The increasing prevalence of cardiovascular diseases, atrial fibrillation, venous thromboembolism, and prosthetic heart valves has led to a substantial rise in the long-term use of anticoagulant and antiplatelet medications [1]. Agents such as aspirin, clopidogrel, warfarin, and direct oral anticoagulants (DOACs) play a pivotal role in preventing thromboembolic complications and reducing cardiovascular morbidity and mortality [2]. As the population ages and the burden of chronic cardiovascular disease increases, a growing number of patients receiving these therapies require elective or emergency surgical procedures, making perioperative antithrombotic management an increasingly common clinical challenge [3].

The perioperative management of patients receiving anticoagulant and antiplatelet therapy requires careful balancing of two competing risks: excessive perioperative bleeding if therapy is continued and thromboembolic complications if therapy is interrupted [4]. Clinical decisions regarding the timing of drug discontinuation, the use of bridging anticoagulation, and the optimal timing for postoperative resumption depend on multiple patient- and procedure-related factors, including the indication for antithrombotic therapy, thromboembolic risk, bleeding risk associated with surgery, renal function, and the pharmacokinetic properties of individual drugs [5,6]. Current international guidelines recommend individualized management strategies; however, significant variations in clinical practice continue to exist across institutions and specialties [7].

Several observational studies and randomized trials have evaluated perioperative antithrombotic management, yet uncertainty remains regarding the optimal approach for minimizing adverse outcomes [8,9]. While interruption of therapy may reduce surgical bleeding, it can expose patients to potentially life-threatening thromboembolic events [10]. Conversely, bridging anticoagulation has been associated with increased bleeding without consistently demonstrating a reduction in thromboembolic complications in many patient populations [10]. Consequently, understanding real-world perioperative management practices and their associated clinical outcomes is essential for optimizing patient safety and improving evidence-based decision-making.

The present study aimed to evaluate the perioperative management strategies employed in patients receiving anticoagulant and antiplatelet therapy undergoing surgical procedures and to assess their association with perioperative bleeding, thromboembolic events, and other postoperative clinical outcomes.

This prospective observational study was conducted in the Department of Anaesthesiology over a period of one year, from September 2024 to September 2025, to evaluate the perioperative management of patients receiving anticoagulant and antiplatelet therapy who underwent surgical procedures. A total of 150 consecutive adult patients aged 18 years and above receiving chronic anticoagulant and/or antiplatelet therapy and scheduled for elective or emergency surgery were enrolled after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to inclusion in the study. Patients with incomplete clinical records, those unwilling to participate, or those who underwent minor procedures not requiring perioperative modification of antithrombotic therapy were excluded. Baseline demographic and clinical characteristics, including age, sex, body mass index (BMI), medical comorbidities (hypertension, diabetes mellitus, coronary artery disease, atrial fibrillation, chronic kidney disease, heart failure, previous stroke or transient ischemic attack, and peripheral arterial disease), indication for antithrombotic therapy, and details of anticoagulant or antiplatelet medications (aspirin, clopidogrel, dual antiplatelet therapy, warfarin, apixaban, rivaroxaban, and dabigatran), were recorded using a predesigned case record form. Surgical details including type of surgery (elective or emergency), surgical specialty, perioperative discontinuation of antithrombotic therapy, use of bridging anticoagulation, and timing of postoperative resumption of therapy were also documented. Patients were followed throughout the perioperative period to assess clinical outcomes. The primary outcome was the occurrence of major perioperative bleeding, while secondary outcomes included minor bleeding, blood transfusion requirement, re-operation for bleeding, thromboembolic events (myocardial infarction, ischemic stroke, and deep vein thrombosis), intensive care unit (ICU) admission, and in-hospital mortality. Bleeding complications were identified based on clinical assessment, perioperative blood loss, need for transfusion, requirement for surgical re-exploration, and postoperative documentation. Thromboembolic complications were confirmed using appropriate clinical evaluation and relevant diagnostic investigations. Data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequency and percentage. Associations between categorical variables were evaluated using the Chi-square test or Fisher's exact test, as appropriate. Variables demonstrating clinical relevance or statistical significance on univariate analysis were included in a multivariable logistic regression model to identify independent predictors of major perioperative bleeding. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. A two-tailed p-value <0.05 was considered statistically significant.

