Anticoagulation Pauses and Anesthetic Options: A Case for Multidisciplinary Harmonization

Perioperative anticoagulation management is increasingly guided by recommendations from multiple specialties, including cardiology, thrombosis medicine, stroke medicine, and surgery. These frameworks, while intending to improve standardization of interruption and resumption strategies for antithrombotic therapy, are largely centered on surgical bleeding risk and thromboembolic risk, while regional anesthesia (RA) guidelines differ in pause intervals for many oral anticoagulants due to the differing thresholds for acceptable residual anticoagulant activity, with the potentially catastrophic consequences of neuraxial hematoma in mind. Emerging evidence also suggests that measurable direct oral anticoagulant (DOAC) activity may persist despite guideline-consistent interruption in some patients, highlighting pharmacokinetic variability in real-world perioperative populations. Multidisciplinary, institution-specific frameworks and testing of anticoagulant activity in select cases may help harmonize multiple sources of guidance and support coordinated decision-making across surgical, anesthesia, and perioperative care teams. In this perspective piece, we intend to highlight discrepancies in perioperative anticoagulation guidance and discuss ways to promote harmonization strategies with considerations for RA choices.