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Internal and Emergency Medicine

, Volume 8, Issue 6, pp 477–484 | Cite as

Perioperative management of patients who are receiving a novel oral anticoagulant

  • Aaron Liew
  • James DouketisEmail author
IM - REVIEW

Abstract

The use of novel oral anticoagulants (NOACs) is increasing since these drugs are at least as efficacious and safe as vitamin K antagonists (VKAs) for the management of patients with non-valvular atrial fibrillation and venous thromboembolism. Compared with VKAs, NOACs have a faster onset and offset of action, a predictable and consistent pharmacokinetic profile, fewer drug interactions, and ease of use since anticoagulant monitoring is not required. Current perioperative management will be affected by these characteristics, with the potential to obviate the need for heparin bridging. This review aims to summarize the current evidence of perioperative thromboembolic and bleeding risk during anticoagulant interruption, which is derived predominantly from patients receiving VKA therapy, and early studies involving NOACs which mainly focus on patients who are receiving dabigatran. The role of heparin bridging is discussed. We also provide a practical approach for the perioperative management of patients who are receiving NOAC therapy.

Keywords

Bleeding New oral anticoagulants Perioperative Thrombosis 

Notes

Conflict of interest

A. Liew has received educational and research support from AstraZeneca, BI, BMS, MSD, Novo Nordisk, Novartis, Sanofi-Aventis and Medtronic. J. Douketis was a consultant for Boehringer-Ingelheim and served as a consultant during advisory board meetings (by Sanofi-Aventis, AstraZeneca, Boehringer-Ingelheim, Bristol-Myers-Squibb) relating to the development and clinical use of novel antiplatelet drugs (ticagrelor) and anticoagulant drugs (apixaban, semuloparin, [not approved for clinical use] and dabigatran).