A total of 150 patients were included in the study. The majority of patients belonged to the 60–69 years age group (32.0%), followed by those aged ≥70 years (30.6%). The mean age of the study population was 64.8 ± 11.7 years. Males constituted 61.3% of the participants, while females accounted for 38.7%. The mean body mass index (BMI) was 27.1 ± 4.6 kg/m², indicating that most patients were overweight. (Table 1)

Table 1. Baseline Demographic Characteristics of the Study Population (N=150)

Hypertension was the most common comorbidity, observed in 67.3% of patients, followed by coronary artery disease (48.7%) and diabetes mellitus (45.3%). Atrial fibrillation was present in 34.7% of the study population, while previous stroke or transient ischemic attack was reported in 17.3%. Chronic kidney disease and heart failure were identified in 12.7% and 14.0% of patients, respectively, with peripheral arterial disease affecting 12.0%. (Table 2)

Table 2. Clinical Characteristics (N=150)

Atrial fibrillation was the leading indication for antithrombotic therapy, accounting for 34.7% of patients, followed by coronary artery disease or previous percutaneous coronary intervention in 28.7%. Venous thromboembolism was the indication in 16.0% of cases, while mechanical heart valves, stroke prevention, and peripheral arterial disease contributed to smaller proportions of the cohort. (Table 3)

Table 3. Indications for Antithrombotic Therapy

Among antithrombotic medications, aspirin was the most frequently prescribed agent (37.3%), followed by clopidogrel (20.7%) and direct oral anticoagulants (16.7%). Warfarin therapy was observed in 13.3% of patients, while 12.0% received dual antiplatelet therapy. Among DOAC users, apixaban was the most commonly used agent, followed by rivaroxaban and dabigatran. (Table 4)

Table 4. Antithrombotic Medications Used

Most surgical procedures were elective (81.3%), whereas emergency surgeries accounted for 18.7% of cases. General surgery represented the largest surgical specialty (27.3%), followed by orthopedic surgery (24.0%). Urological, vascular, neurosurgical, and other procedures collectively comprised the remaining surgical interventions included in the study. (Table 5)

Table 5. Surgical Characteristics

Perioperative interruption of antithrombotic therapy was performed in 82.7% of patients, while therapy was continued in 17.3%. Bridging anticoagulation was utilized in 20.7% of the study population. Nearly half of the patients (48.0%) resumed antithrombotic therapy within 24 hours after surgery, whereas 52.0% restarted treatment after more than 24 hours. (Table 6)

Table 6. Perioperative Management of Antithrombotic Therapy

Major bleeding occurred in 7.3% of patients, while minor bleeding was observed in 16.0%. Blood transfusion was required in 11.3% of cases, and re-operation due to bleeding was necessary in only 2.7%. Thromboembolic complications were uncommon (3.3%), including myocardial infarction, stroke, and deep vein thrombosis. ICU admission was required in 12.7% of patients, and the overall in-hospital mortality rate was 2.0%. (Table 7)

Table 7. Perioperative Outcomes

Major bleeding occurred significantly more frequently among patients who received bridging anticoagulation compared to those managed without bridging (19.4% vs. 4.2%). This association was statistically significant (χ² = 7.78, p = 0.005), suggesting that bridging therapy was associated with an increased risk of perioperative major bleeding. (Table 8)

Table 8. Association Between Bridging Therapy and Major Bleeding

Patients undergoing emergency surgery experienced a significantly higher incidence of major bleeding than those undergoing elective procedures (21.4% vs. 4.1%). Statistical analysis demonstrated a significant association between emergency surgery and major bleeding (χ² = 9.53, p = 0.002). (Table 9)

Table 9. Association Between Emergency Surgery and Major Bleeding

Multivariate logistic regression identified emergency surgery (Adjusted OR: 3.94, p = 0.004), bridging anticoagulation (Adjusted OR: 4.27, p = 0.002), and age ≥70 years (Adjusted OR: 1.82, p = 0.041) as independent predictors of major perioperative bleeding. Although chronic kidney disease and dual antiplatelet therapy showed increased odds of bleeding, these associations did not reach statistical significance. (Table 10)

Table 10. Predictors of Major Bleeding (Multivariate Logistic Regression)

