Original Article

Perioperative Resumption of Direct Oral Anticoagulants: Review of the Mayo Clinic Experience

Authors: Joan M. Irizarry Alvarado, MD, Emily K. Carpenter, BS, Daniela A. Haehn, MD, Natalia Chamorro Pareja, MD, Ismael Carrillo-Martin, MD, Pedro Malavet, MD

Abstract

Objective: We aimed to review recommendations for the postoperative resumption of direct oral anticoagulants (DOACs) and report complications 30 days postoperatively.

Methods: We retrospectively reviewed patients receiving DOAC therapy who underwent preoperative evaluations from January 1, 2015 through May 30, 2018. We noted days that DOAC therapy was withheld, postoperative time until resumption of the DOAC, and complications within 30 postoperative days.

Results: A total of 317 patients were included. Ten had complications. Complication rates among patients stratified by time to resumption were not significantly different, except for the deep vein thrombosis rate when DOACs were resumed after 72 hours (n = 2 [4.17%]; P = 0.02). The total time without DOACs did not affect the complication rates.

Conclusions: We suggest withholding DOACs for 48 to 72 hours before surgery and resuming them 48 to 72 hours after surgery, if safe. The interruption of therapy was not associated with an increase in thrombotic events for patients who resumed DOACs within 72 hours postoperatively. Patients who resumed DOACs after 72 hours postoperatively had a low rate of thrombotic complications.
Posted in: Neurology11

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Kirley K, Qato DM, Kornfield R, et al. National trends in oral anticoagulant use in the United States, 2007 to 2011. Circ Cardiovasc Qual Outcomes 2012;5:615–621.
 
2. Anter E, Jessup M, Callans DJ. Atrial fibrillation and heart failure: treatment considerations for a dual epidemic. Circulation 2009;119:2516–2525.
 
3. Go AS, Hylek EM, Borowsky LH, et al. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med 1999;131:927–934.
 
4. Kaatz S, Douketis JD, Zhou H, et al. Risk of stroke after surgery in patients with and without chronic atrial fibrillation. J Thromb Haemost 2010;8:884–890.
 
5. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 suppl):e326S–e350S.
 
6. Irizarry-Alvarado JM, Seim LA. Perioperative management of anticoagulants. Curr Clin Pharmacol 2017;12:145–151.
 
7. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008;61:344–349.
 
8. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981–992.
 
9. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883–891.
 
10. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139–1151.
 
11. Chai-Adisaksopha C, Hillis C, Isayama T, et al. Mortality outcomes in patients receiving direct oral anticoagulants: a systematic review and meta-analysis of randomized controlled trials. J Thromb Haemost 2015;13:2012–2020.
 
12. Eliquis (apixaban) [package insert]. Princeton, NJ: Bristol-Myers Squibb; 2019.
 
13. Pradaxa (dabigatran etexilate mesylate) [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals; 2018.
 
14. Xarelto (rivaroxaban) [package insert]. Titusville, NJ: Janssen Pharmaceuticals; 2019.
 
15. Savaysa (edoxaban) [package insert]. Tokyo: Daiichi Sankyo; 2015.
 
16. PL Detail-Document. Stopping antithrombotics before surgery. Pharmacist’s Letter/Prescriber’s Letter. Stockton, CA: Therapeutic Research Center; 2013.
 
17. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC Expert Consensus decision pathway for periprocedural management of anticoagulation in patients With nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 2017;69:871–898.