Continuous vs interrupted direct oral anticoagulants for minimal bleeding-risk surgical procedures-a systematic...

Evidence supporting the perioperative interruption of direct oral anticoagulants (DOACs) is varied, especially for procedures with minimal bleeding risk.

This review compared the risk of bleeding events and thromboembolism in patients undergoing minimal bleeding-risk procedures, in whom DOACs were interrupted or continued.

Prospective, retrospective, and randomized trials examining a continuous or interrupted DOAC strategy in patients undergoing minimal bleeding-risk surgeries were included. Primary outcomes included the rates of venous or arterial thromboembolism and rates of major and minor bleeding events. Secondary outcomes included rates of surgical complications, mortality, and hospital length of stay.

We retrieved 24 studies (N = 8663 patients). Cardiac ablations were the most common procedure (n = 13), followed by pacemaker insertion (n = 4) and dental procedures (n = 4). Nineteen studies examined thromboembolic events, with a pooled odds ratio (OR) favoring continuous DOAC use (OR, 0.54; 95% CI, 0.33-0.91; I ² = 60%), although these results failed to persist in the high-quality randomized clinical trial data. Twenty studies examined bleeding events, with a significant reduction in major bleeds favoring continuous DOACs (OR, 0.57; 95% CI, 0.37-0.87; I ² = 0%), which failed to reach significance in the randomized data. There were no difference in minor bleeding (OR, 0.93; 95% CI, 0.69-1.24; I ² = 0%) events. No differences were noted in the rates of total complications or mortality.

While our meta-analysis found an improvement in thrombotic and major bleeding events with continuous perioperative DOAC use, these results were likely subject to selection bias with no significant differences in all outcomes in the high-quality randomized trials. The findings in the randomized data noted no significant differences between a continuous and interrupted DOAC strategy, although further research is required to provide a more definitive conclusion.