Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital

Wamala, Henry; Scott, Ian A; Caney, Xenia

doi:10.1111/imj.13513

Cited by 6 publications

(5 citation statements)

References 43 publications

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“…While most patients included in the analysis had AF (75.3% of the patients), only a small fraction had suffered a previous stroke or TIA (18.7% of patients). 12 Similar to our study, the adherence to anticoagulation interruption was low with the perioperative guidelines (59/150 or 40% did not adhere). Anticoagulation was stopped in patients who underwent high-and low-bleed risk procedures, but nonadherence (59/150) was shown only in the low-bleeding risk group.…”

Section: Discussionsupporting

confidence: 84%

“…10,11 There are only a few studies that have reviewed adherence to anticoagulation but have rarely looked specifically at high-risk patients, especially those with a prior history of stroke. 12,13 In the ROCKET AF study, temporary interruptions of anticoagulants were frequent, and this was associated with an increased risk of stroke and bleeding. 14 There is, however, limited data on the adherence to perioperative anticoagulation guidelines for invasive procedures and the risk of embolic complications in patients with AF and prior stroke, and this requires further study.…”

Section: Introductionmentioning

confidence: 99%

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Adherence to Anticoagulation Interruption Guidelines in Patients with Atrial Fibrillation

Siddique

Butt

Sultan

et al. 2022

Can. J. Neurol. Sci.

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Introduction: Annually, 15% of patients who receive oral anticoagulation require interruption for surgery or an invasive procedure. This study evaluates the adherence of patients with atrial fibrillation with a history of stroke or transient ischemic attack to the Thrombosis Canada Perioperative guidelines for the discontinuation and reinitiation of anticoagulation treatment. Methods: We collected data from a prospective patient survey at the Stroke Prevention Clinic in the University of Alberta hospital. Patients’ charts were reviewed from the electronic medical records, and adherence was looked at according to the Thrombosis Canada Perioperative guidelines for the interruption of anticoagulants. Results: During the study period (2016–2019), there were 509 patients surveyed. Anticoagulation treatment was interrupted in 150 patients with 98 interrupted for surgical or invasive procedures. The interruption was adherent to guidelines in only 29 (29.6%) of patients and inappropriate or nonadherent in 69 (70.4%) patients. There were seven ischemic strokes recorded during the period of interruption. The proportion of strokes was higher in patients whose anticoagulation interruption was longer than what the guidelines recommended (6/61 or 9.8%) when compared to those who adhered to recommended perioperative anticoagulation guidelines (1/29 or 3.4%). Conclusion: Our results indicate that significant discrepancy with following the recommended perioperative anticoagulation guidelines is common in real-life practice. Delay in re-anticoagulation may increase the risk of complications.

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Section: Discussionsupporting

confidence: 84%

Section: Introductionmentioning

confidence: 99%

Adherence to Anticoagulation Interruption Guidelines in Patients with Atrial Fibrillation

Siddique

Butt

Sultan

et al. 2022

Can. J. Neurol. Sci.

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“…This is consistent with a recent audit of elective surgical patients on NOAC drugs. 11 While this was associated with most patients in our cohort having normal coagulation profiles and negligible dabigatran concentrations on day of surgery, the downside to this approach is that there may an increased risk of thromboembolic complications. Further, even though our sample size is too small to make meaningful comments on complication rates, it should be noted that two of our patients suffered ischaemic strokes in the perioperative period, which would far exceed numbers predicted for such a population.…”

Section: Discussionmentioning

confidence: 90%

The effect of routine preoperative interruption of dabigatran therapy on coagulation parameters and dabigatran plasma levels in a mixed surgical population

Brett

Chin

2019

Anaesth Intensive Care

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Summary Dabigatran is an oral anticoagulant used for atrial fibrillation and venous thromboembolism. While an effective antibody reversal agent is available, its cost precludes routine use and the mainstay of preoperative management is timely dabigatran interruption. Unlike warfarin, there are no universally accepted protocols for interruption of dabigatran in the preoperative period and there is uncertainty around the interpretation of standard coagulation tests in the presence of dabigatran. We performed a prospective, observational pilot study in patients presenting for elective surgery to examine: 1) the preoperative plasma dabigatran concentrations on day of surgery associated with the local dabigatran interruption protocol, 2) the potential utility of dabigatran concentrations on day of surgery, and 3) the utility of standard coagulation tests in determining whether dabigatran concentrations were below a ‘safe’ threshold for surgery. We recruited patients presenting to pre-admission clinics for elective surgery. Dabigatran concentrations below 30 µg/L were considered adequate for proceeding with surgery. Data were obtained and analysed from 21 patients with a median (range) age of 70 (20–86) years. Median (range) dabigatran concentrations on the day of surgery were 5 (0–59) µg/L. Two patients had day of surgery concentrations exceeding 30 µg/L. Of the standard coagulation tests examined, only the thrombin clotting time (TCT) was abnormal for these two patients. Our interruption protocol was associated with safe dabigatran concentrations in most patients on the day of surgery. A minority of patients had dabigatran concentrations above the safe threshold, which were detectable by abnormal TCT results.

