Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review

Efficacy of direct oral anticoagulants versus low-molecular-weight heparin for thromboprophylaxis after gynecological cancer surgery: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to enoxaparin, a low molecular weight heparin (LMWH). for postoperative thromboprophylaxis in patients undergoing gynecologic cancer surgery.

METHODS

This systematic review and meta-analysis followed Cochrane Handbook guidelines and PRISMA recommendations. We searched PubMed, Embase, Scopus, and CENTRAL for randomized controlled trials (RCTs) and observational studies comparing DOACs and LMWHs for postoperative VTE prophylaxis in gynecologic cancer surgeries. Outcomes included VTE incidence, major bleeding, clinically relevant non-major bleeding (CRNMB), hospital readmission, and drug adherence. The risk of bias was assessed using the Cochrane tools (RoB-2 and ROBINS-I), and statistical analyses were conducted using Review Manager 5.

RESULTS

Five studies (1436 patients) were included: two RCTs and three observational studies. There was no significant difference in 30-day VTE incidence between DOAC and LMWH groups (OR, 0.55; 95 % CI, 0.17 to 1.77; P = 0.31). Similarly, major bleeding rates showed no difference (OR, 1.13; 95 % CI, 0.29 to 4.42; P = 0.90). DOACs significantly reduced CRNMB events compared to LMWHs (OR, 0.44; 95 % CI, 0.23 to 0.82; P = 0.01). Hospital readmissions (OR, 0.68; 95 % CI, 0.33 to 1.41; P = 0.30) and drug adherence rates (OR, 0.95; 95 % CI, 0.36 to 2.52; P = 0.29) were comparable between the groups.

CONCLUSIONS

DOACs provide a safe and effective alternative to LMWH for postoperative thromboprophylaxis in gynecologic cancer surgeries. The significant reduction in CRNMB events suggests a potential safety advantage of DOACs.

Risk of Neck Hematoma Following Thyroidectomy in Patients Taking Direct Oral Anticoagulants: A Propensity Score Matching Analysis from Nine High-Volume European Centers (RAGNO Study)

Background: Postoperative neck hematoma is an infrequent but potentially fatal complication following thyroidectomy. The main aim of this study was to evaluate the impact of direct oral anticoagulants (DOACs) on the occurrence of this complication. Methods: Patients who underwent thyroidectomy between January 2020 and December 2022 in nine high-volume thyroid surgery centers in Europe were retrospectively evaluated. Based on taking direct oral anticoagulants, patients were divided into two groups: the DOAC Group and the Control Group. Propensity score matching 1:1 was performed between the two groups, which were then compared through a univariate analysis. Results: The total number of patients enrolled based on the inclusion/exclusion criteria was 8985. Following propensity score matching, the study population consisted of 316 patients: 158 in the DOAC Group and 158 in the Control Group. In the DOAC Group, the overall incidence of neck hematoma was 5.70% (4.43% for neck hematomas managed conservatively, and 1.27% for those that required surgical revision of hemostasis). No statistically significant difference was found between the two groups in terms of the incidence of this complication. Hospital readmission due to neck hematoma was not observed in any patient. No statistically significant difference was found between the two groups in terms of the timing of the onset of neck hematomas that required surgical revision of hemostasis. Conclusions: This study showed that direct oral anticoagulants, in the field of thyroid surgery, have no impact on the occurrence of postoperative neck hematoma. Therefore, based on our findings, it can be concluded that thyroidectomy can be safely performed in patients taking this class of drugs.

The critical role of platelets in venous thromboembolism: Pathogenesis, clinical status, and emerging therapeutic strategies

Venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), is a complex vascular disorder with high morbidity and mortality, driven by Virchow's Triad: blood stasis, hypercoagulability, and endothelial injury. VTE is now recognized as an inflammatory process involving multiple components. Platelets are involved in the process of VTE, contributing to thrombosis initiation, progression, resolution and recurrence through coagulation activation, and interactions with immune and endothelial cells. Anticoagulation remains the cornerstone of VTE treatment; however, antiplatelet agents like aspirin have demonstrated therapeutic potential, particularly following major orthopedic surgeries. Furthermore, emerging platelet-targeted therapies and biomarkers offer new opportunities for improving VTE diagnosis and treatment. This review explores the evolving role of platelets in VTE pathophysiology, assesses current antiplatelet strategies, and highlights novel therapeutic approaches. Advancing platelet research in VTE may lead to safer, more effective interventions, optimizing outcomes for patients with this life-threatening condition.

