Medicines

Simple perioperative DOAC strategy has good outcomes in AF


A standardised strategy for stopping and resuming DOAC therapy in patients with atrial fibrillation (AF) requiring elective surgery is associated with low rates of bleeding and arterial thromboembolism.

The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) study comprised 3,000 AF patients from North America and Europe who were on apixaban, dabigatran, or rivaroxaban for stroke prevention.

Patients having low bleeding risk procedures such as colonoscopy, pacemaker implantation, skin biopsy or cataract surgery stopped their DOAC one day before surgery and resumed one day after surgery.

Patients facing high bleeding risk procedures including major cardiothoracic, orthopaedic or abdominopelvic surgery stopped their DOAC two days before surgery and resumed 2-3 days after surgery.

The study found 30-day postoperative major bleeding rates ranged from 0.90% in the dabigatran cohort to 1.35% in the apixaban cohort and 1.85% in the rivaroxaban cohort.

The rate of arterial thromboembolism ranged from 0.16% with apixaban to 0.37% with rivaroxaban and 0.60% with dabigatran.

All major bleeding events and nine of ten arterial thromboembolism events occurred at a median of two days post-op.

The study authors concluded that their standardised perioperative management strategy, which did not require the use of heparin bridging or preoperative coagulation function testing, was associated with low rates of perioperative major bleeding (<2%) and arterial thromboembolism (<1%).

“Furthermore, a high proportion of patients (>90% overall; 98.8% of those at high bleeding risk) had a minimal or no residual anticoagulant level at the time of the procedure.”

Professor John Amerena, a member of the CSANZ working group that delivered the Australian clinical guidelines for AF last year, told the limbic the DOAC study findings were consistent with local recommendations.

“I think it is a good algorithm for how to manage this. They broadly reflect what we do in clinical practice and are very reasonable. All the cardiology team would agree with it.”

“The biggest issue we have with this is that the surgeons don’t want to adhere to these sorts of guidelines.”

He said surgeons will often ask patients to come off their anticoagulants a week before their operation.

“I think it is their unfamiliarity with DOACs and their fear of bleeding that they don’t want to take any chances. They think it is like aspirin or clopidogrel where you need a longer duration off.”

“What we would encourage the surgeons to do is contact us to discuss it rather than just making a unilateral decision. We would encourage consultation.”

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