Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Abstract

Non–vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.

Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: An evaluation of the evidence and consensus recommendations

“…The perioperative management and bridging of oral anticoagulants and the decision to reverse them will depend upon the last dose relative to surgery, renal function, risk of thromboembolism and their anticoagulant activity. 110 Warfarin may be reversed with Vitamin K and fresh frozen plasma. Of the NOACs, only dabigatran has an FDA-approved reversal agent (Idarucizumab).…”

Transcatheter aortic valve implantation. Expert Consensus of the Association of Cardiovascular Interventions of the Polish Cardiac Society and the Polish Society of Cardio-Thoracic Surgeons, approved by the Board of the Polish Cardiac Society…

“…The recommended antiplatelet and antithrombotic therapy after TAVI, based on comorbidities and patient bleeding risk, is presented in Tables 4 and 5 [121][122][123][124]. Publication of randomised clinical trials evaluating optimal antiplatelet and antithrombotic therapy after TAVI (novel oral anticoagulants [NOAC], and their pairing with ticagrelor), the introduction of new stents, as well as the publication of new guidelines on the use of dual antiplatelet therapy may modify our current recommendations.…”

Direct Oral Anticoagulant Drugs in Dental Clinical Practice

“…or slightly reduced renal function (GFR, 50-80 ml / min.) (10,11). Therefore, the final dose of dabigatran in patients with high risk of bleeding should be stopped 2-3 days before the surgical procedure and one to two days before the surgical procedure in patients with normal risk of bleeding (Table 3).…”

“…2 DOAC advantages and disadvantages (7,8,9 - Apixaban, edoxaban and rivaroxaban Preoperative discontinuation of apixaban, edoxaban and rivaroxaban depends on: 1) the halflife of the drug (apixaban 8-15 hours, edoxaban 10-14 hours and rivaroxaban 5-13 hours) and 2) the renal clearance of the drug (apixaban 25 %, edoxaban 50 % and rivaroxaban 33 %) (10,11,14). According to SPC the administration of edoxaban and rivaroxaban should be discontinued at least 24 hours prior to the procedure, and treatment should be restarted as soon as the clinical situation allows (8).…”

“…concentration of DOAC is decreased by rifampin, carbamazepine, phenytoin; concentration of DOAC is increased especially by ketoconazole, dronedarone, cyclosporine and in less extent by verapamil, amiodarone, quinidine, clarithromycin, ticagrelor, etc.) (11). In these situations the consultation with hematologist and specialist indicating anticoagulant treatment is necessary.…”