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The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Perioperative management of patients on new oral anticoagulants
A Lai1, N Davidson, S W Galloway
1Department of General Surgery, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK.
Background:
New oral anticoagulants (NOACs) offer an alternative to warfarin for preventing stroke in patients with atrial fibrillation. NOACs are expected to replace warfarin and other vitamin K antagonists for most of their indications in the future. Knowledge of the use of NOACs in the perioperative period is important for optimal care.
Methods:
Studies that reported on the use of NOACs were identified, focusing on evidence-based guidance relating to the perioperative period. PubMed was searched for relevant articles published between January 2000 and January 2014.
Results:
The anticipated expanded clinical use of NOACs such as rivaroxaban (Xarelto™), apixaban (Eliquis™) and dabigatran (Pradaxa™) has the potential to simplify perioperative anticoagulant management because of fewer drug-drug interactions, rapid onset of action, predictable pharmacokinetics and relatively short half-lives. However, coagulation status cannot be monitored by international normalized ratio and no antidotes are currently available. In elective surgery, it is important to discontinue the use of NOACs, with special consideration of renal function as route of elimination. Guidelines for the management of bleeding complications in patients on NOACs are provided, and may be considered for trauma and emergency surgery. Haemodialysis could be considered for bleeding with use of dabigatran. Better options for reversal of the effects of NOACs when bleeding occurs may follow with novel drugs.
Conclusion:
Management of NOACs in elective and emergency conditions requires knowledge of time of last intake of drug, current renal function and the planned procedure in order to assess the overall risk of bleeding. Currently no antidote exists to reverse the effects of these drugs.
Insights
New oral anticoagulants (NOACs) simplify perioperative management but require careful consideration of renal function and procedure timing. Currently, no antidotes exist for NOACs, necessitating informed clinical decisions for bleeding risk assessment.
Area of Science:
- Pharmacology and Therapeutics
- Cardiology
- Anesthesiology
Background:
- New oral anticoagulants (NOACs) are emerging as alternatives to warfarin for stroke prevention in atrial fibrillation.
- Optimal perioperative management of patients on NOACs is crucial due to their anticipated widespread future use.
Purpose of the Study:
- To review evidence-based guidance for perioperative use of NOACs.
- To inform optimal patient care during surgical procedures.
Main Methods:
- Systematic literature search of PubMed for articles on NOACs in the perioperative period (January 2000 - January 2014).
- Focus on evidence-based guidance for managing NOACs around surgery.
Main Results:
- NOACs (e.g., rivaroxaban, apixaban, dabigatran) offer simplified perioperative management due to rapid onset and predictable pharmacokinetics.
- Challenges include lack of routine monitoring (INR) and available antidotes.
- Discontinuation timing depends on renal function and procedure type; guidelines for bleeding management are provided.
Conclusions:
- Effective perioperative NOAC management requires understanding drug intake timing, renal function, and procedure risks.
- Currently, no specific antidotes exist to reverse NOAC effects, emphasizing the need for careful clinical assessment.
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