Defining the safest perioperative anticoagulation management approach for patients who are receiving chronic anticoagulant therapy stroke prevention has been a challenging and longstanding dilemma, especially for patients with atrial fibrillation who constitute the most common patient group receiving long term anticoagulation. Using a case-based format, we summarize the findings of recent clinical trialswhich have helped to informed best practices for perioperative anticoagulant management in patients with atrial fibrillation and provide an algorithmic management approach to this problem. We have done so by exploring the evidence to address 3 key questions: Is it necessary to interrupt anticoagulation for a procedure? How to estimate a patient's risk for perioperative thromboembolism and bleeding? If chronic anticoagulation interruption is required, is bridging anticoagulation with heparin needed?