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Perioperative management strategy lowers stroke, bleeding risk in patients on direct oral anticoagulants

In patients with atrial fibrillation, or AF, treated with direct oral anticoagulants, standardized perioperative management approaches were tied to lower rates of bleeding and stroke, according to a study published in JAMA Internal Medicine.

“The perioperative management of patients who receive a direct oral anticoagulant (DOAC) for AF and require elective surgery or procedure is a common clinical scenario for which best practices are uncertain,” James D. Douketis, MD, of the department of medicine at McMaster University, Hamilton, Canada, and colleagues wrote.

The Perioperative Anticoagulation Use for Surgery Evaluation study assessed patients with AF treated with direct oral anticoagulant who needed to interrupt treatment for an elective surgery or procedure. The cohort study enrolled patients from Aug. 1, 2014 through July 31, 2018 in 23 clinical centers in the United States, Canada and Europe.

The cohort consisted of patients with AF who were long-term users of apixaban, dabigatran etexilate, or rivaroxaban, and were scheduled for an elective surgery or procedure that would require them to interrupt their anticoagulation treatment.

Patients were managed with a perioperative DOAC therapy interruption and resumption strategy based on the pharmacokinetic properties, procedure-associated bleeding risk and creatinine clearance levels. The strategy did not involve heparin bridging. Treatment regimens were stopped 1 day before low-bleeding risk procedures and resumed 1 day after the procedure. For high-bleeding risk procedures, treatment was stopped 2 days before and resumed 2 to 3 days after the procedure.

Researchers enrolled 3,007 patients with AF with a mean age of 72.5 years in the study. Of those, 1,257 (41.8%) were in the apixaban cohort, 668 (22.2%) were in the dabigatran cohort, and 1,082 (36.0%) made up the rivaroxaban cohort.

A total of 1,007 (33.5%) had a procedure with a high bleeding risk. Among patients who had these procedures, the rate of major bleeding was 2.96% (95% CI, 0-4.68) in the apixaban cohort and 2.95% (95% CI, 0-4.76) in the rivaroxaban cohort.

The rate of 30-day postoperative bleeding was 1.35% (95% CI, 0-2) in the apixaban cohort, 0.9% (95% CI, 0-1.73) in the dabigatran cohort and 1.85% (95% CI, 0-2.65) in the rivaroxaban cohort.

Atrial thromboembolism occurred in 0.16% (95% CI,0-0.48) of the apixaban cohort, 0.6% (95% CI, 0-1.33) of the dabigatran cohort, and 0.37% (95% CI, 0-0.82) of the rivaroxaban cohort.

“In this study, patients with AF who had DOAC therapy interruption for elective surgery or procedure, a simple standardized perioperative management strategy without heparin bridging or measurement of coagulation function was associated with low rates of major bleeding and arterial thromboembolism,” Douketis and colleagues wrote. – by Erin Michael

Disclosures: Douketis reported personal fees from Bristol-Myers Squibb, Janssen, Leo Pharma, The Merck Manual, Pfizer, Sanofi and UpToDate outside of the submitted work.