Wojciech Owczarek, Krzysztof Składowski, Igor Biernacki, Jacek Owczarek, Anna Wiktorowska-Owczarek

Anticoagulant therapy and planned non-cardiac surgery: is bridging therapy always necessary?

 

2026-04-09

Background. An increasing number of patients receive long-term oral anticoagulant therapy (VKA – vitamin K anticoagulants, DOAC – direct oral anticoagulants) due to atrial fibrillation, venous thromboembolism, or mechanical heart valve implantation. These patients require individualized perioperative management. Elective non-cardiac surgical procedures present particular challenges related to balancing bleeding and thromboembolic risks.

Objective. To evaluate the rationale for using bridging therapy in patients chronically treated with oral anticoagulants undergoing planned surgical procedures, and to outline clinical decision-making criteria for drug discontinuation and resumption.

Methods. A review of the current recommendations of scientific societies, i.e., the European Society of Cardiology, the Polish Society of Cardiology, and the available scientific literature regarding perioperative management in patients treated with oral anticoagulants (vitamin K antagonists: acenocoumarol, warfarin; direct oral anticoagulants: dabigatran, rivaroxaban, apixaban, edoxaban). Three clinical cases were presented illustrating the perioperative approach depending on the patient’s risk of bleeding during the procedure and thromboembolism.

Results. DOACs (e.g., rivaroxaban, dabigatran) – due to their short half-lives and renal clearance dependence, generally do not require bridging therapy; VKAs (e.g., warfarin) – in patients with high thromboembolic risk (e.g., mechanical heart valves), bridging with therapeutic-dose low-molecular-weight heparin is indicated; Risk assessment should be based on surgical procedure classification and clinical scoring systems (e.g., CHA₂DS₂-VA); Management decisions should be multidisciplinary and tailored to the patient’s clinical profile and preferences.

Conclusions. Bridging therapy is not necessary in all clinical scenarios. The key is to balance the risk of thromboembolism and bleeding related to the planned procedure. DOAC-treated patients typically do not require bridging, while it is essential in selected VKA-treated patients with high thromboembolic risk. Management should follow current evidence-based guidelines and be individualized.

Keywords: anticoagulant therapy, bridging therapy, VKA, DOAC, low‑molecular-weight heparin, bleeding risk, thromboembolic risk, non-cardiac surgery, perioperative management.

© Farm Pol, 2025, 81(8): 467–476