References

  1. 1.
    Coccheri S, Orlando D (2013) New oral anticoagulants in atrial fibrillation: a reappraisal of trial results looking at absolute figures. Intern Emerg Med 8(2):115–122PubMedCrossRefGoogle Scholar
  2. 2.
    Southworth MR, Reichman ME, Unger EF (2013) Dabigatran and postmarketing reports of bleeding. N Engl J Med 368(14):1272–1274Google Scholar
  3. 3.
    Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R, American College of Chest P (2012) Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th edn: American college of chest physicians evidence-based clinical practice guidelines. Chest 141(2 Suppl):e326S–e350SGoogle Scholar
  4. 4.
    Douketis JD (2010) Pharmacologic properties of the new oral anticoagulants: a clinician-oriented review with a focus on perioperative management. Curr Pharm Des 16(31):3436–3441PubMedCrossRefGoogle Scholar
  5. 5.
    Healey JS, Eikelboom J, Douketis J, Wallentin L, Oldgren J, Yang S, Themeles E, Heidbuchel H, Avezum A, Reilly P, Connolly SJ, Yusuf S, Ezekowitz M (2012) Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the randomized evaluation of long-term anticoagulation therapy (re-ly) randomized trial. Circulation 126(3):343–348PubMedCrossRefGoogle Scholar
  6. 6.
    van Ryn J, Stangier J, Haertter S, Liesenfeld KH, Wienen W, Feuring M, Clemens A (2010) Dabigatran etexilate–a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 103(6):1116–1127PubMedCrossRefGoogle Scholar
  7. 7.
    Becker RC, Yang H, Barrett Y, Mohan P, Wang J, Wallentin L, Alexander JH (2011) Chromogenic laboratory assays to measure the factor Xa-inhibiting properties of apixaban–an oral, direct and selective factor Xa inhibitor. J Thromb Thrombolysis 32(2):183–187PubMedCrossRefGoogle Scholar
  8. 8.
    Kaplan RC, Tirschwell DL, Longstreth WT Jr, Manolio TA, Heckbert SR, Lefkowitz D, El-Saed A, Psaty BM (2005) Vascular events, mortality, and preventive therapy following ischemic stroke in the elderly. Neurology 65(6):835–842PubMedCrossRefGoogle Scholar
  9. 9.
    Longstreth WT Jr, Bernick C, Fitzpatrick A, Cushman M, Knepper L, Lima J, Furberg CD (2001) Frequency and predictors of stroke death in 5,888 participants in the cardiovascular health study. Neurology 56(3):368–375PubMedCrossRefGoogle Scholar
  10. 10.
    Martinell J, Jimenez A, Rabago G, Artiz V, Fraile J, Farre J (1991) Mechanical cardiac valve thrombosis. Is thrombectomy justified? Circulation 84(5 Suppl):III70–III75PubMedGoogle Scholar
  11. 11.
    Carrier M, Le Gal G, Wells PS, Rodger MA (2010) Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med 152(9):578–589PubMedCrossRefGoogle Scholar
  12. 12.
    Kaatz S, Douketis JD, Zhou H, Gage BF, White RH (2010) Risk of stroke after surgery in patients with and without chronic atrial fibrillation. J Thromb Haemost 8(5):884–890PubMedGoogle Scholar
  13. 13.
    Attaya H, Wysokinski WE, Bower T, Litin S, Daniels PR, Slusser J, Heit JA, McBane RD 2nd (2013) Three-month cumulative incidence of thromboembolism and bleeding after periprocedural anticoagulation management of arterial vascular bypass patients. J Thromb Thrombolysis 35(1):100–106Google Scholar
  14. 14.
    McBane RD, Wysokinski WE, Daniels PR, Litin SC, Slusser J, Hodge DO, Dowling NF, Heit JA (2010) Periprocedural anticoagulation management of patients with venous thromboembolism. Arterioscler Thromb Vasc Biol 30(3):442–448PubMedCrossRefGoogle Scholar
  15. 15.
    Tafur AJ, Wysokinski WE, McBane RD, Wolny E, Sutkowska E, Litin SC, Daniels PR, Slusser JP, Hodge DO, Heit JA (2012) Cancer effect on periprocedural thromboembolism and bleeding in anticoagulated patients. Ann Oncol 23(8):1998–2005PubMedCrossRefGoogle Scholar
  16. 16.
    Daniels PR, McBane RD, Litin SC, Ward SA, Hodge DO, Dowling NF, Heit JA (2009) Peri-procedural anticoagulation management of mechanical prosthetic heart valve patients. Thromb Res 124(3):300–305PubMedCrossRefGoogle Scholar
  17. 17.
    Halbritter KM, Wawer A, Beyer J, Oettler W, Schellong SM (2005) Bridging anticoagulation for patients on long-term vitamin-K-antagonists. A prospective 1 year registry of 311 episodes. J Thromb Haemost 3(12):2823–2825PubMedCrossRefGoogle Scholar
  18. 18.
    Malato A, Saccullo G, Lo Coco L, Caramazza D, Abbene I, Pizzo G, Casuccio A, Siragusa S (2010) Patients requiring interruption of long-term oral anticoagulant therapy: the use of fixed sub-therapeutic doses of low-molecular-weight heparin. J Thromb Haemost 8(1):107–113PubMedCrossRefGoogle Scholar
  19. 19.
