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Perioperative Factor Xa Inhibitor Discontinuation for Patients Undergoing Procedures With Minimal or Low Bleeding
So-Ryoung Lee1,2, Kyung-Yeon Lee1, Jong-Sung Park3
1Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
Insights
Discontinuing factor Xa inhibitors for procedures with minimal bleeding risk is safe for atrial fibrillation patients. The PERIXa protocol showed low rates of major bleeding and thromboembolism, supporting its use.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Oral anticoagulant treatment discontinuation is common for procedures due to bleeding concerns.
- Factor Xa inhibitors are widely used for atrial fibrillation (AF) stroke prevention.
Purpose of the Study:
- To evaluate the safety of perioperative factor Xa inhibitor discontinuation in AF patients undergoing low-bleeding-risk procedures.
- To assess the association between factor Xa inhibitor discontinuation and major bleeding or thromboembolic events.
Main Methods:
- A prospective, multicenter, single-arm cohort study (PERIXa) in Korea.
- Included 1902 AF patients undergoing procedures like endoscopy, dental surgery, or ocular surgery.
- Patients followed a protocol to stop factor Xa inhibitors 24 hours before and restart 24 hours after the procedure.
Main Results:
- The 30-day major bleeding rate was very low at 0.1% (2 patients).
- No composite thromboembolic events were observed within 30 days.
- Results were consistent across different procedures and factor Xa inhibitor types (apixaban, edoxaban, rivaroxaban).
Conclusions:
- The PERIXa protocol for perioperative factor Xa inhibitor management is safe and effective for AF patients undergoing minimal to low bleeding risk procedures.
- This approach demonstrates low rates of major bleeding and thromboembolism.
- Suggests a safe and reasonable strategy for managing anticoagulation in this patient group.
Importance:
Discontinuation of oral anticoagulant treatment is common in clinical practice due to concerns about bleeding, even for procedures with minimal to low bleeding risk.
Objective:
To explore whether perioperative discontinuation of factor Xa inhibitors is associated with major bleeding and thromboembolic events in patients with atrial fibrillation (AF) undergoing procedures with minimal to low bleeding risk.
Design, Setting, And Participants:
This prospective, multicenter, single-arm cohort study conducted in Korea included patients with AF who planned to undergo a procedure with minimal to low bleeding risk between September 25, 2020, and April 5, 2024.
Exposure:
The PERIXa (Perioperative Factor Xa Inhibitor Discontinuation in Patients With Atrial Fibrillation Undergoing Minimal to Low Bleed Risk Procedures) protocol recommending giving the last dose of factor Xa inhibitor (ie, apixaban, edoxaban, or rivaroxaban) 24 hours before the procedure (ie, endoscopy, dental procedure, or ocular surgery) and restarting treatment with the inhibitor the next day.
Main Outcomes And Measures:
The primary outcome was major bleeding, and the secondary outcome included a composite of thromboembolic events 30 days after the index procedure with minimal to low bleeding risk.
Results:
In total, 1902 patients were included in the modified intention-to-treat analysis set encompassing all patients who underwent the intended procedure (mean [SD] age, 70.4 [8.8] years; 1135 [59.7%] male; mean [SD] CHA2DS2-VASc [congestive heart failure, hypertension, age 75 years or older, diabetes, stroke, vascular disease, age 65-74 years, and female sex; range, 0-9, with higher scores indicating higher risk of stroke] score, 2.8 [1.3]; mean [SD] HAS-BLED [hypertension, kidney or liver disease, stroke history, prior bleeding, unstable international normalized ratio, age >65 years, and drug or alcohol use; range, 0-9, with higher scores indicating higher risk of bleeding] score, 1.6 [0.7]). Among them, 921 (48.4%) were receiving apixaban, 616 (32.4%) were receiving edoxaban, and 365 (19.2%) were receiving rivaroxaban. Of the total procedures, 948 (49.8%) were endoscopy, 820 (43.1%) were dental procedures, and 120 (6.3%) were ocular surgery. The 30-day event rate of major bleeding was 0.1% (n = 2), and there were no composite thromboembolic events. The results were consistent in the per-protocol analysis, and no differences were observed by procedure category or factor Xa inhibitor type.
Conclusions And Relevance:
In this cohort study, patients with AF receiving a factor Xa inhibitor and undergoing a procedure with minimal to low bleeding risk had low rates of major bleeding and thromboembolism when following the standardized PERIXa protocol for perioperative management of oral anticoagulant treatment, suggesting that this may be a safe and reasonable option for this patient population.
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