[Diagnostics and management of perioperative bleeding disorders]

Perioperative bleeding is and remains a major complication during and after surgical interventions, resulting in increased morbidity and mortality. The main causes of a non-primary vascular-related bleeding are congenital or multifactorial pre-existing hemostatic disorders that have not yet been diagnosed, the operating procedure itself and acquired hemostatic abnormalities as a secondary phenomenon, e.g., after excessive volume depletion in hypothermia, trauma or extracorporeal circulation, concomitant hypothermia and loss or consumption of coagulation factors and thrombocytes. Beginning with the preoperative preparation, including an extensive medical history, the detection of potential risk factors for increased bleeding including the precise description of current medication is required and prophylactic strategies and procedures should be initiated. In cases of excessive bleeding it is essential to implement adequate diagnostic and therapeutic algorithms, which are suitable for the partly complex and variable alterations of the hemostasis (e.g., in interventions after trauma or with extracorporeal circulation). A multimodal management is necessary to improve the patient's outcome, to limit the administration of blood products to that which is absolutely necessary and to minimize the risks associated with transfusion.

More Cyberbullying, Less Happiness, and More Injustice-Psychological Changes During the Pericyberbullying Period: Quantitative Study Based on Social Media Data

BACKGROUND

The phenomenon of cyberbullying is becoming increasingly severe, and many studies focus on the negative psychological impacts of cyberbullying survivors. However, current survey methods cannot provide direct and reliable evidence of the short-term psychological effects of cyberbullying survivors, as it is impractical to measure psychological changes before and after such an unpredictable event in a short period.

OBJECTIVE

This study aims to explore the psychological impacts of cyberbullying on survivors during the pericyberbullying period, defined as the critical time frame surrounding the first cyberbullying incident, encompassing the psychological changes before, during, and after the event.

METHODS

We collected samples from 60 cyberbullying survivors (experimental group, 94/120, 78% female) and 60 individuals who have not experienced cyberbullying (control group, matched by sex, location, and number of followers) on Sina Weibo, a social media platform developed by Sina Corporation. During the pericyberbullying period, we retrospectively measured psychological traits 3 months before and after the first cyberbullying incident for both groups. Social media data and predictive models were used to identify survivors' internal psychological traits, including happiness, suicide risk, personality traits, and moral perceptions of the external environment. Network analysis was then performed to explore the interplay between cyberbullying experiences and psychological characteristics.

RESULTS

During the pericyberbullying period, survivors exhibited significantly reduced happiness (t59=2.14; P=.04), marginally increased suicide risk, and significant changes in the Big 5 personality traits, including decreased conscientiousness (t59=2.27; P=.03), agreeableness (t59=2.79; P=.007), and extraversion (t59=2.26; P=.03), alongside increased neuroticism (t59=-3.42; P=.001). Regarding moral perceptions of the external environment, survivors showed significant increases in communicative moral motivation (t59=-2.62; P=.011) and FairnessVice (t59=-2.20; P=.03), with a marginal rise in PurityVice (t59=-1.88; P=.07). In contrast, the control group exhibited no significant changes during the same time frame. Additionally, network analysis revealed that beyond cyberbullying experiences, core psychological characteristics in the network were neuroticism, conscientiousness, and Oxford Happiness.

CONCLUSIONS

By leveraging noninvasive retrospective social media data, this study provides novel insights into the short-term psychological impacts of cyberbullying during the pericyberbullying period. The findings highlight the need for timely interventions focusing on enhancing survivors' happiness, reducing suicide risk, adjusting personality traits, and rebuilding moral cognition to mitigate the negative effects of cyberbullying.

Perioperative Factor Xa Inhibitor Discontinuation for Patients Undergoing Procedures With Minimal or Low Bleeding Risk

Importance

Discontinuation of oral anticoagulant treatment is common in clinical practice due to concerns about bleeding, even for procedures with minimal to low bleeding risk.

Objective

To explore whether perioperative discontinuation of factor Xa inhibitors is associated with major bleeding and thromboembolic events in patients with atrial fibrillation (AF) undergoing procedures with minimal to low bleeding risk.

Design, Setting, and Participants

This prospective, multicenter, single-arm cohort study conducted in Korea included patients with AF who planned to undergo a procedure with minimal to low bleeding risk between September 25, 2020, and April 5, 2024.

