Clinical question: Is it safe to adopt a standardized approach to direct oral anticoagulant (DOAC) interruption for patients with atrial fibrillation (AFib) who are undergoing elective surgeries/procedures?
Background: At present, perioperative management of DOACs for patients with AFib has significant variation, and robust data are absent. Points of controversy include: The length of time to hold DOACs before and after the procedure, whether to bridge with heparin, and whether to measure coagulation function studies prior to the procedure.
Study design: Prospective cohort study.
Setting: Conducted in Canada, the United States, and Europe.
Synopsis: The PAUSE study included adults with atrial fibrillation who were long-term users of either apixaban, dabigatran, or rivaroxaban and were scheduled for an elective procedure (n = 3,007). Patients were placed on a standardized DOAC interruption schedule based on whether their procedure had high bleeding risk (held for 2 days prior; resumed 2-3 days after) or low bleeding risk (held for 1 day prior; resumed 1 day after).
The primary clinical outcomes were major bleeding and arterial thromboembolism. Authors determined safety by comparing to expected outcome rates derived from research on perioperative warfarin management.
They found that all three drugs were associated with acceptable rates of arterial thromboembolism (apixaban 0.2%, dabigatran 0.6%, rivaroxaban 0.4%). The rates of major bleeding observed with each drug (apixaban 0.6% low-risk procedures, 3% high-risk procedures; dabigatran 0.9% both low- and high-risk procedures; and rivaroxaban 1.3% low-risk procedures, 3% high-risk procedures) were similar to those in the BRIDGE trial (patients on warfarin who were not bridged perioperatively). However, it must still be noted that only dabigatran met the authors’ predetermined definition of safety for major bleeding.
Limitations include the lack of true control rates for major bleeding and stroke, the relatively low mean CHADS2-Va2Sc of 3.3-3.5, and that greater than 95% of patients were white.
Bottom line: For patients with moderate-risk atrial fibrillation, a standardized approach to DOAC interruption in the perioperative period that omits bridging along with coagulation function testing appears safe in this preliminary study.
Citation: Douketis JD et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med. 2019 Aug 5. doi: 10.1001/jamainternmed.2019.2431.
Dr. Gordon is a hospitalist at Maine Medical Center in Portland.