Perioperative Management of Vitamin K Antagonists and Direct Oral Anticoagulants: a Systematic Review and Meta-analysis.

BACKGROUND: The management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or invasive procedure is a common clinical scenario.

RESAERCH QUESTION: What is the best available evidence to support the development of American College of Chest Physicians (ACCP) guideline on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery/procedures?

STUDY DESIGH AND METHODS: Literature search including multiple databases from database inception to July 16, 2020, was performed. Meta-analyses were conducted when appropriate.

RESULTS: In patients receiving VKA (warfarin) undergoing elective non-cardiac surgery, shorter (<5 days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging [mostly with low molecular weight heparin (LMWH)] was associated with a statistically significant increased risk of major bleed (RR: 9.1 [95% CI, 1.62-51.3]); very low certainty of evidence (COE). Compared with DOACs interruption 1-4 days before surgery, continuing DOACs was not associated with a statistically significant difference in the risk of bleeding; very low COE. Continuing dabigatran was associated with a statistically significant increased risk of thromboembolism (RR: 2.2 [95% CI, 1.3-3.8]); low COE. In patients who needed DOACs interruption, bridging with LMWH was associated a with statistically significant increased risk of minor bleeding compared to no bridging (RR: 1.7 [95% CI, 1.13-2.7]); low COE.

INTERPRETATION: The certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery/procedure, or the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vs. short-term interruption of a DOAC (1-4 days) perioperatively.