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Perioperative anticoagulation — MCCQE Part 1 MCQ

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ModeratePost-operative ComplicationsPerioperative anticoagulationMCCQE Part 1

A 70-year-old man with nonvalvular atrial fibrillation takes warfarin and has a CHADS2 score of 2, with no previous stroke or TIA. His INR is 2.5. He is scheduled for elective inguinal hernia repair under general anaesthesia in 5 days. What is the most appropriate perioperative anticoagulation plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Stop warfarin now, do not bridge with heparin, and resume warfarin within 24 hours after surgery if haemostasis is secure

This is a low-to-moderate stroke-risk patient with atrial fibrillation (CHADS2 2) undergoing a procedure that is not minimal bleeding risk. Canadian Stroke Best Practices recommends stopping warfarin 5 days before the procedure and resuming it within 24 hours afterward once haemostasis is secure, without heparin bridging. Therapeutic bridging is reserved for high stroke risk, such as CHADS2 5–6 or a prior perioperative stroke, because bridging in lower-risk atrial fibrillation adds bleeding without sufficient thromboembolic benefit. Continuing warfarin is reserved for minimal-bleeding-risk procedures, and acetylsalicylic acid is not a substitute for anticoagulation in atrial fibrillation.

Reference: Canadian Stroke Best Practices, Perioperative Management of Anticoagulant and Antiplatelet Therapy: https://www.strokebestpractices.ca/recommendations/secondary-prevention-of-stroke/perioperative-management-of-anticoagulant-and-antiplatelet-therapy