Prasugrel, a platelet-aggregation inhibitor [Effent in the US; Efent in the European Union] is stopped 7 days preoperatively, and Ticagrelor, [a platelet-aggregation inhibitor] 5 days preoperatively. For the anticoagulants (warfarin), the local anticoagulant service should be informed at the time of listing. If low risk (e.g., non-valvular atrial fibrillation), warfarin should be stopped 2 days preoperatively, the INR is checked on the surgical day, and continued if <2. Re-start on evening of surgery. If high risk, discuss with physician. For the DOACs, the recommended action is the same as for low-risk procedures.
In conclusion, the authors emphasized the importance of considering the indications for anti-thrombotic agents and the risk of thromboembolic events and hemorrhagic complications depending on the patient and surgery. Bridging anticoagulation should be considered when oral anticoagulants are discontinued.
“The most appropriate surgical procedure should be offered to the patient depending on the risk of haemorrhage perioperatively when anti-thrombotic agents are continued. When urgent surgery is required or when a patient’s case is complex, it is important to take a multidisciplinary approach to the perioperative management of anti-thrombotic agents,” they said.