Exposure

The PERIXa (Perioperative Factor Xa Inhibitor Discontinuation in Patients With Atrial Fibrillation Undergoing Minimal to Low Bleed Risk Procedures) protocol recommending giving the last dose of factor Xa inhibitor (ie, apixaban, edoxaban, or rivaroxaban) 24 hours before the procedure (ie, endoscopy, dental procedure, or ocular surgery) and restarting treatment with the inhibitor the next day.

Main Outcomes and Measures

The primary outcome was major bleeding, and the secondary outcome included a composite of thromboembolic events 30 days after the index procedure with minimal to low bleeding risk.

Results

In total, 1902 patients were included in the modified intention-to-treat analysis set encompassing all patients who underwent the intended procedure (mean [SD] age, 70.4 [8.8] years; 1135 [59.7%] male; mean [SD] CHA2DS2-VASc [congestive heart failure, hypertension, age 75 years or older, diabetes, stroke, vascular disease, age 65-74 years, and female sex; range, 0-9, with higher scores indicating higher risk of stroke] score, 2.8 [1.3]; mean [SD] HAS-BLED [hypertension, kidney or liver disease, stroke history, prior bleeding, unstable international normalized ratio, age >65 years, and drug or alcohol use; range, 0-9, with higher scores indicating higher risk of bleeding] score, 1.6 [0.7]). Among them, 921 (48.4%) were receiving apixaban, 616 (32.4%) were receiving edoxaban, and 365 (19.2%) were receiving rivaroxaban. Of the total procedures, 948 (49.8%) were endoscopy, 820 (43.1%) were dental procedures, and 120 (6.3%) were ocular surgery. The 30-day event rate of major bleeding was 0.1% (n = 2), and there were no composite thromboembolic events. The results were consistent in the per-protocol analysis, and no differences were observed by procedure category or factor Xa inhibitor type.

Conclusions and Relevance

In this cohort study, patients with AF receiving a factor Xa inhibitor and undergoing a procedure with minimal to low bleeding risk had low rates of major bleeding and thromboembolism when following the standardized PERIXa protocol for perioperative management of oral anticoagulant treatment, suggesting that this may be a safe and reasonable option for this patient population.

Prediction and prevention of post-procedural bleedings in patients with cirrhosis

Although post-procedural bleedings are infrequent in patients with cirrhosis, they are associated with significant morbidity and mortality. Therefore, predicting and preventing such bleedings is important. Established predictors of post-procedural bleeding include high-bleeding risk procedure, severe cirrhosis and high body mass index; prognostic value of anemia, acute kidney injury and bacterial infection is more uncertain. While prothrombin time and international normalized ratio do not predict post-procedural bleeding, some evidence suggests that platelet count, whole blood thrombin generation assay and viscoelastic tests may be helpful in this context. Prevention of postprocedural bleeding involves careful management of antithrombotic drugs during the periprocedural period. Patients with cirrhosis present unique challenges due to altered pharmacokinetics and pharmacodynamics of antithrombotic drugs, but there is a lack of dedicated studies specifically focused on this patient population. Guidelines for periprocedural management of antithrombotic drugs developed for patients without liver disease are thus applied to those with cirrhosis. Some technical aspects may decrease the risk of post-procedural bleeding, namely ultrasoundguidance, opting for transjugular route rather than percutaneous route, and the level of expertise of the operator. The effectiveness of platelet transfusions or thrombopoietin-receptor agonists remains uncertain. Transfusion of fresh-frozen plasma, of fibrinogen, and administration of tranexamic acid are not recommended for reducing post-procedural bleeding in patients with cirrhosis. In conclusion, prediction of post-procedural requires a global approach taking into account the patients characteristics, the risk of the procedure, and the platelet count. There is little data to support prophylactic correction of hemostasis, and dedicated studies are needed.

Direct-acting oral anticoagulant removal by intraoperative hemoadsorption in CABG and/or single valve surgery: interim analysis of the International Safe and Timely Antithrombotic Removal (STAR) registry

OBJECTIVE

Patients on direct-acting oral anticoagulants (DOACs) are at high risk of perioperative bleeding complications. Intraoperative hemoadsorption is a novel strategy to reduce perioperative bleeding in patients on DOACs undergoing non-deferable cardiac surgery. The international STAR-registry reports real-world clinical outcomes associated with this application.

