New algorithm for periprocedural anticoagulation management in nonvalvular Afib

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  • Managing anticoagulation in patients with atrial fibrillation (Afib) undergoing surgical procedures is an ongoing challenge across specialties, and this consensus algorithm offers step-by-step guidance.


  • Focused on patients with nonvalvular Afib for whom anticoagulation is a clinical indication and who are having elective surgeries.
  • Summary graphic included in paywalled article.
  • Algorithm addresses key decision points:
  • --Whether to interrupt: Evaluate bleed risk (eg, HAS-BLED), use clinical judgment; if risk low, no need to interrupt. If high, decide when to interrupt.
  • --When to interrupt: Consider anticoagulant, kidney function, internal normalized ratio (INR). INR determines time frame for interruption (eg, at goal INR=might discontinue 5 d before procedure); specific actions for vitamin K antagonists (VKA) vs direct oral anticoagulants (DOACs).
  • --Whether to bridge: Consider thrombotic, bleed risk; VKA vs DOAC. 
  • --How to bridge: Consider allergies, creatinine clearance; no bridging with DOAC; with VKA, based on thrombotic risk.
  • --How to restart: Consider procedure type, medication type, bleed risk, etc (eg, with stable, low-risk patient, consider delaying reinitiation of anticoagulation).

Study design

  • Guidance consensus statement.
  • Funding: None specified; tables of task force declarations.