How should perioperative anticoagulants be managed?

• A. Continue as usual without interruption
• B. Typically held preoperatively if bleeding risk is high; bridging with short-acting agents if high thrombotic risk; restart once hemostasis is achieved postoperatively
• C. Reduced dose only
• D. Discontinue permanently after surgery

Answer: (B)

Balancing bleeding risk with thromboembolic risk is the key idea in perioperative anticoagulation. For procedures with a meaningful bleeding risk, anticoagulants are typically stopped before surgery to minimize bleeding. If the patient has a high risk of thrombosis, a bridging strategy with a short-acting agent (such as heparin) is used during the window when the primary anticoagulant is paused, to provide some protection against clotting. After surgery, once hemostasis is secured, the bridging agent is stopped and the original anticoagulant is restarted, with timing guided by bleeding status and wound healing. This approach reduces bleeding during the operation while still protecting against thromboembolism, and is preferred over continuing the usual dose or stopping anticoagulation permanently.