Direct oral anticoagulants and cardiac surgery: A descriptive study of preoperative management and postoperative outcomes

Impact of perioperative direct oral anticoagulant assays: a multicenter cohort study

BACKGROUND

There is little evidence to guide the perioperative management of patients on a direct oral anticoagulant(DOAC) in the absence of a last known dose. Quantitative serum titers may be ordered but there is little evidence supporting this.

AIMS

This multi-center retrospective cohort study of consecutive surgical in-patients with a DOAC assay, performed over a five-year period, aimed to characterize preoperative DOAC assay orders and their impact on perioperative outcomes.

MATERIALS AND METHODS

Patientsprescribed regular DOAC (both prophylactic and therapeutic dosing) with apreoperative DOAC assay were included. DOAC assay titer was evaluated againstendpoints. Further, patients with an assay were compared against anticoagulatedpatients who did not receive a preoperative DOAC assay. The primary endpointwas major bleeding. Secondary endpoints included perioperative hemoglobinchange, blood transfusions, idarucizumab or prothrombin complex concentrateadministration, postoperative thrombosis, in-hospital mortality andreoperation. Adjusted and unadjusted linear regression models were used forcontinuous data. Binary logistic models were performed for dichotomous outcomes.

RESULTS

1065 patientswere included, 232 had preoperative assays. Assays were ordered most commonlyby Spinal (11.9%), Orthopedics (15.4%) and Neurosurgery (19.4%). For every10ng/ml increase in titer, the hemoglobin decreases by 0.5066g/L and the oddsof a preoperative reversal increases by 13%. Compared to those without anassay, patients with preoperative DOAC assays had odds 1.44x higher for majorbleeding, 2.98x higher for in-hospital mortality and 16.3x higher for receivinganticoagulant reversal.

CONCLUSION

A preoperativeDOAC assay order was associated with worse outcomes despite increased reversaladministration. However, the DOAC assay titer can reflect the patient'slikelihood of bleeding.

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

An increasing number of patients on systemic oral anticoagulants present for cardiac surgery, and cardiac anesthesiologists should be well-informed on their management in the perioperative period. Direct oral anticoagulants (DOACs), including factor Xa inhibitors and direct thrombin inhibitors, are an attractive alternative to warfarin due to fewer dietary and drug interactions, less frequent monitoring requirements, and an improved patient adherence. Since the approval of DOACs by the Food and Drug Administration in 2010, the number of patients on these medications only has increased. The guidelines vary on the periprocedural management of DOACs for cardiac surgery. This review evaluated the current evidence for medication cessation before surgery, based on timing as well as plasma drug concentration. The practice recommendations of various monitoring tests and new evolving point-of-care testing are examined herein. The different reversal agents were discussed by the authors for both elective and urgent procedures. The cardiac anesthesiologist needs to be intimately familiar with the management and current best practices of DOACs for safe and appropriate patient care.