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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e50

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

6.7 Periprocedural Management

Recommendations for Periprocedural Management Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-R* 1 In patients with AF (excluding those with recent

stroke or TIA, or a mechanical valve) and on oral anticoagulation with either warfarin* or DOAC† who are scheduled to undergo an invasive procedure or surgery, temporary cessation of oral anticoagulation without bridging anticoagulation is recommended.1–4 B-NR†

1 A 2 In patients with AF on warfarin anticoagulation and

an annual predicted risk of thromboembolism of ≥5% undergoing pacemaker or defibrillator implantation or generator change, continued anticoagulation is recommended in preference to interruption of warfarin and bridging anticoagulation with heparin to reduce the risk of pocket hematoma.5–7

2a A 3 In patients with AF with CHA2DS2-VASc score ≥2 or

equivalent risk of stroke, on DOAC anticoagulation and undergoing pacemaker or defibrillator implantation or generator change, either uninterrupted or interrupted DOAC is reasonable.8–10

1 B-NR 4 In patients with AF on DOAC and scheduled to

undergo an invasive procedure or surgery that cannot be performed safely on uninterrupted anticoagulation, the timing of interruption of DOAC should be guided by the specific agent, renal function, and the bleeding risk of the procedure (Table 18).4,11,12

2a B-NR 5 In patients with AF on DOAC that has been inter-

rupted for an invasive procedure or surgery, in general, resumption of anticoagulation the day after low bleeding risk surgery and between the evening of the second day and the evening of the third day after high bleeding risk surgery is reasonable, as long as hemostasis has been achieved and further bleeding is not anticipated.4

3: Harm B-R 6 In patients with AF on warfarin anticoagulation, who

are undergoing surgeries or procedures for which they are holding warfarin, except in patients with mechanical valve or recent stroke or TIA, bridging anticoagulation with low-molecular-weight heparin should not be administered.1,3,13–15

*B-R LOE applies to the data on warfarin. †B-NR LOE applies to the data on DOAC. Synopsis Periprocedural anticoagulation management is driven by 2 competing aims: to hold the anticoagulant agent for the shortest possible time to minimize the risk of thromboembolism and to ensure coagulation parameters are as close to normal as possible at the time of the procedure to facilitate hemostasis and avoid intra- and postoperative bleeding. Considerations include the bleeding risk of the procedure, consequences of bleeding should it occur, patient-specific risk factors, and thrombotic risk while off anticoagulation. Invasive procedures and surgeries have been divided into high and low bleeding risks in several different classifications.16 Generally, endoscopic, dental extraction, many ophthalmologic procedures, and percutaneous vascular access, such as cardiac catheterization, are considered to be of low bleeding risk. Higher bleeding risk surgeries include intra-abdominal, pelvic, orthopedic, neurosurgical, cardiac, and transvenous lead extraction procedures. Very high bleeding risk procedures include neuraxial anesthesia and spinal surgery. Available data do not suggest high rates of bleeding from these procedures, although bleeding could cause significant consequences.17 Patient-specific factors include abnormal liver and kidney function, bleeding or clotting disorders, concomitant antiplatelet or nonsteroidal anti-inflammatory use, alcohol, and anemia. Recent bleeding or thromboembolism may increase the risk for recurrent events. To put thrombotic risk in perspective, the incidence of thromboembolism while anticoagulation was temporarily held has generally been <1%.3,18

Recommendation-Specific Supportive Text 1.	 To mitigate thromboembolic risk during inter-

ruption of warfarin therapy for a procedure or surgery, “bridging” anticoagulation can be administered. However, observational studies consistently showed an increased risk of bleeding without a difference in thromboembolic risk with this strategy.3 The BRIDGE (Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery) trial included patients with a mean CHADS2 score of 2.3 (range, 1-6); 61.7% of patients had a CHADS2 score <3.1 In this study, discussed in more depth below, interruption of warfarin without bridging anticoagulation was superior to bridging.1 In a meta-analysis of 6 observational studies reporting on patients not at high thromboembolic risk receiving prophylactic dose or no bridging had an overall thromboembolic event

Table 18.  Timing of Discontinuation of OACs in Patients With AF Scheduled to Undergo an Invasive Procedure or Surgery in Whom Anticoagulation Is to Be Interrupted

Anticoagulant Low Bleeding Risk Procedure High Bleeding Risk Procedure Apixaban (CrCl >25 mL/min)* 1 d† 2 d Dabigatran (CrCl >50 mL/min) 1 d 2 d Dabigatran (CrCl 30-50 mL/min) 2 d 4 d Edoxaban (CrCl >15 mL/min) 1 d 2 d Rivaroxaban (CrCl >30 mL/min) 1 d 2 d Warfarin 5 d for a target INR <1.5 2-3 d for a target INR <2 5 d *For patients on DOAC with creatinine clearance lower than the values in the table, few clinical data exist. Consider holding for an additional 1 to 3 days, especially for high bleeding risk procedures. †The number of days is the number of full days before the day of surgery in which the patient does not take any dose of anticoagulant. The drug is also not taken the day of surgery. For example, in the case of holding a twice daily drug for 1 day, if the drug is taken at 8 pm, and surgery is at 8 am, at the time of surgery, it will be 36 hours since the last dose was taken. AF indicates atrial fibrillation; CrCl, creatinine clearance; DOAC, direct oral anticoagulation; INR, international normalized ratio; and OAC, oral anticoagulant.

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