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Importance: Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.
Observations: For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.
Conclusions and relevance: When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.
Guideline title Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline
Release date November 2022
Developer and funding source American College of Chest Physicians
Target population Patients taking oral anticoagulation or antiplatelet therapy who are undergoing an elective surgery or procedure
Selected recommendations
For patients requiring aspirin therapy who are undergoing an elective noncardiac surgery, continuing aspirin through the surgery is suggested (conditional recommendation; moderate certainty of evidence [COE]).
For patients with atrial fibrillation taking vitamin K antagonists (VKAs) who are undergoing an elective surgery or procedure with low to moderate risk of thromboembolism, temporary use of therapeutic heparin doses during interruption of VKA (heparin bridging) is not recommended (strong recommendation; moderate COE).
For patients with a mechanical heart valve with low to moderate risk of thromboembolism who require VKA interruption for an elective surgery or procedure, heparin bridging is not suggested (conditional recommendation; very low COE).
For patients receiving a direct oral anticoagulant (DOAC) who will be undergoing an elective surgery or procedure, discontinuing DOAC therapy is suggested with the timing dependent on the specific DOAC and the bleeding risk of the procedure (conditional recommendation; very low COE).