The present prospective observational study evaluated perioperative management strategies and clinical outcomes among 150 patients receiving anticoagulant and antiplatelet therapy who underwent surgical procedures. Most patients were elderly (mean age 64.8 ± 11.7 years), predominantly male, and had multiple cardiovascular comorbidities, particularly hypertension, coronary artery disease, diabetes mellitus, and atrial fibrillation. Similar patient characteristics have been reported in contemporary studies, reflecting the increasing prevalence of chronic cardiovascular disease requiring long-term antithrombotic therapy in the aging surgical population [11]. Our findings also demonstrated that aspirin remained the most frequently prescribed antithrombotic agent, followed by clopidogrel and direct oral anticoagulants (DOACs), which is consistent with current prescribing trends and guideline recommendations for cardiovascular and thromboembolic disease management [12]. These observations support the growing complexity of perioperative care in patients receiving antithrombotic medications. In the present study, antithrombotic therapy was interrupted before surgery in 82.7% of patients, while bridging anticoagulation was used in only 20.7%. Major bleeding occurred in 7.3% of patients, whereas thromboembolic complications were infrequent (3.3%). These findings are comparable with those reported in the BRIDGE trial by Douketis et al., which demonstrated that withholding bridging anticoagulation did not increase thromboembolic events but significantly reduced major bleeding among patients receiving warfarin for atrial fibrillation [13]. Likewise, the PAUSE study demonstrated that standardized interruption of DOAC therapy without routine heparin bridging resulted in low rates of both major bleeding and arterial thromboembolism, supporting simplified perioperative management strategies [14]. Our findings further reinforce the growing evidence that selective rather than routine use of bridging anticoagulation is appropriate in most surgical patients receiving chronic antithrombotic therapy. An important finding of the present study was the significant association between bridging anticoagulation and major perioperative bleeding. Patients receiving bridging therapy had a significantly higher incidence of major bleeding than those managed without bridging (19.4% vs. 4.2%; p=0.005). Similarly, emergency surgery was independently associated with increased bleeding risk, with bleeding occurring in 21.4% of emergency procedures compared with 4.1% of elective surgeries. Multivariable logistic regression further identified bridging therapy, emergency surgery, and age ≥70 years as independent predictors of major bleeding. These findings closely parallel the recommendations of the American College of Chest Physicians (CHEST) guideline, which emphasizes individualized risk assessment and recommends avoiding routine bridging in most patients because of its association with increased perioperative bleeding without substantial reduction in thromboembolic events [12]. Recent reviews by Douketis and colleagues similarly advocate patient-specific decision-making based on thromboembolic risk, procedural bleeding risk, renal function, and pharmacologic characteristics of individual agents [15]. Overall, the findings of the present study demonstrate that contemporary perioperative management strategies involving appropriate interruption of anticoagulant or antiplatelet therapy, judicious use of bridging anticoagulation, and timely postoperative resumption of treatment are associated with acceptable rates of bleeding and thromboembolic complications. The study highlights the importance of individualized perioperative planning and multidisciplinary collaboration among anesthesiologists, surgeons, physicians, and cardiologists to optimize patient outcomes. Further multicenter studies with larger sample sizes and longer follow-up are warranted to validate these findings and refine evidence-based perioperative management protocols for patients receiving antithrombotic therapy.

The present study demonstrates that individualized perioperative management of patients receiving anticoagulant and antiplatelet therapy can achieve favorable clinical outcomes with acceptable rates of bleeding and thromboembolic complications. Routine interruption of antithrombotic therapy with selective use of bridging anticoagulation, guided by patient-specific thromboembolic risk and surgical bleeding risk, appears to be an effective management strategy. Bridging anticoagulation, emergency surgery, and advanced age were identified as significant predictors of major perioperative bleeding, emphasizing the importance of careful risk stratification and multidisciplinary perioperative planning. Adherence to evidence-based guidelines and tailored management protocols may further optimize patient safety and improve perioperative outcomes in this high-risk population.

