeding rises without a usual thromboembolic benefit.
CHEST suggests against elective bridging for mechanical valves/VTE. AHA/ACC allows selected very-high-risk exceptions. Resolve the indication and event date with the managing specialist.
Recent PCI / DAPT do not stop either agent casually. Define stent date/type, ACS indication, and procedural urgency, then contact interventional cardiology.
Aspirin continuation depends on indication and procedure. Primary-prevention aspirin is not equivalent to recent-PCI therapy.
Practice boundary: verify the procedure bleeding-risk matrix, Cockcroft–Gault cutoffs, neuraxial rules, mechanical-valve bridging criteria, and PCI/DAPT escalation process.
2 · Define exposureDrug, dose, last time, kidney/liver function, concomitant antiplatelet/NSAID, available drug-specific assay.
3 · Control sourceCompression, endoscopy, interventional radiology, surgery, obstetrics, or neurosurgery as the site requires.
A
What counts as major
activate a pathway
ACC major bleeding: a critical site, hemodynamic instability, hemoglobin fall ≥2 g/dL, or transfusion ≥2 units of red cells. A dangerous evolving bleed can require action before those laboratory thresholds.
Hold/reverse the responsible anticoagulant when indicated. Record the protected indication and plan reassessment. Secondary-prevention aspirin in GI bleeding has a separate continuation/restart rule.
B
Reversal map
availability + current guidance
Exposure
Major/life-threatening bleed direction
Checks and cautions
Warfarin
4-factor PCC + IV vitamin K under the current reversal standard
INR, weight/dose standard, thrombosis risk. Plasma if PCC is unavailable or contraindicated
Dabigatran
Idarucizumab 5 g IV (two 2.5-g vials). Dialysis may help selected persistent exposure with kidney failure
Time, renal function, thrombin time/aPTT limitations, rebound
Factor Xa inhibitor
4F-PCC may be used off label under the specialist pathway. Andexxa U.S. Sales ended 22 December 2025 after FDA judged risks to outweigh benefit
Time, renal function, calibrated anti-Xa if available, thrombosis risk. Current availability matters
UFH
Protamine based on heparin received recently
aPTT/anti-Xa context. Hypotension/anaphylactoid reaction if given rapidly
Anti-Xa may help in selected cases. Kidney dysfunction prolongs exposure
Antiplatelet
Stop when appropriate. Use the current hemostatic/critical-bleed pathway and urgent specialist input
Platelets are not a universal antidote. Aspirin-associated spontaneous ICH without emergency surgery: platelet transfusion is harmful
C
Laboratory interpretation
do not over-trust screens
Normal PT/aPTT does not reliably exclude clinically important Xa-inhibitor exposure.
A normal thrombin time can exclude clinically relevant dabigatran when the local assay is sensitive. A normal aPTT cannot reliably exclude it.
Use calibrated drug-specific anti-Xa when available and when the result will change management.
Do not delay life-saving source control or indicated reversal while waiting for a send-out assay.
Practice boundary: verify PCC dosing, reversal-agent availability and regulatory status, assay interpretation, transfusion thresholds, and massive-hemorrhage integration before treatment.
A
Post-procedure restart
representative timing
Situation
Typical direction after secure hemostasis
Do not proceed until
Low/moderate bleed-risk procedure
DOAC often resumes at about 24 h. Warfarin often the evening of or next day
Procedure team confirms hemostasis, oral route, and no re-operation concern
High bleed-risk procedure
DOAC often resumes about 48–72 h. Individualize prophylactic-dose VTE prevention
Hemostasis, drain/output trend, hemoglobin, renal function, and procedural approval
Neuraxial catheter/procedure
Follow the current anesthesia/ASRA interval exactly
Catheter timing and drug-specific interval are documented
B
After a bleed: five restart questions
answer all five
Is the indication still present? AF stroke prevention, recent VTE, mechanical valve, LV thrombus, recent PCI, or another protected state.
