title: Periprocedural management of anticoagulation in patients taking novel oral anticoagulants: Review of the literature and recommendations for specific populations and procedures.
abstract: An increasing number of individuals are on novel oral anticoagulants (NOAC) for anticoagulation instead of vitamin K antagonists (VKA) and roughly 10% of these individuals will require interruption of these agents for procedures annually. Recent evidence surrounding bridging as well as the FDA approval of a new NOAC call for a comprehensive review and update regarding periprocedural NOAC management. The periprocedural management of NOACs involves striking a balance between the risks of bleeding and thromboembolism associated with interruption, bridging, and reinitiation of anticoagulation. NOACs have a distinct pharmacokinetic advantage in this setting with their quick onset and elimination from the body. Procedures at low risk for bleeding do not require interruption and can be scheduled at the start of the next dosing interval. Procedures at moderate-high risk of bleeding require interruption of NOAC for 5 half lives prior to the procedure to allow for adequate elimination of the drug. In light of new evidence highlighting the risks of bleeding, and given shorter "unprotected" times with NOAC interruption versus VKA, patients at low-moderate risk for thromboembolism should not be bridged when "unprotected" time is less than 96 h. For patients at high risk for thromboembolism, individual patient and surgical factors need to be considered before the decision to bridge is made. The benefit of bridging these patients who have a considerable risk of bleeding may not outweigh the benefits. Focused randomized studies on periprocedural management of NOACs are urgently needed.
authors.affiliation: Department of Internal Medicine, University of Louisville, Louisville, KY, USA.
authors.forename: Philip L
authors.initials: PL
authors.lastname: Mar
authors.affiliation: Department of Internal Medicine, University of Louisville, Louisville, KY, USA.
authors.forename: Dmitry
authors.initials: D
authors.lastname: Familtsev
authors.affiliation: Division of Cardiovascular Medicine, Lankenau Medical Center, Philadelphia, PA, USA.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Ezekowitz
authors.affiliation: Division of Cardiovascular Medicine, University of Kansas Hospital, Kansas City, KS, USA.
authors.forename: Dhanunjaya
authors.initials: D
authors.lastname: Lakkireddy
authors.affiliation: Department of Internal Medicine, University of Louisville, Louisville, KY, USA. Electronic address: rakesh.gopinathannair@louisville.edu.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Gopinathannair
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage* / Q000191:economics / Q000493:pharmacokinetics*; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000378:metabolism; D001777:Blood Coagulation / Q000187:drug effects*; D006470:Hemorrhage / Q000188:drug therapy / Q000378:metabolism / Q000517:prevention & control; D006801:Humans; D019934:International Normalized Ratio; D019990:Perioperative Care / Q000379:methods; D020521:Stroke / Q000378:metabolism / Q000517:prevention & control; D013923:Thromboembolism / Q000188:drug therapy / Q000378:metabolism; D028761:Withholding Treatment
chemical_list: D000925:Anticoagulants
keywords: Ablation; Bridging; NOAC; Periprocedural anticoagulation; Renal impairment