DOACs can be safely continued during elective procedures on AFib patients
With shorter half-lives and more predictable effects, direct oral anticoagulants (DOACs) could help simplify perioperative treatment decisions for patients with non-valvular atrial fibrillation (NVAF), suggests a meta-analysis published May 24 in Circulation.
Those aspects of DOACs allow them to be safely administered throughout the perioperative period or stopped closer to procedures than warfarin, wrote lead author Bassel Nazha, MD, MPH, and colleagues. All these drugs are used for stroke prevention in NVAF but DOACs are becoming increasingly popular.
The researchers pooled results from four randomized, phase III clinical trials that encompassed 24,024 procedures from 19,353 patients. They analyzed the 30-day incidence of stroke/systemic embolism (SSE), major bleeding and death with DOACs versus warfarin, and also stratified the results based on whether patients received an interruption in anticoagulant treatment.
Overall, the strategies yielded similar risks of death and SSE but when the drugs were administered continuously, DOACs had a 38 percent lower rate of major bleeding (2 percent versus 3.3 percent).
“Our large study strongly suggests that a periprocedural strategy of simply continuing a DOAC or interrupting it without the use of laboratory or drug assays is associated with an acceptably low periprocedural adverse event rate that is comparable, and in some cases, safer than a similar strategy used for warfarin,” Nazha et al. wrote. “These findings are supported by recent experiences of cohort studies with dabigatran and rivaroxaban in periprocedural settings that describe low rates of periprocedural adverse events using a simple pharmacokinetic/pharmacodynamic approach to DOAC management with a pre-specified protocol based on patient renal function, perceived procedural bleed risk and drug half-life.”
Warfarin has a half-life between 36 and 60 hours, compared to ranges of seven to 14 hours for different DOACs. The authors said warfarin is often withheld five days prior to an elective procedure.
In contrast, the researchers found 78 percent of patients on a DOAC stopped using the drug either the day of the procedure or the day before. For these cases, the risk of major bleeding was about 55 percent lower for people on DOACs than those on warfarin whose anticoagulation was discontinued in the same time period.
When the study drug was stopped at least two days prior to the procedure, there was no significant difference in terms of major bleeding, and bleeding rates were actually 39 percent lower with warfarin when the drugs were halted at least three days prior to the operation.
“Our study showed a lower risk of MB (major bleeding) favoring DOACs over warfarin and no significantly different rates of SSE and death in an uninterrupted oral anticoagulant strategy or with an interruption close to the time of procedure,” Nazha and colleagues wrote. “This represents a potential advantage for DOACs over warfarin in the majority of patients undergoing procedures deemed minimal or low bleed risk, which constitute over 80 percent of procedures assessed for periprocedural anticoagulant interruption.”
The mean age of the patients was 71 to 73 in the studies, and about one-third were female. Most individuals in the trials had normal kidney function and 95 percent of the procedures were elective, raising the possibility that patients with impaired renal function or requiring emergent procedures would experience different outcomes.
Another limitation of the meta-analysis was the definition of major bleeding varied among the trials.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.