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If you take a blood thinner and need an operation, biopsy or endoscopy, your team will make a written plan saying exactly when to take your last dose and when to restart. Aspirin is often continued. Warfarin is usually stopped five days before, and the newer tablets (apixaban, rivaroxaban, edoxaban, dabigatran) one to three days before. Most people do not need heparin injections in the gap.
The CHEST 2022 guideline (44 recommendations, GRADE) makes two strong recommendations: against heparin bridging in atrial fibrillation, and to continue a vitamin K antagonist for pacemaker or defibrillator implantation; the rest are conditional, and the panel states that most perioperative questions remain uncertain. BRIDGE (n=1884, AF, warfarin) found no bridging noninferior for arterial thromboembolism (0.4% vs 0.3%) with less major bleeding (1.3% vs 3.2%). PAUSE (n=3007, AF, apixaban, dabigatran, rivaroxaban) omitted the DOAC 1 day before a low-bleeding-risk and 2 days before a high-bleeding-risk procedure, resumed 1 day or 2 to 3 days after, without bridging or coagulation testing, with low rates of bleeding and stroke. ASH 2018 recommends strongly against periprocedural LMWH bridging for people on anticoagulation for VTE. For endoscopy, BSG/ESGE 2021 continue aspirin for all procedures (strong, low), continue P2Y12 inhibitors and warfarin for low-risk procedures, stop P2Y12 inhibitors 7 days and warfarin 5 days before high-risk procedures in people at low thrombotic risk (INR below 1.5), take the last DOAC dose 3 days before a high-risk procedure (5 days for dabigatran with CrCl 30 to 50), and resume up to 2 to 3 days after (strong, moderate). Unlike CHEST, BSG/ESGE still bridge with LMWH for warfarin in high thrombotic risk (mechanical valves, AF with mitral stenosis, VTE within 3 months). Coronary stents: liaise with a cardiologist before stopping a P2Y12 inhibitor.
Why: Stopping a blood thinner raises the risk of a stroke or clot; continuing it raises the risk of bleeding. The balance differs for each person and each procedure.
“We recommend that all patients are advised of the thrombotic risks of discontinuing antiplatelets or anticoagulants, as well as the haemorrhagic risks of continuing therapy (strong recommendation, low quality evidence).”
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 · Strong recommendation, low quality evidence
Why: Mistakes in timing are common when several drugs or injections are involved; a written plan prevents them.
“Once the decision to modify antithrombotic medication is made, then a personal plan for that patient should be made. This should include written as well as verbal information regarding the precise timing of any changes.”
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 · Not graded (guideline text)
Why: Aspirin taken to prevent a second heart attack or stroke protects more than it harms around most procedures.
“For all endoscopic procedures we recommend continuing aspirin (strong recommendation, low quality evidence), with the exception of ampullectomy (weak recommendation, low quality evidence).”
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 · Strong recommendation, low quality evidence (endoscopy)
Why: These drugs affect platelets for about a week; stopping them too soon after a stent can cause the stent to block.
“For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists 7 days before the procedure (strong recommendation, moderate quality evidence). In patients on DAPT, we recommend continuing aspirin (strong recommendation, low quality evidence).”
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 · Strong recommendation, moderate quality evidence
Why: Warfarin takes several days to wear off; the INR blood test shows when clotting is back to a safe level for surgery.
“For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing warfarin for 5 days before the procedure (strong recommendation, high quality evidence). Check INR prior to the procedure to ensure <1.5 (strong recommendation, low quality evidence).”
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 · Strong recommendation, high quality evidence (stop 5 days); strong, low (INR check)
Why: In a large randomised trial, heparin injections in the gap did not prevent strokes and more than doubled major bleeding.
“of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation”
American College of Chest Physicians 2022 · Strong recommendation (GRADE)
Why: These tablets wear off within a day or two in people with normal kidneys, so a short planned gap is enough.
“The DOAC regimens were omitted for 1 day before a low-bleeding-risk procedure and 2 days before a high-bleeding-risk procedure.”
