Management and clinical outcomes in patients treated with apixaban vs warfarin undergoing procedures

Abstract

Key Points• Short-term preprocedure interruptions of either apixaban or warfarin are associated with a low rate of stroke or systemic embolism.• Some patients taking apixaban or warfarin are able to undergo procedures safely without a preprocedure interruption of anticoagulation.Using data from ARISTOTLE, we describe the periprocedural management of anticoagulation and rates of subsequent clinical outcomes among patients chronically anticoagulated with warfarin or apixaban. We recorded whether (and for how long) anticoagulant therapy was interrupted preprocedure, whether bridging therapy was used, and the proportion of patients who experienced important clinical outcomes during the 30 days postprocedure. . Among patients in ARISTOTLE, the 30-day postprocedure stroke, death, and major bleeding rates were low and similar in apixaban-and warfarin-treated patients, regardless of whether anticoagulation was stopped beforehand. Our findings suggest that many patients on chronic anticoagulation can safely undergo procedures; some will not require a preprocedure interruption of anticoagulation. ARISTOTLE was registered at www.clinicaltrials.gov as #NCT00412984. (Blood. 2014;124(25):3692-3698)

Perioperative interruption of direct oral anticoagulants in patients with atrial fibrillation: A systematic review and meta‐analysis

“…A total of 8 publications including 14 446 patients and 17 107 periprocedural interruptions met full eligibility criteria (Table 1, Figure 1). 20, 21, 22, 23, 24, 25, 26, 27 Four studies consisted of post‐hoc retrospective analyses of prospectively collected randomized controlled trial data and the remaining four studies were prospective or retrospective cohort studies. Five studies evaluated the perioperative interruption of dabigatran, whereas there was one study for each of rivaroxaban, apixaban and edoxaban.…”

“…The pooled risk of postoperative thromboembolic events among studies evaluating dabigatran was similar at 0.44% (95% CI 0.26‐ 0.68, I 2  = 0%) (Table 5). The meta‐analysis including the 4 randomized controlled trials is reported in Figure 2A 20, 21, 22, 23. There were no significant differences between postoperative thromboembolic risk following procedural interruption of DOACs as compared to VKA.…”

“…The majority of major bleeding events occurred in the perioperative analysis of one randomized trial 20. The meta‐analysis including the four randomized controlled trials is reported in Figure 2B 20, 21, 22, 23. There were no significant differences between postoperative major bleeding episodes following procedural interruption of DOACs as compared to VKA.…”

Management of Novel Oral Anticoagulants in the Perioperative Setting

“…The aim of this review is to summarise a growing body of evidence surrounding the perioperative management of NOACs; dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis). NOACs hold many advantages over warfarin in the management of procoagulant disorders, such as their rapid onset with no bridging required, short half-life allowing timely cessation and not requiring monitoring blood tests [3][4][5]. The advantage of not requiring monitoring blood tests is, however, a disadvantage in the perioperative setting, as coagulation studies are therefore a poor predictor of agent reversal [6].…”

“…Currently, only one study is available investigating perioperative cessation of apixaban [5]. The Aristotle trial (n= 9260) primarily assessed low risk procedures in which cessation occurred in 60% of these.…”