Perioperative management of chronic anticoagulation

What it is

Perioperative management of chronic anticoagulation requires an assessment of two things at once: the patients risk for thromboembolism, and the risk of bleeding from the surgical procedure. The first decides whether the patient needs bridging, the second decides how the anticoagulant is stopped.

Causes and risk

High-risk patients are of four kinds: first, those with mechanical heart valves; second, a stroke or TIA within the past 3 months; third, venous thromboembolism within the past 3 months; fourth, coronary stenting within the previous 12 months. In atrial fibrillation the decision rests on the CHA2DS2-VASc score, and two numbers are given for it: first, 6 or above, at which the patient should receive bridging therapy; second, 3, which is low risk for thromboembolism. The score itself is made of eight items: first CHF; second HTN; then Age ≥75, which is worth 2 points; DM; Stroke/TIA, which is worth 2 points; Vascular disease; Age 65-74; and Sex female. The level at which to anticoagulate is ≥2 in men and ≥3 in women, which is a different question from bridging.