Question 1

How long do I hold apixaban before surgery?

Accepted Answer

Hold apixaban for **24 hours** before low-bleeding-risk procedures and **48 hours** before high-bleeding-risk procedures. With CrCl < 30 mL/min, extend hold by an additional 24 hours. The same intervals apply to rivaroxaban and edoxaban.

Question 2

How long do I hold dabigatran before surgery?

Accepted Answer

Dabigatran hold time depends heavily on CrCl. With CrCl ≥ 80, hold 24 hours (low risk) or 48 hours (high risk). With CrCl 50–79, hold 36 / 72 hours. With CrCl 30–49, hold 48 / 96 hours. With CrCl < 30, dabigatran is contraindicated for elective surgery; consult or switch.

Question 3

Should I bridge a DOAC patient with LMWH?

Accepted Answer

No. The PAUSE study (JAMA Intern Med 2019) established that simply holding the DOAC by bleeding risk produces low rates of both thromboembolism and bleeding without bridging. LMWH bridging adds bleeding risk without reducing thromboembolic events in DOAC patients.

Question 4

When can I restart the DOAC after surgery?

Accepted Answer

After low-bleeding-risk procedures, restart at full dose 24 hours after the procedure once hemostasis is confirmed. After high-bleeding-risk procedures, restart at 48–72 hours, often with prophylactic-dose anticoagulation or no anticoagulation for the first 24–48 hours.

Question 5

What's "high bleeding risk" for procedures?

Accepted Answer

High bleeding risk includes major abdominal, thoracic, orthopedic, vascular, and cardiac surgery; neurosurgery; prostate or kidney biopsy; ERCP with sphincterotomy; polypectomy of large polyps; and any neuraxial anesthesia. Low bleeding risk includes cataract surgery, dental cleaning, joint injections, simple skin procedures, and diagnostic endoscopy without biopsy.

Question 6

What if a DOAC patient needs emergency surgery?

Accepted Answer

Specific reversal agents are available: idarucizumab for dabigatran, andexanet alfa for apixaban and rivaroxaban. Where these are unavailable, 4-factor prothrombin complex concentrate (4F-PCC) is used. The decision involves balancing the urgency of the procedure against the bleeding risk of reversal — generally a hematology / cardiology consult.

DOAC Peri-Procedural Hold Times

References

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