Guidelines on When to stop anticoagulation before a procedure?

October 11, 2025 •

3 min read

Up to 20% of patients taking antithrombotic medications will eventually need an invasive procedure. The crucial decision of when to stop anticoagulation before a procedure involves balancing the risk of bleeding during and after the procedure against the risk of dangerous blood clots forming due to the interruption of medication.

Quick Summary

The decision to interrupt anticoagulation for a procedure depends on balancing bleeding and thromboembolic risks, considering the anticoagulant type, procedure risk level, and renal function. Specific hold times are required, especially for Warfarin and Direct Oral Anticoagulants (DOACs), with bridging used only for high-risk Warfarin patients.

Key Points

Balance Risks: Periprocedural anticoagulant management requires balancing bleeding risk from the procedure and thrombosis risk from stopping medication.
DOACs vs. Warfarin: DOACs typically require shorter hold times (1-4 days) than warfarin (~5 days) due to their shorter half-lives.
Bridging is Rare: Heparin bridging is reserved for very high-risk warfarin patients and is generally not recommended for DOACs.
Factor in Renal Function: Renal function is a major determinant for DOAC hold times, especially dabigatran.
Re-Assess After Procedure: Resumption timing depends on achieving hemostasis and the procedure's bleeding risk level.
Minimal Bleeding Risk: Procedures with minimal bleeding risk may not require interruption of anticoagulation at all.
Consult Your Doctors: Never stop or restart your anticoagulant without a specific plan from your healthcare providers.

Understanding the Risk-Benefit Analysis

Deciding to pause anticoagulant therapy for a procedure involves balancing the risk of excessive bleeding during and after the procedure against the risk of a thromboembolic event while medication is held. This decision is guided by the type of anticoagulant, the patient's thrombosis risk, and the procedure's bleeding risk.

Assessing Procedural Bleeding Risk

Procedures are classified by bleeding risk to help determine the management approach:

Minimal Bleeding Risk: Procedures like simple dental extractions, dermatological excisions, and cataract surgery often allow anticoagulation to continue or require only a single dose omission.
Low-to-Moderate Bleeding Risk: These procedures, such as laparoscopic cholecystectomy or coronary angiography via the femoral approach, require temporary interruption.
High Bleeding Risk: Procedures including major surgeries (orthopedic, cancer, abdominal) or those needing neuraxial anesthesia require complete cessation of anticoagulant effect.

Direct Oral Anticoagulants (DOACs)

DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) have predictable, short half-lives, simplifying periprocedural management. Management depends on the procedure's bleeding risk and the patient's renal function, as DOACs are renally cleared. Heparin bridging is not typically recommended for DOACs due to short hold times.

DOAC Holding Periods (Approximate)

Holding periods vary based on risk and renal function:

Low-to-Moderate Bleeding Risk: Stop DOAC 1 to 2 days before the procedure.
High Bleeding Risk: Stop DOAC 2 to 4 days before the procedure. Longer holds may be needed for dabigatran, especially with impaired renal function.

Management of Warfarin (Vitamin K Antagonist)

Warfarin's long half-life requires stopping it well in advance for low-to-moderate or high bleeding risk procedures. The INR must be monitored to reach a safe level (<1.5) before the procedure.

Warfarin Holding Periods and Bridging

Holding Period: Warfarin is usually stopped about 5 days pre-procedure.
Bridging Therapy: For patients at very high risk of thromboembolism (e.g., mechanical heart valve), bridging with LMWH may be considered. However, bridging for many with atrial fibrillation does not prevent stroke better than no bridging and increases bleeding risk.

Comparison of Anticoagulant Management Strategies


Anticoagulant Type	Typical Pre-Procedure Hold Time	Bridging Therapy	Resumption Post-Procedure
Warfarin (VKA)	~5 days (until INR <1.5)	Consider for high thrombotic risk; not for low/moderate risk	Resume within 12-24 hours; wait longer for high bleeding risk
Apixaban (Eliquis)	1-2 days (low/mod bleed risk); 2-3 days (high bleed risk)	Not recommended	Resume 1 day (low/mod) or 2-3 days (high) after hemostasis
Rivaroxaban (Xarelto)	1 day (low/mod bleed risk); 2-3 days (high bleed risk)	Not recommended	Resume 1 day (low/mod) or 2-3 days (high) after hemostasis
Dabigatran (Pradaxa)	1-4 days (depending on renal function and bleed risk)	Not recommended	Resume 1 day (low/mod) or 2-4 days (high) after hemostasis

Resuming Anticoagulation After a Procedure

The timing of restarting anticoagulation is critical. Warfarin is usually restarted the same day or day after the procedure, as its effect is delayed. DOAC resumption is based on achieving hemostasis and the procedure's bleeding risk.

Low-to-Moderate Bleeding Risk: Restart DOAC 24 hours post-procedure.
High Bleeding Risk: Delay restarting DOAC for 48 to 72 hours, or until hemostasis is confirmed.

The Critical Role of Communication

Effective management requires clear communication between the patient and all involved healthcare providers (prescribing physician, proceduralist). This collaboration ensures risks are assessed and a personalized plan is developed.

Conclusion

Determining when to stop anticoagulation before a procedure is a complex decision weighing thrombosis and bleeding risks. DOACs offer shorter hold times and generally don't require bridging, while Warfarin management is more intricate and may involve bridging for high-risk patients. Close communication among the healthcare team is vital. Patients should always follow their healthcare provider's specific instructions.

For more detailed clinical guidelines, resources such as the American College of Chest Physicians (ACCP) are available.

Frequently Asked Questions

For a high-risk procedure, Warfarin should typically be stopped approximately five days before the procedure to allow the INR to decrease to a safe level.

No, bridging with heparin is generally not necessary or recommended for patients on DOACs because of their rapid onset and clearance, which minimizes the time of a non-therapeutic effect.

The timing depends on the procedure's bleeding risk. For low-to-moderate risk procedures, you may restart in 24 hours. For high-risk procedures, resumption may be delayed for 48 to 72 hours to ensure adequate hemostasis.

For minimal bleeding risk procedures, such as routine dental extractions or cleanings, it is often safe to continue anticoagulation. Your dentist and prescribing doctor should decide based on the specific procedure.

Bridging therapy is the temporary use of a shorter-acting anticoagulant, like heparin, during the interruption of a long-acting one, like Warfarin, for a procedure. It is primarily used for patients at a very high risk of thromboembolism.

If your surgery is canceled or postponed, you should immediately contact your anticoagulation clinic or prescribing physician for new instructions on when to restart your medication. It is important to resume anticoagulation as soon as possible unless told otherwise.

Yes, renal function is especially important for dabigatran, which is highly renally cleared. Patients with impaired renal function may need to hold dabigatran for a longer period before a procedure.