2012 ACCP Periprocedure anticoagulation guidelines


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Risk of bleedingassociated with surgery/procedure? Low risk Minor dental procedure Intermediate or high risk Continue VKA with oral prohemostatic agent -OR- Stop VKA 2-3 days prior to surgery/procedure Minor dermatologic procedure Cataract surgery Continue VKA and optimize local hemostasis Continue VKA Stop VKA 5 days prior to surgery/procedure Risk for perioperative thromboembolism based on patient's indication for VKA therapy Low risk Moderate risk High risk No bridging Bridging or no bridging depends on patient- and surgery-related factorsUpdate: consider no bridgefor moderate risk a-fib(PMID 26095867) Bridging
Bleeding risk and surgery type:
Indication for VKA Therapy:
  Mechanical Valve A-fib VTE
Any mitral valve prosthesis
Any caged-ball or tilting disc aortic valve prosthesis
Recent (within 6 mo) stroke or transient ischemic attack
CHADS2 score of 5 or 6
Recent (within 3 mo) stroke or transient ischemic attack
Rheumatic valvular heart disease
VTE within 3 mo

Severe thrombophilia (eg, deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)
Bileaflet aortic valve prosthesis and one or more of the of following risk factors: atrial fibrillation, prior stroke or transient ischemic attack, hypertension, diabetes, congestive heart failure, age > 75 y CHADS2 score of 3 or 4 VTE within the past 3-12 mo

Nonsevere thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation)
Recurrent VTE
Active cancer (treated within 6 mo or palliative)
Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke CHADS2 score of 0 to 2 (assuming no prior stroke or transient ischemic attack) VTE > 12 mo previous and no other risk factors
"High-risk patients may also include those with a prior stroke or transient ischemic attack occurring > 3 mo before the planned surgery and a CHADS2 score < 5, those with prior thromboembolism during temporary interruption of VKAs, or those undergoing certain types of surgery associated with an increased risk for stroke or other thromboembolism (eg, cardiac valve replacement, carotid endarterectomy, major vascular surgery)."

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Additional considerations for this patient

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American College of Chest Physicians

  1. Douketis JD et al; American College of Chest Physicians. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012. PMID: 22315266 PMCID: PMC3278059.
  2. Douketis JD et al; American College of Chest Physicians. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):299S-339S. doi: 10.1378/chest.08-0675. PMID: 18574269.
  3. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):204S-233S. Erratum in: Chest. 2005 Jan;127(1):415-6. Dosage error in article text. PMID: 1538347


  1. Souto JC, Oliver A, Zuazu-Jausoro I, Vives A, Fontcuberta J. Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: a prospective randomized study. J Oral Maxillofac Surg. 1996 Jan;54(1):27-32; discussion 323. PMID: 8530996