What Is the Optimal DOAC Stop Time Before Cardiac Surgery?

Following cardiac surgery, the risk of postoperative bleeding is higher among those who discontinue direct oral anticoagulants (DOACs) 2 days before surgery compared with 3 days, according to study results presented at the American College of Cardiology (ACC) Annual Meeting, held online from May 15 to May 17, 2021.

This retrospective study included 238 individuals (n=157 men [66%]; mean age, 72.9±10 years) who were treated with DOACs (n=115; 48.3%) or Vitamin K Antagonists (VKAs; n=123; 51.7%) before undergoing cardiovascular surgery. All individuals underwent surgery between 2013 and 2016 and had both baseline and pharmacy data available, including anticoagulant preoperative stop time and postoperative restart time.

Major bleeding was the primary endpoint and was defined by a resultant hemoglobin drop greater than 20 g/L, life-threatening loss of blood, a transfusion of at least 2 units of pack cells, and symptomatic bleeding in critical organs. Stroke, mortality, and thromboembolism comprised secondary endpoints.

Study researchers performed receiver operating characteristic analysis to determine a threshold value for DOAC termination to predict postsurgical bleeding, while multivariate regression was used to determine risk of bleeding according to stop time.

The median stop time for DOACs presurgery was 3 (interquartile range, 1-4) days. Study researchers identified a threshold of 2.5 days of DOAC termination (AUC, 0.67; 95% CI, 0.51-0.83; P =.04; specificity, 68%; sensitivity, 67%). VKAs did not produce significant results.

Those who discontinued DOACs no more than 2 days before surgery had higher risks of bleeding (odds ratio [OR], 17.5; 95% CI, 2.9-199.7) and more postsurgical transfusions (Beta, 2.6; 95% CI, 0.28-5.1). The risk of bleeding was reduced when stop time reached no more than 3 days after procedure (OR, 6.1; 95% CI, 1.28-40.8).

The risk for stroke, mortality, or thromboembolism did not differ significantly between the 2- and 3-day stop times. Multivariate modeling showed no significant difference between VKAs and DOACs with respect to increased risk for complications, though presurgical aspirin was associated with an increased risk of postsurgical major bleeding (OR, 2.14; 95% CI, 1.18-3.92), mortality (OR, 3.45; 95% CI, 1.08-12.2), or pack cell transfusion (Beta, 1.1; 95% CI, 0.32-1.89).

The study researchers concluded that those who “discontinued DOACs 2 days prior to cardiac surgery were at higher risk of bleeding post procedure compared [with] 3 days.”

Reference

Shamiss Y, Azizi Z, Malcolm R, et al. Perioperative management of oral anticoagulants in cardiac surgery, when is the optimal stop time. Presented at: ACC 2021; May 15-17, 2021. Abstract 2232