1/
This week, I gave a talk about one of my favorite clinical topics: #preop medication management! One class of meds I covered was anticoagulants. Let’s quickly review how to handle preop DOAC interruption in this 🧵:
#MedTwitter #MedEd #FOAMed
This week, I gave a talk about one of my favorite clinical topics: #preop medication management! One class of meds I covered was anticoagulants. Let’s quickly review how to handle preop DOAC interruption in this 🧵:
#MedTwitter #MedEd #FOAMed
2/
First off, decide if the DOAC even needs to be held. Certain surgeries, like cataracts, have minimal bleeding risk where anticoagulation can be safely continued.
jacc.org
First off, decide if the DOAC even needs to be held. Certain surgeries, like cataracts, have minimal bleeding risk where anticoagulation can be safely continued.
jacc.org
3/
If a surgery’s bleeding risk is significant enough to warrant interruption, how long should we hold the DOAC for?
If a surgery’s bleeding risk is significant enough to warrant interruption, how long should we hold the DOAC for?
4/
This brings us to the PAUSE trial from 2019, which studied the safety of an easy-to-follow schedule for DOAC interruption:
jamanetwork.com
This brings us to the PAUSE trial from 2019, which studied the safety of an easy-to-follow schedule for DOAC interruption:
jamanetwork.com
5/
PAUSE looked at rates of arterial thromboembolism and major bleeding after pts followed this standardized approach. Rates of both outcomes were low, showing this approach can be safe! Here’s a visual abstract I made summarizing this study:
PAUSE looked at rates of arterial thromboembolism and major bleeding after pts followed this standardized approach. Rates of both outcomes were low, showing this approach can be safe! Here’s a visual abstract I made summarizing this study:
6/
One caveat about PAUSE’s generalizability: only 230/3007 pts underwent neuraxial anesthesia. As even small amts of bleeding would be unacceptable with this procedure, I still err on holding DOACs for longer (following the ASRA guidelines).
rapm.bmj.com
One caveat about PAUSE’s generalizability: only 230/3007 pts underwent neuraxial anesthesia. As even small amts of bleeding would be unacceptable with this procedure, I still err on holding DOACs for longer (following the ASRA guidelines).
rapm.bmj.com
7/
The PAUSE-2 trial hopes to shed more light on this important clinical question.
clinicaltrials.gov
The PAUSE-2 trial hopes to shed more light on this important clinical question.
clinicaltrials.gov
8/
To end, let’s briefly talk about bridging. Pts on warfarin generally hold it for at least 5 days preop. Depending on how high their clot risk is, bridging may make sense.
To end, let’s briefly talk about bridging. Pts on warfarin generally hold it for at least 5 days preop. Depending on how high their clot risk is, bridging may make sense.
9/
However, when DOACs are held, bridging is NOT recommended. I find this article’s figures are really helpful in hammering home this last point for learners.
jacc.org
However, when DOACs are held, bridging is NOT recommended. I find this article’s figures are really helpful in hammering home this last point for learners.
jacc.org
10/
In summary:
1⃣Some surgeries don’t need anticoagulation to be stopped.
2⃣If you do need to stop a DOAC, consider a strategy like in PAUSE. (Stay tuned to see what PAUSE-2 says re: DOACs + neuraxial procedures)
3⃣🚫 bridging when holding DOACs.
Thank you for reading!
In summary:
1⃣Some surgeries don’t need anticoagulation to be stopped.
2⃣If you do need to stop a DOAC, consider a strategy like in PAUSE. (Stay tuned to see what PAUSE-2 says re: DOACs + neuraxial procedures)
3⃣🚫 bridging when holding DOACs.
Thank you for reading!
Loading suggestions...