Acknowledgement: None

Funding: None

Conflict of Interest: None

1. Massel DR, Little SH. Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database Syst Rev. 2013 Jul 9;2013(7):CD003464. doi: 10.1002/14651858.CD003464.pub2. PMID: 23839768; PMCID: PMC8094423.
2. Chen A, Stecker E, A Warden B. Direct Oral Anticoagulant Use: A Practical Guide to Common Clinical Challenges. J Am Heart Assoc. 2020 Jul 7;9(13):e017559. doi: 10.1161/JAHA.120.017559. Epub 2020 Jun 15. PMID: 32538234; PMCID: PMC7670541.
3. Santana DC, Hadad MJ, Emara A, Klika AK, Barsoum W, Molloy RM, et al. Perioperative management of chronic antithrombotic agents in elective hip and knee arthroplasty. Medicina (Kaunas). 2021;57(2):188. doi:10.3390/medicina57020188.
4. Ortel TL. Perioperative management of patients on chronic antithrombotic therapy. Blood. 2012 Dec 6;120(24):4699-705. doi: 10.1182/blood-2012-05-423228. Epub 2012 Aug 1. PMID: 22855600; PMCID: PMC3653565.
5. Berry J, Patell R, Zwicker JI. The bridging conundrum: Perioperative management of direct oral anticoagulants for venous thromboembolism. J Thromb Haemost. 2023;21(4):780-86. doi:10.1016/j.jtha.2022.12.024.
6. Moster M, Bolliger D. Perioperative guidelines on antiplatelet and anticoagulant agents: 2022 update. Curr Anesthesiol Rep. 2022;12(3):286-96. doi:10.1007/s40140-021-00511-z.
7. Crowley K, Ó Scanaill P, Hermanides J, Buggy DJ. Current practice in the perioperative management of patients with diabetes mellitus: A narrative review. Br J Anaesth. 2023;131(2):242-52. doi:10.1016/j.bja.2023.02.039.
8. Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e326S-e350S. doi: 10.1378/chest.11-2298.
9. Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, et al. Perioperative management of antithrombotic therapy: An American College of Chest Physicians clinical practice guideline. Chest. 2022;162(5):e207-e243. doi:10.1016/j.chest.2022.07.025.
10. Kuo HC, Liu FL, Chen JT, Cherng YG, Tam KW, Tai YH. Thromboembolic and bleeding risk of periprocedural bridging anticoagulation: A systematic review and meta-analysis. Clin Cardiol. 2020 May;43(5):441-449. doi: 10.1002/clc.23336. Epub 2020 Jan 16. PMID: 31944351; PMCID: PMC7244304.
11. Douketis JD, Spyropoulos AC. Perioperative Management of Anticoagulant and Antiplatelet Therapy. NEJM Evid. 2023 Jun;2(6):EVIDra2200322. doi: 10.1056/EVIDra2200322. Epub 2023 May 23. PMID: 38320132.
12. Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. 2022 Nov;162(5):e207-e243. doi: 10.1016/j.chest.2022.07.025. Epub 2022 Aug 11. Erratum in: Chest. 2023 Jul;164(1):267. doi: 10.1016/j.chest.2023.05.019. PMID: 35964704.
13. Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, Garcia DA, Jacobson A, Jaffer AK, Kong DF, Schulman S, Turpie AG, Hasselblad V, Ortel TL; BRIDGE Investigators. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Aug 27;373(9):823-33. doi: 10.1056/NEJMoa1501035. Epub 2015 Jun 22. PMID: 26095867; PMCID: PMC4931686.
14. Douketis JD, Spyropoulos AC, Anderson JM, Arnold DM, Bates SM, Blostein M, Carrier M, Caprini JA, Clark NP, Coppens M, Dentali F, Duncan J, Gross PL, Kassis J, Kowalski S, Lee AY, Le Gal G, Le Templier G, Li N, MacKay E, Shah V, Shivakumar S, Solymoss S, Spencer FA, Syed S, Tafur AJ, Vanassche T, Thiele T, Wu C, Yeo E, Schulman S. The Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) Study for Patients on a Direct Oral Anticoagulant Who Need an Elective Surgery or Procedure: Design and Rationale. Thromb Haemost. 2017 Dec;117(12):2415-2424. doi: 10.1160/TH17-08-0553. Epub 2017 Dec 6. Erratum in: Thromb Haemost. 2018 Sep;118(9):1679-1680. doi: 10.1055/s-0038-1668582. PMID: 29212129.
15. Tafur A, Douketis J. Perioperative management of anticoagulant and antiplatelet therapy. Heart. 2018;104(17):1461-67. doi:10.1136/heartjnl-2016-310581.