Surgical Procedures and Interventions: Patients with AF on long-term prophylaxis with OACs may need surgical or interventional procedures that require appropriate management. Since bleeding risk may obviously be increased by the anticoagulant effect, interrupting anticoagulation for an intervention or a procedure transiently exposes the patient to increased risk of thromboembolism. Appropriate management requires balancing reducing the risk of thromboembolism and preventing excessive procedure- related bleeding. In the NOAC RCTs, surgical or other invasive procedures were required during a follow up of around 2 years in one-quarter of patients in RE-LY and one-third of patients in ROCKET AF and ARISTOTLE.72-74 1186 Evidence-Based Medicine [ 1 5 4 # 5 C H E S T N O V E M B E R 2 0 1 8 ] General principles of management can be considered, to be combined with individual clinical judgment, but they are derived from consensus of experts, since no data from RCTs are available to guide clinical decision- making. The following steps are important for appropriate management:  Estimation of the bleeding risk associated with a speci c intervention/procedure. The risk of bleeding can be predicted by the type of intervention and by its need, urgent or elective. e-Table 23 classi es surgical and interventional procedures according to bleeding risk as well as thromboembolic risk.205,464,465 The direct consequence of this evaluation is that in- terventions or procedure at very low bleeding risk, such as simple dental extractions or minor skin excision, can be planned and performed without interruption of oral anticoagulation. If the bleeding risk is substantial, then interruption of anticoagulation prior to the procedure intervention is needed to minimize the hemorrhagic risk, both in the intra-operative and immediate postoperative phase.  Estimation of patient thromboembolic risk. 