    Dunn AS, Spyropoulos AC, Turpie AG (2007) Bridging therapy in patients on long-term oral anticoagulants who require surgery: the prospective peri-operative enoxaparin cohort trial (PROSPECT). J Thromb Haemost 5(11):2211–2218PubMedCrossRefGoogle Scholar
  20. 20.
    Wysokinski WE, McBane RD, Daniels PR, Litin SC, Hodge DO, Dowling NF, Heit JA (2008) Periprocedural anticoagulation management of patients with nonvalvular atrial fibrillation. Mayo Clin Proc 83(6):639–645PubMedGoogle Scholar
  21. 21.
    Siegal D, Yudin J, Kaatz S, Douketis JD, Lim W, Spyropoulos AC (2012) Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation 126(13):1630–1639PubMedCrossRefGoogle Scholar
  22. 22.
    Spyropoulos AC, Douketis JD (2012) How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood 120(15):2954–2962PubMedCrossRefGoogle Scholar
  23. 23.
    Omran H, Bauersachs R, Rubenacker S, Goss F, Hammerstingl C (2012) The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national multicentre BNK online bRiDging REgistRy (BORDER). Thromb Haemost 108(1):65–73PubMedCrossRefGoogle Scholar
  24. 24.
    Tafur AJ, McBane R 2nd, Wysokinski WE, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA (2012) Predictors of major bleeding in peri-procedural anticoagulation management. J Thromb Haemost 10(2):261–267PubMedCrossRefGoogle Scholar
  25. 25.
    Jaffer AK, Ahmed M, Brotman DJ, Bragg L, Seshadri N, Qadeer MA, Klein A (2005) Low-molecular-weight-heparins as periprocedural anticoagulation for patients on long-term warfarin therapy: a standardized bridging therapy protocol. J Thromb Thrombolysis 20(1):11–16PubMedCrossRefGoogle Scholar
  26. 26.
    Kaseno K, Naito S, Nakamura K, Sakamoto T, Sasaki T, Tsukada N, Hayano M, Nishiuchi S, Fuke E, Miki Y, Yamashita E, Kumagai K, Oshima S, Tada H (2012) Efficacy and safety of periprocedural dabigatran in patients undergoing catheter ablation of atrial fibrillation. Circ J 76(10):2337–2342PubMedCrossRefGoogle Scholar
  27. 27.
    Lakkireddy D, Reddy YM, Di Biase L, Vanga SR, Santangeli P, Swarup V, Pimentel R, Mansour MC, D'Avila A, Sanchez JE, Burkhardt JD, Chalhoub F, Mohanty P, Coffey J, Shaik N, Monir G, Reddy VY, Ruskin J, Natale A (2012) Feasibility and safety of dabigatran versus warfarin for periprocedural anticoagulation in patients undergoing radiofrequency ablation for atrial fibrillation: results from a multicenter prospective registry. J Am Coll Cardiol 59(13):1168–1174PubMedCrossRefGoogle Scholar
  28. 28.
    Kim JS, She F, Jongnarangsin K, Chugh A, Latchamsetty R, Ghanbari H, Crawford T, Suwanagool A, Sinno M, Carrigan T, Kennedy R, Saint-Phard W, Yokokawa M, Good E, Bogun F, Pelosi F Jr, Morady F, Oral H (2013) Dabigatran vs warfarin for radiofrequency catheter ablation of atrial fibrillation. Heart Rhythm 10(4):483–489PubMedCrossRefGoogle Scholar
  29. 29.
    Nin T, Sairaku A, Yoshida Y, Kamiya H, Tatematsu Y, Nanasato M, Inden Y, Hirayama H, Murohara T (2013) A randomized controlled trial of dabigatran versus warfarin for periablation anticoagulation in patients undergoing ablation of atrial fibrillation. Pacing Clin Electrophysiol 36(2):172–179PubMedCrossRefGoogle Scholar
  30. 30.
    Baglin T, Hillarp A, Tripodi A, Elalamy I, Buller H, Ageno W (2013) Measuring oral direct inhibitors (ODIs) of thrombin and factor Xa: A recommendation from the subcommittee on control of anticoagulation of the scientific and standardisation committee of the international society on thrombosis and haemostasis. J Thromb Haemost 11(4):756–760. doi: 1111/jth.12149 Google Scholar
  31. 31.
    Garcia D, Barrett YC, Ramacciotti E, Weitz JI (2013) Laboratory assessment of the anticoagulant effects of the next generation of oral anticoagulants. J Thromb Haemost 11(2):245–252PubMedCrossRefGoogle Scholar
  32. 32.
    Helin TA, Pakkanen A, Lassila R, Joutsi-Korhonen L (2013) Laboratory assessment of novel oral anticoagulants: method suitability and variability between coagulation laboratories. Clin Chem 59(5):807–814PubMedCrossRefGoogle Scholar
  33. 33.
    Stangier J, Rathgen K, Stahle H, Gansser D, Roth W (2007) The pharmacokinetics, pharmacodynamics and tolerability of dabigatran etexilate, a new oral direct thrombin inhibitor, in healthy male subjects. Br J Clin Pharmacol 64(3):292–303PubMedCrossRefGoogle Scholar

Copyright information

© SIMI 2013

Authors and Affiliations

  1. 1.Department of MedicineMcMaster UniversityHamiltonCanada
  2. 2.St. Joseph’s HealthcareHamiltonCanada

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