Direct oral anticoagulant use and risk of perioperative bleeding: Evidence of absence or absence of evidence?

Abstract

For apixaban, each procedure was classified as either “no interruption” (if the study drug was not interrupted or interrupted on the same day of the procedure) or “any interruption” (if the study drug was stopped between one and seven days before the procedure), but the final decision about when apixaban would be interrupted was left to local investigators. [...]we do not exactly know the perioperative management in the included apixaban and rivaroxaban studies. In the meta‐analysis, Shaw et al. did include patients with atrial fibrillation on DOAC who had an invasive procedure outside clinical trial settings, but these comprised only 7% (n = 679) of the total study population (ie, all other patients came from clinical trials). [...]it can be questioned whether the relatively low outcome rates of thromboembolic and major bleeding events at 30‐days post invasive procedure are due to a safe interruption strategy only. HIGH BLEEDING RISK INVASIVE PROCEDURES Of the eight studies included, there were three that exclusively concerned patients undergoing permanent pacemaker insertion or implantable cardioverter defibrillator procedures. In this cohort study (which was a sub‐analysis from one of the cohort studies that was reported in the meta‐analysis ), performed by Douketis and colleagues, it was shown that in 181 patients who took dabigatran and were requesting an elective invasive procedure, the anticoagulant effect had not worn off in all patients despite that they withheld dabigatran therapy for 24‐48 hours before the procedure.