METHODS

The hemoadsorption device was incorporated into the cardiopulmonary bypass (CPB) circuit and active for the duration of the pump run. Patients on DOACs undergoing CABG and/or single valve surgery before completing the recommended washout were included. Outcome measurements included bleeding events according to standardized definitions and 24-hour chest-tube-drainage (CTD).

RESULTS

A total of 62 patients were included from 7 institutions in Austria, Germany, Sweden, and the UK (mean age 69.9 ± 7.5years, 71% male). Approximately half were on apixaban and the other half was split between rivaroxaban and edoxaban with 21% of patients also on aspirin. Surgery occurred at a median time of 28.9 h since the last DOAC dose with single valve surgery accounting for 2/3 of cases. Mean CPB duration was 118.6 ± 46.4 min. Severe bleeding (UDPB ≥ 3) occurred in 4.8%, and BARC-4 bleeding occurred in 3.2% of the patients. Only one patient (1.6%) required reoperation for bleeding control. The mean 24-hour CTD was 771.3 ± 482.79mL. No device-related adverse events were reported.

CONCLUSIONS

This interim report of the ongoing STAR-registry shows that, in patients on DOAC undergoing non-deferable CABG and/or single valve surgery, the use of intraoperative hemoadsorption is associated with low rates of severe perioperative bleeding complications. Further prospective studies in larger cohorts are needed to validate the efficacy of this method.

CLINICAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT05077124.

Clopidogrel Management in Abdominal Surgery: A Comparison of Perioperative Bleeding Risks with Low-Molecular-Weight Heparin Bridging, No-Bridging and Clopidogrel Continuation Strategies

Clopidogrel is usually discontinued 5-7 days before elective surgery to reduce the risk of bleeding. However, the perioperative safety of patients receiving low-molecular-weight heparin (LMWH) bridging therapy or continuing clopidogrel therapy remains unknown. We identified patients who received clopidogrel for cardiovascular diseases and underwent elective surgery at a large central hospital in China between June 2022 and January 2024. The primary endpoints were perioperative blood transfusion events and bleeding-related reoperations. A total of 62 patients who received clopidogrel and underwent abdominal surgery were included in this study. Based on the preoperative clopidogrel therapy strategy, patients were categorised into three groups: the LMWH bridging group (clopidogrel withdrawal followed by LMWH bridging therapy for 5-7 days; n = 22), the no-bridging group (clopidogrel withdrawal for 5-7 days; n = 26), and the continued group (clopidogrel therapy maintained; n = 24). Perioperative blood transfusion rates were higher in the LMWH bridging and continued groups. However, there was not a significant distinction (P = .197). Additionally, hospital stay length, bleeding-related reoperation, and 3-month mortality were similar across the groups (P > .05). No patients experienced myocardial infarction or stroke within 3 months post-procedure. Patients who received preoperative LMWH bridging therapy or continued clopidogrel therapy had a slightly higher risk of perioperative bleeding. These findings need to be confirmed by further randomised controlled trials.

Improving decision-making for timing of surgery for high-risk comorbid patients

Deciding the optimal time for surgery in patients with pre-existing comorbid disease is complex. A careful balance of risks is required to weigh up the therapeutic benefits of surgery against an increased risk of perioperative adverse outcomes, whereas the subsequent risk of adverse events and mortality is more dependent on pre-existing conditions. A study in a recent issue of BJA shows that people with a previous cardiovascular or cerebrovascular event within 10 yr of elective surgery were at a higher risk of major adverse cardiovascular events within 1 yr from surgery and that an at-risk period existed if surgery occurred within 37 months of the preoperative event. Before this observation can be used to inform clinical decision-making, caution is needed to interpret these findings because of biases introduced by the analytical approach and potential confounding.

[Cardiovascular management of patients undergoing noncardiac surgery]

The risk assessment of patients with cardiovascular diseases before noncardiac surgery (NCS) is particularly relevant in cardiology because of the frequency and the involvement of different disciplines. The risk is determined by the operation itself and the disease or risk profile, including the patient's age. Specialist preoperative consultation can therefore remain limited if the surgery-related risk is low. The subjective symptoms (exercise tolerance) and also the determination of the cardiac biomarkers N‑terminal pro-brain natriuretic peptide (NT-proBNP) and troponin are particularly relevant for assessing the indications for an instrumental or specialist examination. Cardiovascular drug treatment should predominantly be continued perioperatively but not initiated just for the operation. There are practical guidelines for pausing oral anticoagulation, whereby a general heparin bridging is no longer recommended.