How dangerous is interruption? Specify valve type, VTE recency, CHA₂DS₂-VASc context, thrombus, and coronary timing. Avoid vague “high risk.”
Is the source controlled? Endoscopic/procedural result, imaging, hemodynamics, hemoglobin, drain/output, and rebleed plan.
Can the regimen be safer? Correct dose/renal function, remove unnecessary aspirin/NSAID, treat ulcer/HTN, shorten triple therapy, address adherence/alcohol/falls.
Who owns restart? Exact date or objective gate, agent/dose, follow-up labs, and contingency if the gate is not met.
C
High-consequence sites
multidisciplinary decision
Bleed
Restart frame
Intracranial
Neurology/neurosurgery + cardiology/hematology. Cause, location, stability imaging, BP, indication, and alternatives determine timing. Avoid a generic day-number rule.
GI
Treat lesion and reversible risks. Early restart is often favored once hemostasis is secure when thrombotic risk is meaningful, but timing is lesion- and course-specific.
Retroperitoneal / operative
Require source stability, hemoglobin trend, anatomy/drain plan, and procedural clearance. Consider staged prophylactic then therapeutic strategy only when explicitly agreed.
Copy-ready ledger: “Held ___ (indication ___), last dose ___, because ___. Hemostasis gate ___. Plan to restart ___ at ___ dose on/when ___. Labs ___. Owner ___. If not met, contact ___.”
Original schematic. The later applicable interval governs. New bleeding, traumatic puncture or renal decline requires reassessment.
A
Build the hold from first principles
not calendar folklore
Procedure: minimal, low/moderate, high, or neuraxial/high-consequence bleeding risk.
Drug exposure: last dose and adherence, formulation, interacting P-gp/CYP3A drugs, kidney/liver function.
Thrombotic risk: indication, timing of VTE/PCI/thrombus, mechanical valve type/location, prior event during interruption.
Plan: last dose, bridging decision, day-of checks, prophylaxis, therapeutic restart gate and owner.
B
Class-specific cautions
representative, verify
Class
What changes the window
Day-of / restart issue
Dabigatran
Most kidney-dependent DOAC. CrCl and high-bleed/neuraxial consequence can extend the hold substantially
Thrombin time can help exclude meaningful presence. Restart only after hemostasis and route
Check INR near procedure. Low-dose vitamin K correction only under the procedural plan
UFH infusion
Short half-life. Indication and aPTT/anti-Xa pathway
Often stopped hours rather than days before. Restart after procedural hemostasis
Therapeutic LMWH
Kidney function, once vs twice daily, weight, neuraxial consequence
Last therapeutic dose is usually earlier than prophylactic dosing. Partial protamine reversibility
C
Thrombotic-risk triggers for specialist planning
do not improvise bridging
Mechanical valve, especially mitral or older thrombogenic design • recent stroke/systemic embolism • very recent VTE • severe thrombophilia with recent/recurrent event • active intracardiac thrombus.
Recent ACS/PCI or complex stent anatomy • interruption before the intended antiplatelet minimum • prior stent thrombosis.
Urgent procedures where there is insufficient time for ordinary clearance: proceduralist, anesthesia, pharmacy/hematology, and the indication-owning service decide reversal versus delay.
Practice boundary: Use the agent/CrCl table and worked DOAC calendar. Stable renal estimates do not capture rapidly changing AKI. Pacemaker/ICD procedures may favor uninterrupted warfarin over interruption plus bridging.
A
Recent PCI / DAPT checklist
call interventional cardiology
Question
Why it changes the plan
When and why was PCI done?
For elective surgery requiring antiplatelet interruption after DES, ideally ≥12 months after ACS and ≥6 months after chronic-disease PCI. Time-sensitive surgery may be considered ≥3 months if delaying is riskier
Aspirin, clopidogrel, ticagrelor, prasugrel have different offsets. Genotype/response and stroke history may matter
Can the procedure wait or change?
