SUMMARY: 

The management of DOACs in patients undergoing surgical procedures is challenging, since interrupting anticoagulation for a procedure transiently increases the risk of thromboembolism. A balance between reducing the risk of thromboembolism and preventing excessive bleeding must be reached for each patient. A general decision-making approach involves estimating the individual patient’s thrombotic and bleeding risk and weighing the surgical bleeding risk to optimally determine the strategy for DOAC interruption.  

DOACs 

Factor Xa inhibitors  

• Apixaban, edoxaban, and rivaroxaban 

Factor IIa (thrombin) inhibitor  

• Dabigatran  

Assessment of Thromboembolic Risk  

• High risk   
  • Stroke within 3 months 
  • TIA within 3 months 
  • VTE within 3 months  
  • Active cancer  

• Calculators are used to predict atrial fibrillation-related thromboembolic risk in the absence of anticoagulation 

CHADS2 score and the CHADS2-VASc score predict atrial fibrillation-related thromboembolic risk in the absence of anticoagulation 

Assessment of Bleeding Risk 

• Calculators are used to assess bleeding risk  

HAS-BLED score or the ORBIT Bleeding Risk Score

Management of DOAC and Elective Surgery/Procedure  

 High-bleed-risk Surgery/Procedure  

• Withhold DOAC for 2 full days before surgery/procedure  
• Examples  
• Intracranial surgery | Cancer surgery | Thoracic surgery | Cardiac surgery | Major orthopedic surgery | ENT surgery | Liver/kidney biopsy  

 Low-bleed-risk Surgery/Procedure 

• Withhold DOAC for 1 full day before surgery/procedure 
• Examples  
• Cataract surgery | Tooth extraction (1 to 3 teeth) | Endoscopy without biopsy | Superficial surgery  

 CrCl <50 mL/min  

In dabigatran-treated patients, withhold DOAC for 3 to 4 full days before surgery/procedure  

Liver Insufficiency   

• No alteration to standard withholding recommendations 
• Withhold 2 days prior to high bleeding risk surgery/procedure or 1 day before low-bleeding risk surgery/procedure  

Heparin Bridge 

• Heparin bridge has no clinical benefit in patients with short period of perioperative DOAC interruption 
• In patients’ high thromboembolic risk and a prolonged DOAC interruption, patients would benefit from a multidisciplinary management to decide if heparin bridging should be prescribed 

Management of DOAC in Emergency Surgery  

• If possible, residual DOAC plasma concentration < 30 ng/ml should be reached before undertaking high bleeding risk surgery 
• Antidotes include  
• Idaruzcizumab for dabigatran | Andexanet alpha for apixaban | edoxaban | rivaroxaban 

Perioperative Laboratory Measurement of DOAC Therapy  

• Role of measuring DOAC levels before surgery/procedure is uncertain  
• If DOAC was withheld for an elective surgery/procedure, guidelines suggest against routine DOAC coagulation function testing to guide perioperative DOAC management  
• DOAC-level testing may be considered in nonelective perioperative clinical situations (emergency surgery, etc.)  

Resumption of DOAC after elective surgery/procedure  

• Resume DOAC >24 hours after surgery/procedure  

Learn More – Primary Sources 

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

Perioperative Management of Patients on Direct Oral Anticoagulants