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August, 2019 QQ: DOAC Bridging

Our August, 2019 Quick Question, suggested by frequent contributor, Dave McGlasson, demonstrated the variability in clinical antithrombotic therapy bridging policies when a patient requires a procedure. Here is the question and answers provided by 70 participants:

A 60-YO man taking 20 mg/day rivaroxaban for AFIB needs a high bleeding risk surgery. His creatinine is 0.9 mg/dL When should the DOAC be discontinued?

  1. Never–continue treatment: 4% (3)
  2. 24 h before surgery: 16% (10)
  3. 36 h before surgery: 10% (7)
  4. 48 h before surgery: 36% (25)
  5. 60 h before surgery: 7% (5)
  6. 72 h before surgery: 27% (20)

The lack of uniformity is obvious from these results. The answer requires a clinical and laboratory analysis of the patient’s bleeding and thrombotic risk. Fortunately, the SSC Subcommittee on Perioperative and Critical Care Thrombosis and Haemostasis of the International Society on Thrombosis and HaemostasisInternational has just submitted the following communication: Spyropoulos AC, Brohi K, Caprini J, et al. Scientific and Standardization Committee Communication: Guidance document on the periprocedural management of patients on chronic oral anticoagulant therapy: Recommendations for standardized reporting of procedural/surgical bleed risk and patientā€specific thromboembolic risk. J Thromb Haemostas 2019: DOI: 10.1111/jth.14598. The article helps delineate definitions for bleeding and thrombosis risks. In order to reach a definitive answer to our question, we would need to include an assessment of the patient’s thrombotic risk.

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