Delay, minimally invasive technique, continuation of aspirin, or alternative anesthesia can avoid a dangerous interruption
Who restarts?
Postoperative omission is a preventable stent-thrombosis risk. Specify date/time and loading question
B
Antiplatelet principles
indication matters
Primary-prevention aspirin has a different interruption threshold from secondary prevention or recent PCI.
Aspirin continuation is often favored for many procedures when coronary risk outweighs manageable bleeding, but exceptions are procedure-specific.
P2Y12 interruption after interruption is authorized: clopidogrel 5–7, prasugrel 7–10, ticagrelor 3–5 days for platelet recovery. Neuraxial ticagrelor requires 5 days.
Triple therapy should have a documented stop date for aspirin and a clear OAC/P2Y12 plan.
Platelet function testing is not a universal substitute for recommended interruption intervals. Use only in a defined pathway.
Bridging antiplatelets may be considered in selected high-risk PCI patients. Heparin does not replace DAPT. Interventional cardiology owns the plan.
C
Neuraxial / deep block safety
anesthesia owns the interval
Neuraxial bleeding is a low-frequency, catastrophic-consequence event. Follow the current anesthesia/ASRA agent-, dose-, kidney-, and catheter-specific table exactly.
Document last dose → needle/catheter removal → first postoperative dose. High-dose apixaban/rivaroxaban: ≥72 hours before and ≥24 hours from needle/removal to next dose. Longer surgical intervals still apply. Dose category depends on indication as well as dose.
New weakness, sensory loss, severe back pain, or bowel/bladder dysfunction after neuraxial instrumentation while anticoagulated is an emergency: stop drug, urgent imaging and spine/neurosurgical pathway.
Stop the anticoagulant and identify agent/last dose. Obtain urgent CT and activate BP management, reversal, neurology/neurosurgery and critical care. Do not delay indicated reversal for routine coagulation assays that cannot exclude DOAC effect.
Aspirin-associated spontaneous ICH: no platelet transfusion if emergency surgery is not planned. Emergency neurosurgery or severe thrombocytopenia needs its own pathway. Desmopressin benefit remains uncertain.
Restart depends on serial imaging, cause/site, BP and indication. Mechanical valves need separate early-resumption review. AF timing and possible left atrial appendage strategies cannot be transferred to mechanical valves.
B
GI bleeding
treat lesion + regimen
Phase
Actions
Acute
Resuscitate and control the lesion. Reserve anticoagulant reversal for selected severe/life-threatening exposure. ACG-CAG discourages routine reversal in the broader acute GI-bleed population
Before restart
Secondary-prevention aspirin: ACG-CAG suggests continuing. If held, resume the day endoscopic hemostasis is confirmed. This is not a primary-prevention aspirin rule
Regimen redesign
Treat ulcer/H. pylori or variceal cause. Review OAC timing, kidney function and dose. Remove unnecessary aspirin/NSAID, shorten avoidable triple therapy and provide GI protection when indicated
C
Trauma, retroperitoneal & postoperative
anatomy + trajectory
Image/source control and compartment effects matter more than visible blood loss.
Trend hemodynamics, hemoglobin, drain/output and repeat imaging when the course requires it.
Prophylactic VTE prevention and full therapeutic anticoagulation are separate decisions.
Postoperative restart requires procedural confirmation, not only a clock.
When full-dose therapy is delayed, document mechanical prophylaxis and whether/when prophylactic anticoagulation begins.
State: bleed site/cause and control. Repeat imaging/hemoglobin. Original antithrombotic indication and untreated risk. Modifiable bleeding risks. Alternatives. Proposed agent/dose/date or objective gate. Responsible service. Patient preference and contingency.
Practice boundary: ICH resumption, mechanical-valve exceptions, lesion-specific GI timing, trauma prophylaxis, and LAAO alternatives require multidisciplinary decisions.