Figure 1. The figure shows a scheme of a coagulation cascade.

Table 1. Antithrombotic drugs types.

Table 1. Antithrombotic drugs types.

Anticoagulant DrugsDrug GroupApproximate Metabolism TimeAntiplatelet drugsAcetylsalicylic acid7 daysP2Y12 receptor blockers (Clopidogrel, Prasugrel, Ticagrelor)5 daysGlycoprotein IIb/IIa inhibitors36 hTxA2 synthetase inhibitorsno dataprostacyclin PG122–4 hAnticoagulantsVitamin K antagonists
(VKA)3–5 daysNon-vitamin K antagonists
(NOACs)1–2 daysHeparins1.5–24 hPentasaccharides15 h

Table 2. The table shows the management regimen for patients receiving double anticoagulant therapy.

Table 2. The table shows the management regimen for patients receiving double anticoagulant therapy.

Intraoperative Bleeding
RiskRisk of ThrombosisLow Risk/Moderate RiskHigh RiskLow riskDo not interrupt ASA or P2Y12 receptor blockers
Treatment.Moderate riskDo not interrupt ASA or P2Y12 receptor blockers
Treatment, increase postoperative hemostasis.High riskDo not interrupt ASA treatment, discontinue P2Y12 receptor blockers 5 days before the procedure after consultation with a cardiologist.
Resume treatment 24–72 h postoperatively by administering a saturating dose of the discontinued drug.Postpone scheduled procedures.
In urgent cases do not interrupt ASA treatment, discontinue P2Y12 receptor blockers 5 days before the procedure after consultation with a cardiologist, resume treatment 24–72 h postoperatively by administering a saturating dose of the discontinued drug. Alternatively apply bringing therapy using Glycoprotein IIb/IIa inhibitors which should be discontinued 4 h before surgery.

Table 3. The table shows the management regimen for patients receiving Vitamin K antagonists (VKA).

Table 3. The table shows the management regimen for patients receiving Vitamin K antagonists (VKA).

Intraoperative Bleeding
RiskRisk of ThrombosisLow Risk/Moderate RiskHigh RiskLow riskDo not interrupt VKA treatment, 24 h before the procedure assess the INR value which should not exceed 3, if above the given value postpone the procedure until INR value normalizes.Moderate riskHigh riskDecrease the perioperative INR value to 2.0–2.5.Discontinue VKA treatment, Apply bridging therapy. In urgent cases administer FFP or prothrombin complex concentrate together with low doses of vitamin K (2.5–5.0 mg) intravenously or orally.

Table 4. The table shows the management regimen for patients taking NOACs, depending on renal function and bleeding risk.

Table 4. The table shows the management regimen for patients taking NOACs, depending on renal function and bleeding risk.

Bleeding RiskRenal FunctionPerioperative Antithrombotic Therapy ManagementLow to moderate riskNormal kidney function or mild kidney function impairment—GFR ≥ 50 mL/minInterrupt NOAC treatment 12–24 h before surgery, resume ≥6 h postoperativelyModerate to severe kidney function impairment—GFR 49–30 mL/minInterrupt NOAC treatment 24–48 h before surgeryHigh riskNormal renal function or mild renal function impairment—GFR ≥ 50 mL/minInterrupt NOAC treatment 48 h before surgery, resume treatment 2–3 days post-surgery, consider a different antithrombotic therapy for 2–3 daysModerate to severe kidney function impairment–GFR 49–30 mL/minInterrupt NOAC treatment 72 h before surgery

Table 5. The table shows the management regimen for patients on combination therapy: VKA/NOAC.

Table 5. The table shows the management regimen for patients on combination therapy: VKA/NOAC.

Intraoperative Bleeding
RiskRisk of ThrombosisLow Risk/Moderate RiskHigh RiskLow riskDiscontinue NOAC treatment accordingly to the guidelines presented in Table 4.
Do not interrupt VKA treatment, 24 h before the procedure assess the INR value which should not exceed 3, if above the given value postpone the procedure until INR value normalizes.Moderate riskHigh riskDiscontinue NOAC treatment accordingly to the guidelines presented in Table 4.
Decrease the perioperative INR value to 2.0–2.5.Discontinue NOAC treatment accordingly to the guidelines presented in Table 4.
Discontinue VKA treatment, Apply bridging therapy. In urgent cases administer FFP or prothrombin complex concentrate together with low doses of vitamin K (2.5–5.0 mg) intravenously or orally.

Table 6. The table shows the management regimen for patients on combination therapy: VKA/ASA, VKA/Clopidogrel.

Table 6. The table shows the management regimen for patients on combination therapy: VKA/ASA, VKA/Clopidogrel.

Intraoperative Bleeding
RiskRisk of ThrombosisLow Risk/Moderate RiskHigh RiskLow riskDo not interrupt ASA or P2Y12 receptor blockers treatment.
Do not interrupt VKA treatment, 24 h before the procedure assess the INR value and proceed accordingly to the guidelines presented in Table 3.Moderate riskHigh riskConsultation with the attending physician.
Do not interrupt ASA or P2Y12 receptor blockers treatment.24 h before the procedure assess
the INR value and decrease the perioperative INR value to 2.0–2.5.Discontinue VKA treatment, apply bridging therapy. In urgent cases proceed accordingly to the guidelines presented in Table 3.