The Effect of Direct Oral Anticoagulants on Outcomes After Urgent or Emergent Cardiac Surgery
Jason P Hecht1, Jean Huang1, Andrew Pruitt2
1Department of Pharmacy Services, Saint Joseph Mercy Ann Arbor, Ann Arbor, MI.
Insights
Urgent cardiac surgery after direct oral anticoagulants (DOACs) showed no increased bleeding or mortality risk. This suggests potentially shorter waiting times may be safe for patients on DOACs before coronary artery bypass grafting (CABG).
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Direct oral anticoagulants (DOACs) are increasingly used for anticoagulation.
- Managing patients requiring urgent cardiac surgery while on DOACs presents a clinical challenge.
- Determining optimal timing for surgery after DOAC cessation is crucial for patient safety.
Purpose of the Study:
- To evaluate the safety of performing urgent or emergent cardiac surgery within 5 days of direct oral anticoagulant (DOAC) use.
- To assess the association between recent DOAC use and outcomes in patients undergoing coronary artery bypass grafting (CABG).
Main Methods:
- A multicenter retrospective registry study involving 7,201 patients undergoing urgent or emergent CABG.
- Patients were stratified based on DOAC use within 2 days, 3-5 days, or no recent DOAC use.
- Outcomes including intraoperative transfusion and mortality were compared across groups.
Main Results:
- No significant differences in intraoperative blood transfusion rates were observed between groups.
- Rates of requiring five or more blood products were not significantly different.
- Mortality rates were similar across all patient groups (approximately 3%).
Conclusions:
- Performing urgent or emergent CABG within 5 days of DOAC use does not appear to increase risks of bleeding or mortality.
- These findings are hypothesis-generating and suggest that current guidelines for DOAC cessation before surgery may be conservative.
- Further prospective studies are warranted to confirm these safety findings and refine perioperative management strategies.
Objective:
To determine the safety of performing urgent or emergent cardiac surgery within 5 days of a patient taking a direct oral anticoagulant (DOAC).
Design:
A multicenter retrospective registry study.
Setting:
Thirty-three hospitals in a quality collaborative from 2017 to 2019.
Participants:
Patients were included if they underwent urgent or emergent coronary artery bypass grafting (CABG). Patients were excluded if they received any anticoagulant or antiplatelet agent besides DOACs, heparin, or aspirin.
Interventions:
Patients were stratified based upon the receipt of a DOAC within 5 days of their surgery. Patient cohorts included DOAC within 2 days, DOAC within 3-to-5 days, and no anticoagulation. Data were unavailable on the specific DOAC agent taken prior to admission.
Measurements And Main Results:
There were 7,201 patients included, with 94 on DOACs. Intraoperative blood transfusion was required in 23.9% of patients on no anticoagulant, 26.2% on a DOAC within 3-to-5 days of surgery (odds ratio [OR] 0.98; 95% CI 0.46-2.11), and 30.3% on a DOAC within 2 days (OR 0.99; 95% CI 0.37-2.67). Five or more intraoperative blood products were required in 4.4% on no anticoagulant, 1.7% on DOAC within 3-to-5 days (OR 0.33; 95% CI 0.04-2.71), and 6.1% on DOAC within 2 days (OR 0.47; 95% CI 0.06-4.05). No difference in mortality was observed among the 3 groups (2.9% v 3.3% v 3.0%; p = 0.67).
Conclusions:
For urgent or emergent CABGs, no significant differences in minor bleeding, major bleeding, or mortality were observed in patients taking a DOAC within 5 days of surgery. This study was hypothesis-generating for performing urgent or emergent surgery sooner than 5 days after holding DOACs.
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