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“…Another proposed consideration is the use of a therapeutic bridge utilizing antiplatelet drugs with shorter durations of action. In fact, other comprehensive reviews have offered variable guidance (27,31,32,34,49,54,(124)(125)(126)(127)(128)(129)147,149,212,251,(284)(285)(286)(287)(288)(289)(290)(291)(292)(293)(294)(295)(296)(297)(298)(299) on anticoagulation management. One systematic review (299), which evaluated 31 reports determined that for dental procedures, arthrocentesis, cataract surgery, and diagnostic endoscopy most patients can proceed without alteration to their anticoagulant therapy.…”

Section: Risk/benefits Of Antithrombotic Therapymentioning

confidence: 99%

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Manchikanti

2019

Pain Phys

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Background: Interventional pain management involves diagnosis and treatment of chronic pain. This specialty utilizes minimally invasive procedures to target therapeutics to the central nervous system and the spinal column. A subset of patients encountered in interventional pain are medicated using anticoagulant or antithrombotic drugs to mitigate thrombosis risk. Since these drugs target the clotting system, bleeding risk is a consideration accompanying interventional procedures. Importantly, discontinuation of anticoagulant or antithrombotic drugs exposes underlying thrombosis risk, which can lead to significant morbidity and mortality especially in those with coronary artery or cerebrovascular disease. This review summarizes the literature and provides guidelines based on best evidence for patients receiving anti-clotting therapy during interventional pain procedures. Study Design: Best evidence synthesis. Objective: To provide a current and concise appraisal of the literature regarding an assessment of the bleeding risk during interventional techniques for patients taking anticoagulant and/or antithrombotic medications. Methods: A review of the available literature published on bleeding risk during interventional pain procedures, practice patterns and perioperative management of anticoagulant and antithrombotic therapy was conducted. Data sources included relevant literature identified through searches of EMBASE and PubMed from 1966 through August 2018 and manual searches of the bibliographies of known primary and review articles. Results: 1. There is good evidence for risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk. Also, their risk should be upgraded based on other risk factors. 2. There is good evidence for the risk of thromboembolic events in patients who interrupt antithrombotic therapy. 3. There is good evidence supporting discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and there is moderate evidence that these may be continued for low risk or some intermediate risk procedures.4. There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran (Pradaxa®), argatroban (Acova®), bivalirudin (Angiomax®), lepirudin (Refludan®), desirudin (Iprivask®), hirudin, apixaban (Eliquis®), rivaroxaban (Xarelto®), edoxaban (Savaysa®, Lixiana®), Betrixaban(Bevyxxa®), fondaparinux (Arixtra®) prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety. 5. There is good evidence that diagnosis of epidural hematoma is based on severe pain at the site of the injection, rapid neurological deterioration, and MRI with surgical decompression with progressive neurological dysfunction to avoid neurological sequelae. 6. There is good evidence that if thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure. 7. There is fair evidence that the risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques, though both risks are significant. 8. There is fair evidence that multiple variables including anatomic pathology with spinal stenosis and ankylosing spondylitis; high risk procedures and moderate risk procedures combined with anatomic risk factors; bleeding observed during the procedure, and multiple attempts during the procedures increase the risk for bleeding complications and epidural hematoma. 9. There is fair evidence that discontinuation of phosphodiesterase inhibitors is optional (dipyridamole [Persantine], cilostazol [Pletal]. However, there is also fair evidence to discontinue Aggrenox [dipyridamole plus aspirin]) 3 days prior to undergoing interventional techniques of moderate and high risk. 10. There is fair evidence to make shared decision making between the patient and the treating physicians with the treating physician and to consider all the appropriate risks associated with continuation or discontinuation of antithrombotic or anticoagulant therapy. 11. There is fair evidence that if thromboembolic risk is high antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed. 12. There is limited evidence that discontinuation of antiplatelet therapy (clopidogrel [Plavix®], ticlopidine [Ticlid®], Ticagrelor [Brilinta®] and prasugrel [Effient®]) avoids complications of significant bleeding and epidural hematomas. 13. There is very limited evidence supporting the continuation or discontinuation of most NSAIDs, excluding aspirin, for 1 to 2 days and some 4 to 10 days, since these are utilized for pain management without cardiac or cerebral protective effect. Limitations: The continued paucity of the literature with discordant recommendations. Conclusion: Based on the survey of current literature, and published clinical guidelines, recommendations for patients presenting with ongoing antithrombotic therapy prior to interventional techniques are variable, and are based on comprehensive analysis of each patient and the risk-benefit analysis of intervention. Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions, pain

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Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital

Abstract: Considerable discordance exists between guideline recommendations and perioperative NOAC management. Assistive tools are required that better align decision-making with current best practice.

Cited by 6 publications

References 43 publications

Adherence to Anticoagulation Interruption Guidelines in Patients with Atrial Fibrillation

Adherence to Anticoagulation Interruption Guidelines in Patients with Atrial Fibrillation

The effect of routine preoperative interruption of dabigatran therapy on coagulation parameters and dabigatran plasma levels in a mixed surgical population

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

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