Peri-Operative Management of Anti-thrombotics (antiplatelets, anticoagulants)

Adapted from Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures Todd H. Baron, M.D., Patrick S. Kamath, M.D., and Robert D. McBane, M.D. N Engl J Med 2013; 368:2113-2124

Agent	MOA	Peri-Procedural Management	Labs	Reversal
Anticoagulants
Warfarin	inhibits Vit K dependent factors: 2,7,9,10 and Protein C and S	hold 1-8 days, until INR <=1.5, this happens within 5 days for 93% of patients	INR	Oral or IV Vitamin K, +/- FFP, prothrombin complex concentrate (PCC) 4 factor preferred over 3
Unfractionated Heparin	Antithrombin activation (inhibits 2a, 9a, 10x, 11a, 12a)	IV 2-6hrs depending on dose, SubQ 12-24 hrs depend. on dose	aPTT	Protamine sulfate
LMW Heparins (enoxaparin = lovenox; dalteparin (fragmin))	antithrombin activation (inhibits Xa, some 2a)	24hr	None – perhaps anti-Xa Ab	Protamine (only partial) Also note CKD>Stage 4 impairs elimination
Fondaparinux	Antithrombin activation (Xa inhibitor)	36-48hr	none, consider fondaparinux-specific anti-Xa assays	none, perhaps F7a in high risk major bleed
Dabigatran (pradaxa; argatroban maybe same)	direct thrombin inhibitor	1-2 days if crcl>50, otherwise 3-5days	aPTT or thrombin time	None, perhaps F8 inhibitor bypass activity or recomb activated 7a or dialysis
Rivaroxaban (BAM the Xa)	direct Xa inhibitor	>1 day in nomral renal fx, 2 d cr cl 60-90, 3d crcl 30-59, 4d crcl 15-29	ptt or anti-Xa ab	none, consider PCCs
Apixaban (eliquis)	Direct Xa inhibitor	1-2d crcl>60, 3d crcl 50-59, 5d cr cl <49	anti-Xa ab	non, consider charcoal hemoperfusion or PCCs (4 factor best)
Desirudin (iprivask)	Direct thrombin inhibitor	2hr	aPTT, thrombin time, or ecarin clotting time	none
Antiplatelets
Aspirin	COX inhibitor – irreversible	7-10 days	non, consider platelet function tests (TEG?)	Platelet transfusion
ASA + Dipyridamole	Phosphodiesterase inhibitor	7-10 days	None, but consider platelet function testing	Platelet transfusion
Cilostazol	Phosphodiesterase inhibitor	2 days	None	Platelet transfusion
Thienopyridine agents (clopidogrel – plavix; ticlopidine, prasugrel – effient; ticagrelor – brilinta)	ADP receptor antagonist	5 days	None, but consider platelet function testing	Consider platelet transfusion, but limited efficacy