Clinical Edge

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Management of Patients on NOACs in Acute Care

Circulation; ePub 2017 Feb 6; Ravel, Cigarroa, et al

The American Heart Association (AHA) has issued a scientific statement on the management of patients on non-vitamin K antagonist oral anticoagulants (NOACs) in the acute care and periprocedural setting. Since clinical trial data related to NOAC reversal for bleeding and perioperative management are spare, according to the statement, healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input. The statement also includes many recommendations regarding NOAC use post-MI and post stenting, which will primarily serve as helpful guidance to cardiologist. Questions often come up in primary care about emergency care, pre-operative and peri-operative management of NOACs. The following suggestions are from the writing group:

  • In most situations, the time of last drug ingestion combined with a recent assessment of creatinine clearance (CrCl) should enable appropriate clinical decision making.
  • In patients who are on dabigatran who have minor bleeding, supportive care and careful observation are recommended. For major bleeding, intravenous idarucizumab (Praxbind), will reverse the anticoagulant effect of dabigatran within minutes.
  • For procedures with an extremely low risk of bleeding such as minor dental, dermatologic, or ophthalmologic procedures, anticoagulation may be safely continued without interruption.
  • In patients with a moderate to high procedural risk of bleeding, the thromboembolic risk should be evaluated. For patients with low to moderate thromboembolic risk, NOAC therapy can be stopped sufficiently ahead of the procedure and bridging low-molecular-weight heparin is not recommended as it does not prevent thrombotic events and increases the risk of bleeding.
  • Prior to surgery when NOAC is going to be held, dabigatran should be held for at least 24 hours if CrCl ≥50 mL/min; for at least 72 hours if CrCL <50 mL/min; rivaroxaban, apixaban, and edoxaban should be held for at least 24 hours.

Citation:

Raval AN, Cigarroa JE, Chung MK, et al. Management of patients on non-vitamin K antagonist oral anticoagulants in the acute care and periprocedural setting. [Published online ahead of print February 6, 2017]. Circulation. doi:10.1161/CIR.0000000000000477.

Commentary:

Four NOACs have been approved in the US for prevention of stroke in the setting of nonvalvular atrial fibrillation (AF), as well as the prevention and treatment of VTE. Approved agents are dabigatran etexilate (Pradaxa); rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). When compared to warfarin, NOACs generally have an equal or lower risk of stroke, systemic embolism, major bleeding, and death. About 10 to 20% of patients on oral anticoagulant therapy undergo some invasive procedure each year, so having a sense of how to manage NOACs peri-proceedure is important. These guidelines confirm and expand upon the correct approach to the common clinical question of whether bridging therapy with heparin is needed when a NOAC is stopped for prophylaxis of stroke in AF or prevention of recurrence of DVT/PE. In these common scenarios, the NOAC can be stopped as described above, with no need for bridging anticoagulation.1,2Neil Skolnik, MD

  1. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373:823–833. doi:10.1056/NEJMoa1501035.
  2. Douketis JD, Healey JS, Brueckmann M, et al. Perioperative bridging anticoagulation during dabigatran or warfarin interruption among patients who had an elective surgery or procedure: Substudy of the RELY trial. Thromb Haemost. 2015;113:625–632. doi:10.1160/ TH14-04-0305.