2021 EHRA practical guide: DOACs in pre-operative and bleeding patients

The new and updated 2021 EHRA practical guide on the use of non-vitamin K antagonist oral anticoagulant in patients with atrial fibrillation highlights the importance of post-bleeding management, as well as personalised, peri-procedural oral anticoagulation management by adjusting treatment to the expected bleeding risk [1,2].

Prof. Thomas Vanassche (University Hospitals Leuven, Belgium) presented the new 2021 EHRA practical guide, focussing on pre-operative and bleeding patients [1]. Direct oral anticoagulants (DOAC) have shown to be safer and more effective than vitamin K antagonists, and as a result are recommend by most international guidelines [2]. They also cause fewer bleedings compared with vitamin K antagonists.

The guideline was updated with regards to the use of specific DOAC reversal agents. Idarucizumab, a specific reversal for dabigatran, is administered by intravenous bolus injection in 2 consecutive doses of 2.5 g each. It acts immediately and for up to 24 hours without effects on other anticoagulants. It is available in all European countries. Andexanet alpha is a specific reversal for rivaroxaban and apixaban and is administered as an intravenous bolus followed by continuous infusion. The dose is dependent on the type and timing of last use of DOAC [3]. The effect lasts throughout the infusion time and may affect post-reversal anticoagulation. It is currently available in Germany, Austria, UK, the Netherlands, Sweden, Denmark, and Finland.

The guidelines further emphasised the importance of post-bleeding management even in minor bleeds. The impact of bleeding on the patient’s compliance should be re-evaluated, as well as the risk of repeat bleeding, modifiable risk factors, and choice and dosing of DOAC. Anticoagulation should be re-initiated in the absence of absolute contraindication.

Peri-procedural management of DOACs is a frequent clinical problem. Stopping and restarting anticoagulation increases risk of complications, both in bleeding and thrombosis. The rapid onset and offset of DOAC effect simplify peri-procedural management, eliminating the need for pre-operative heparin bridging. Surgical factors (e.g. bleeding risk of procedure) and patient characteristics (e.g. comorbidities) determine the time of last pre-operative DOAC intake. The full dose of DOAC should be resumed 24 hours after low-risk and 48-72 hours after high-risk interventions. For patients requiring urgent surgical intervention, a decision tree is available (see Figure).

Figure: Decision tree of DOAC management for patients requiring urgent surgical intervention. Modified from [1,2]

aPTT, activated partial thromboplastin time; dTT, diluted thrombin time; Fxa, factor Xa; PT, prothrombin time.

To summarise, Prof. Vanassche highlighted the following updates in the 2021 EHRA practical guide:

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    • updated information on reversal agents;
    • the importance of post-bleeding management and an integrated management of bleeds, including the treatment of modifiable risk factors;
    • for elective procedures, a unified, simplified, and practical approach is feasible without drug level measurement and without heparin treatment.

 

1. 
   
   1. Vannasche T. Focus on special situations: DOACs in pre-operative and bleeding patients. EHRA 2021 Congress, 23-25 April.
   2. Steffel J, et al. EP Europace 2021;00:1-65.
   3. Govender K. Oral anticoagulant and bleeding: role of antidotes. EHRA 2021 Congress, 23-25 April.

 

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Posted on 15 June 202116 June 2021