JAMA Internal Medicine 2019 · Prospective cohort study (not a guideline grade)
Why: The endoscopy guideline counts the gap from the last dose taken, which is the same as missing two full days of tablets.
“For high-risk endoscopic procedures in patients on DOACs, we recommend that the last dose of DOACs be taken 3 days before the procedure (strong recommendation, low quality evidence).”
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 · Strong recommendation, low quality evidence
Why: Leaving it off for longer exposes the person to clots; DOACs work within hours of the first dose, warfarin takes days.
“If antiplatelet or anticoagulant therapy is discontinued, then we recommend this should be resumed up to 2–3 days after the procedure depending on the perceived haemorrhagic and thrombotic risks (strong recommendation, moderate quality evidence).”
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 · Strong recommendation, moderate quality evidence
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
For surgery, CHEST 2022 is the most recent full guideline (GRADE): no heparin bridging in atrial fibrillation (strong), on the evidence of BRIDGE, and a pharmacokinetic DOAC interruption schedule without bridging, on the evidence of PAUSE; ASH 2018 recommends strongly against bridging for people on anticoagulation for VTE. For endoscopy and endoscopic biopsy, BSG/ESGE 2021 is the current specialty standard. The two disagree on one point: BSG/ESGE still substitute LMWH for warfarin in people at high thrombotic risk (mechanical heart valves, atrial fibrillation with mitral stenosis or recent stroke, VTE within 3 months), while CHEST's strong recommendation against bridging covers atrial fibrillation; CHEST's position for mechanical valves could not be read beyond its abstract.
American College of Chest Physicians 2022 · New England Journal of Medicine 2015 · JAMA Internal Medicine 2019 · American Society of Hematology 2018 · British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021
Where it differs: Stops warfarin 5 days before, starts a daily therapeutic LMWH dose 2 days later, gives the last LMWH dose at least 24 hours before the procedure and restarts LMWH the day after until the INR is in range.
Evidence: A strong recommendation in BSG/ESGE 2021 (the quality of evidence is printed as low in the summary and moderate in the section text) for high-risk endoscopic procedures in people at high thrombotic risk, as defined in its table 3. CHEST 2022 recommends strongly against bridging in atrial fibrillation.
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 · American College of Chest Physicians 2022
Where it differs: Does not stop warfarin (INR checked in the week before, not above range) or clopidogrel for diagnostic endoscopy and biopsy; omits only the morning DOAC dose.
Evidence: BSG/ESGE 2021: warfarin continued (weak, low), P2Y12 inhibitors continued (strong, low), morning DOAC dose omitted (weak, low).
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021
Where it differs: Delays restarting antithrombotics for about a week after procedures such as endoscopic submucosal dissection of an early cancer.
Evidence: BSG/ESGE 2021 says it 'may be desirable' on the basis of a meta-analysis of post-ESD bleeding; thrombosis was not analysed.
British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Strong recommendations in CHEST 2022 “A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations” | Two strong of 44; the rest conditional | American College of Chest Physicians 2022 |
| No bridging is as safe for strokes and causes less bleeding (BRIDGE) “The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority).” | Randomised, double-blind trial, n=1884 | New England Journal of Medicine 2015 |
| No LMWH bridging for people on anticoagulation for VTE “Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy.” | Strong recommendation (GRADE) | American Society of Hematology 2018 |
| DOAC resumption after the procedure (PAUSE schedule) “The DOAC regimens were resumed 1 day after a low-bleeding-risk procedure and 2 to 3 days after a high-bleeding-risk procedure.” | Prospective cohort study | JAMA Internal Medicine 2019 |
| Stents: liaise with an interventional cardiologist before stopping a P2Y12 inhibitor “For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a consultant interventional cardiologist about the risk/benefit of discontinuing P2Y12 receptor antagonists (strong recommendation, high quality evidence).” | Strong recommendation, high quality evidence | British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 |
| Uncertainty remains “Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.” | Panel statement | American College of Chest Physicians 2022 |
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