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Am Fam Physician. 2023;108(2):208-211

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Key Points for Practice

• Perioperative antithrombotic management depends on balancing bleeding risk with risk for thrombosis; for surgeries with minimal bleeding risk, continue antithrombotic treatment.

• Because of their rapid onset and degradation, most direct oral anticoagulants can be stopped one to two days before a procedure and restarted one to two days after the procedure in patients without significant chronic kidney disease.

• Bridging with heparin for patients taking warfarin is reserved for those at high risk of thromboembolism in most cases. 

• Aspirin can be continued through most surgeries.

From the AFP Editors

Up to 20% of patients taking antithrombotic medications will need an invasive procedure. The American College of Chest Physicians published updated guidelines on perioperative management of antithrombotic medications for elective procedures based on a systematic review of primarily low-quality evidence.

Balance of Risks

The risk of bleeding following a procedure and the risk of thromboembolism from the initial need for antithrombotic treatment are the two factors used to determine whether and how long to hold medications. Table 1 stratifies common surgeries by bleeding risk. For procedures with minimal bleeding risk, the antithrombotic medication can generally be continued. For low- to moderate- or high-bleeding risk, most medications are stopped before surgery and later restarted. Patient or surgical factors may increase bleeding risk.

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Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at

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