Perioperative Management of Direct Oral Anticoagulants in Cardiac Surgery: Practice Recommendations Based on Current Evidence

Budd, Ashley N.; Wood, Brendan; Zheng, William; Rong, Lisa Q.

doi:10.1053/j.jvca.2022.07.016

Cited by 2 publications

(3 citation statements)

References 64 publications

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“…intravenous direct thrombin inhibitor such as argatroban or bivalirudin) or the substitution with antithrombin concentrate to improve heparin activity and increase ACT as suggested in a case report 66 . The administration of PCC in emergency cardiac surgery or interventions requiring anticoagulation has also been suggested 70 . Alternatively, the use of a haemadsorption filter using a highly porous polymer filter integrated in the CPB circuit might help to reduce DOAC concentrations 71,72 …”

Section: Discussionmentioning

confidence: 99%

“…66 The administration of PCC in emergency cardiac surgery or interventions requiring anticoagulation has also been suggested. 70 Alternatively, the use of a haemadsorption filter using a highly porous polymer filter integrated in the CPB circuit might help to reduce DOAC concentrations. 71,72 PICO 4 Clinical scenario: Adults undergoing urgent surgery with DOAC therapy.…”

Section: (3)mentioning

confidence: 99%

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Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding

Grottke,

Afshari,

Ahmed

et al. 2024

European Journal of Anaesthesiology

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BACKGROUND Anticoagulation is essential for the treatment and prevention of thromboembolic events. Current guidelines recommend direct oral anticoagulants (DOACs) over vitamin K antagonists in DOAC-eligible patients. The major complication of anticoagulation is serious or life-threatening haemorrhage, which may necessitate prompt haemostatic intervention. Reversal of DOACs may also be required for patients in need of urgent invasive procedures. This guideline from the European Society of Anaesthesiology and Intensive Care (ESAIC) aims to provide evidence-based recommendations and suggestions on how to manage patients on DOACs undergoing urgent or emergency procedures including the treatment of DOAC-induced bleeding. DESIGN A systematic literature search was performed, examining four drug comparators (dabigatran, rivaroxaban, apixaban, edoxaban) and clinical scenarios ranging from planned to emergency surgery with the outcomes of mortality, haematoma growth and thromboembolic complications. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to assess the methodological quality of the included studies. Consensus on the wording of the recommendations was achieved by a Delphi process. RESULTS So far, no results from prospective randomised trials comparing two active comparators (e.g. a direct reversal agent and an unspecific haemostatic agent such as prothrombin complex concentrate: PCC) have been published yet and the majority of publications were uncontrolled and observational studies. Thus, the certainty of evidence was assessed to be either low or very low (GRADE C). Thirty-five recommendations and clinical practice statements were developed. During the Delphi process, strong consensus (>90% agreement) was achieved in 97.1% of recommendations and consensus (75 to 90% agreement) in 2.9%. DISCUSSION DOAC-specific coagulation monitoring may help in patients at risk for elevated DOAC levels, whereas global coagulation tests are not recommended to exclude clinically relevant DOAC levels. In urgent clinical situations, haemostatic treatment using either the direct reversal or nonspecific haemostatic agents should be started without waiting for DOAC level monitoring. DOAC levels above 50 ng ml−1 may be considered clinically relevant necessitating haemostatic treatment before urgent or emergency procedures. Before cardiac surgery under activated factor Xa (FXa) inhibitors, the use of andexanet alfa is not recommended because of inhibition of unfractionated heparin, which is needed for extracorporeal circulation. In the situation of DOAC overdose without bleeding, no haemostatic intervention is suggested, instead measures to eliminate the DOACs should be taken. Due to the lack of published results from comparative prospective, randomised studies, the superiority of reversal treatment strategy vs. a nonspecific haemostatic treatment is unclear for most urgent and emergency procedures and bleeding. Due to the paucity of clinical data, no recommendations for the use of recombinant activated factor VII as a nonspecific haemostatic agent can be given. CONCLUSION In the clinical scenarios of DOAC intake before urgent procedures and DOAC-induced bleeding, practitioners should evaluate the risk of bleeding of the procedure and the severity of the DOAC-induced bleeding before initiating treatment. Optimal reversal strategy remains to be determined in future trials for most clinical settings.

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Section: Discussionmentioning

confidence: 99%

Section: (3)mentioning

confidence: 99%

Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding

Grottke,

Afshari,

Ahmed

et al. 2024

European Journal of Anaesthesiology

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“…4F-PCC has been shown to be effective for treating VKA-associated ICH, 13,31 as well as DOAC-associated ICH, 32–35 and is recommended for the treatment of FXa inhibitor-associated ICH. 17,36 Guidelines for urgent or emergent cardiac surgery recommend 4F-PCC, when a specific reversal agent is not available, 37 despite limited clinical data available. 38 Retrospective data have demonstrated no differences in key efficacy outcomes between the direct OAC reversal agent, andexanet alfa, and 4F-PCC.…”

Section: Discussionmentioning

confidence: 99%

Retrospective Analysis of the Real-World Utilization of 4-Factor Prothrombin Complex Concentrate and Plasma in Oral Anticoagulant-Associated Bleeding in US Hospitals

Refaai

Bajčić

McNeill

et al. 2023

Clin Appl Thromb Hemost

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Real-world utilization of 4-factor prothrombin complex concentrate (4F-PCC) and plasma for the management of oral anticoagulant (OAC)-associated bleeding in US trauma hospitals was described. This is amulticenter, retrospective chart review evaluating the use of 4F-PCC and plasma in OAC reversal across medical specialties. Physicians completed a survey and extracted data from 3 to 5 patient charts. Variables of interest included medical specialty, urgency, and bleed type. Two hundred and thirty-five physicians completed the survey, and 861 patient charts were included in the study. 4F-PCC was commonly used in life-threatening or emergent indications, whereas plasma was used in emergent and urgent indications. Plasma was used mostly for patients on warfarin (53% vs 47% 4F-PCC) and 4F-PCC for those on apixaban (82% vs 18% plasma) and rivaroxaban (77% vs 23% plasma). This retrospective analysis showed that 4F-PCC was predominantly used for OAC reversal despite available specific reversal agents for some of the OAC. Although it is not recommended by any reversal guidelines, plasma is still used for OAC reversal. Plasma should be avoided in the management of OAC-associated bleeding.

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Perioperative Management of Direct Oral Anticoagulants in Cardiac Surgery: Practice Recommendations Based on Current Evidence

Cited by 2 publications

References 64 publications

Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding

Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding

Retrospective Analysis of the Real-World Utilization of 4-Factor Prothrombin Complex Concentrate and Plasma in Oral Anticoagulant-Associated Bleeding in US Hospitals

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