Safety and Efficacy of Non–Vitamin K Oral Anticoagulant Use Early After Cardiac Surgery: A Systematic Review

Abstract

Objective: To determine the safety and efficacy of non–vitamin K oral anticoagulants (NOACs) initiated early after cardiac surgery. Data Sources:: Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE (database inception to January 20, 2021), www.clinicaltrials.gov , www.who.int/ictrp/search/en/ , NOAC trial registries, and bibliographies of relevant guidelines and other reviews were used. Study Selection and Data Extraction: Observational studies and randomized controlled trials (RCTs) that initiated NOACs within the index hospitalization and that reported bleeding for the primary outcome were included. Data Synthesis: A total of 6 cohort studies, 1 RCT, and 3 ongoing RCTs were included. Most studies were single-centered, limited to postoperative atrial fibrillation after coronary artery bypass grafting, and with 30-day follow-up; few studies included patients with isolated bioprosthetic valve replacement or valve repair. Bleeding risk varied (0%-28.6%), and all but one study showed no significantly higher risk with NOAC compared with warfarin. Relevance to Patient Care and Clinical Practice: Overall, NOACs were used in 26% to 37.5% of patients early after cardiac surgery. Starting a NOAC on postoperative day 4 appeared to have similar bleeding rates compared with warfarin, but clinical application is limited by heterogeneity of outcome definitions, confounding, and bias. Compared with warfarin, NOACs may have similar thromboembolism risk, reduced length of stay, and cost. Conclusions: There is limited evidence to guide NOAC use early after cardiac surgery. Three ongoing randomized trials will add to the literature and provide guidance for clinicians on whether, in whom, when, and how to use NOACs safely early after cardiac surgery.

Oral anticoagulants in de <i>novo</i> atrial fibrillation after cardiac surgery: a systematic review of the literature and meta-analysis

“…A systematic review by Wang showed that patients being treated with direct oral anticoagulants after cardiac surgery had a similar risk of thromboembolic events as those on warfarin, regardless of the reason for anticoagulation 34 .…”

Anticoagulantes orales en fibrilación auricular de <i>novo</i> en el posoperatorio de cirugía cardíaca: revisión sistemática de la literatura y metaanálisis

“…Una revisión sistemática de Wang mostró que pacientes en tratamiento con anticoagulantes orales directos posterior a cirugía cardíaca, tienen un riesgo de eventos tromboembólicos similar entre anticoagulantes orales directos y warfarina sin importar la indicación de anticoagulación 34 .…”

Impact of COVID-19 on the Prescribing Pattern of Oral Anticoagulants for Atrial Fibrillation After Cardiac Surgery

“…29,30 Although data supporting the premature use of DOAC (<3 months) after a biological aortic valve intervention is lacking, our study shows encouraging safety outcomes that are in keeping with the findings in the literature. 20 Significantly more patients had clinically relevant bleeding events on warfarin compared to DOAC, but it is important to note that bleeding outcomes on OAC were recorded starting from OAC initiation. Our bleeding rate on warfarin compared to DOAC is much higher than the rate reported in a metaanalysis of randomized controlled trials in AF.…”

“…29,30 Although data supporting the premature use of DOAC (<3 months) after a biological aortic valve intervention is lacking, our study shows encouraging safety outcomes that are in keeping with the findings in the literature. 20…”

“…19 The use of DOAC for AF in this post-cardiac surgery context is poorly documented. The only clinical evidence available consists of observational or pilot studies, 20 most of which excluded patients with preoperative AF. However, the safety and efficacy of DOAC are superior to warfarin for the treatment of AF outside of the post-operative context.…”