Perioperative DOAC Interruption

First determine whether anticoagulation can remain uninterrupted. Minimal-risk procedures include cataract surgery and minor dental or dermatologic procedures; the 2024 perioperative guideline defines this category by a 30-day major-bleeding risk of 0%. Low/moderate-risk procedures have an estimated 30-day major-bleeding risk below 2%. Procedures with major bleeding consequences, particularly neuraxial anesthesia, require complete interruption. jaccjacc2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM ...

If interruption is required, use the DOAC, current creatinine clearance (CrCl), and procedural bleeding risk—not a fixed number of calendar days. ACC guidance specifically directs that interruption timing be individualized by agent, renal function, and procedure bleeding risk. Renal function is especially consequential for dabigatran; obtain a current creatinine measurement when kidney function may have changed, including clinical deterioration before an endoscopic procedure. BMJ+1BMJEndoscopy in patients on antiplatelet or anticoagulant ...jacc2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and ... - JACC

Avoid routine drug-level testing for standard elective cases with an adequate pharmacokinetic hold. Consider a calibrated agent-specific anti-Xa level for factor Xa inhibitors or dilute thrombin time (dTT) for dabigatran when severe renal impairment, uncertain last ingestion, or an abbreviated interruption leaves clinically important uncertainty. A residual DOAC concentration below 30 ng/mL is commonly treated by anesthesiology societies as a hemostatic threshold, although this cutoff has not been clinically validated. BMJ+2BMJrapm-2024-105766.full.pdf - Regional Anesthesia & Pain Medicinejacc2020 ACC Expert Consensus Decision Pathway on Management of ...ScienceDirectDirect oral anticoagulant management for neuraxial anaesthesia and deep peripheral nerve blocks

For standard procedures, a pharmacokinetic approach targets approximately 2-3 half-lives off drug for low bleeding risk and 4-5 half-lives for uncertain, intermediate, or high bleeding risk. In the ACC 2020 pathway, apixaban, edoxaban, or rivaroxaban with CrCl at least 30 mL/min are held at least 24 hours for low-risk procedures and 48 hours for uncertain, intermediate, or high-risk procedures. jaccjacc2020 ACC Expert Consensus Decision Pathway on Management of ...

Dabigatran interruption must be extended as renal clearance falls. With CrCl at least 80 mL/min, hold at least 24 hours for low-risk and 48 hours for higher-risk procedures; with CrCl 50-79 mL/min, hold at least 36 and 72 hours, respectively; and with CrCl 30-49 mL/min, hold at least 48 and 96 hours, respectively. For CrCl 15-29 mL/min, the ACC table advises at least 72 hours for low-risk procedures and dTT testing or prolonged withholding for higher-risk procedures. jaccjacc2020 ACC Expert Consensus Decision Pathway on Management of ...

A standardized PAUSE-based strategy used 1 day of interruption before low-bleeding-risk surgery and 2 days before high-bleeding-risk surgery, with longer interruption for dabigatran in renal impairment. Across perioperative DOAC interruption studies in atrial fibrillation, pooled 30-day thromboembolism and major-bleeding rates were 0.4% and 1.8%, respectively. Wiley+1WileyPerioperative interruption of direct oral anticoagulants in patients ...ASHPerioperative Anticoagulant Use for Surgery Evaluation (PAUSE ...

Neuraxial anesthesia should not be managed as an ordinary high-bleeding-risk surgery because spinal or epidural hematoma carries disproportionate neurologic consequence. The 2024 perioperative guideline calls for complete interruption and specifies at least 3 days for factor Xa inhibitors and at least 4 days for dabigatran when minimal drug effect is desired; extend dabigatran to 5-6 days when CrCl is below 50 mL/min. jaccjacc2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM ...

ASRA-oriented guidance uses a conservative residual anticoagulant target of less than 30 ng/mL when level testing is used. In patients with CrCl above 50 mL/min taking high-dose dabigatran, a 60-72-hour interruption yielded dTT evidence of no detectable anticoagulant effect, defined as a plasma concentration below 20 ng/mL, in 95.5% at procedure time. BMJ+2BMJRegional anesthesia in the patient receiving antithrombotic or ...BMJrapm-2024-105766.full.pdf - Regional Anesthesia & Pain MedicineScienceDirectDirect oral anticoagulant management for neuraxial anaesthesia and deep peripheral nerve blocks

For elective neuraxial procedures with uncertain adherence, delayed elimination, or a shorter-than-recommended interval, choose an alternate anesthetic technique, delay the intervention, or obtain a drug-specific level rather than inferring safety from PT, INR, or aPTT. Practice remains variable: anesthesiologists surveyed for high-bleeding-risk surgery with neuraxial anesthesia generally favored 3-5 days of interruption, whereas medical specialists more often favored 2 days. jacc+1jacc2020 ACC Expert Consensus Decision Pathway on Management of ...ScienceDirectA physician survey of perioperative neuraxial anesthesia management in patients on a direct oral anticoagulant

For elective endoscopy, distinguish low-risk diagnostic procedures from interventions with a substantial postprocedural bleeding risk. Endoscopy guidance supports a favorable temporary DOAC interruption interval of 1-2 days before elective endoscopic procedures, excluding the day of the procedure; for dabigatran with CrCl 30-50 mL/min, the last dose should be 5 days before a high-risk procedure. BMJ+1BMJEndoscopy in patients on antiplatelet or anticoagulant ...Oxford AcademicManagement of Anticoagulants and Antiplatelets During Acute ...

Avoid LMWH bridging around endoscopic procedures solely because the DOAC is held. In cited endoscopy data, bridging increased postpolypectomy hemorrhage without reducing thromboembolic events. BMJBMJEndoscopy in patients on antiplatelet or anticoagulant ...

For atrial fibrillation patients undergoing pacemaker, defibrillator, or generator procedures, either uninterrupted or interrupted DOAC therapy is reasonable. Choose with the implanting operator based on anticipated pocket bleeding, procedural complexity, and local protocol rather than applying an automatic multi-day interruption. jaccjacc2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and ... - JACC

Before restarting, confirm procedural-site hemostasis, consider procedure-specific bleeding complications, reassess patient-specific bleeding factors, and involve the proceduralist and managing service in the decision. This is essential because a full DOAC dose restores therapeutic anticoagulation within hours; peak levels and therapeutic effect generally occur about 2-3 hours after DOAC initiation. jacc+1jacc2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Forcejacc2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM ...

After a low postprocedural bleeding-risk procedure, resume the full DOAC dose on the day after the procedure if hemostasis is complete. After a high postprocedural bleeding-risk procedure, wait at least 48-72 hours before full-dose resumption when complete hemostasis has been achieved. PAUSE-based endoscopy guidance similarly reports low thromboembolic risk when DOAC therapy is restarted 2-3 days after high-risk procedures. BMJ+1BMJEndoscopy in patients on antiplatelet or anticoagulant ...jacc2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force

Do not bridge after DOAC interruption when full-dose resumption is planned. Unlike warfarin, DOAC therapy becomes therapeutic rapidly, and ACC guidance states that postinterruption bridging is unnecessary and may be hazardous. If postoperative bleeding occurs, defer resumption until adequate hemostasis is achieved rather than restarting according to a preset clock. jacc+1jacc2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task ForcePubMedPerioperative Anticoagulation Management - StatPearls - NCBI - NIH

Escalate preprocedural planning when CrCl is severely reduced, the last dose is uncertain, an urgent procedure cannot wait for the recommended hold, or neuraxial bleeding consequences are unacceptable. For factor Xa inhibitors, use a calibrated agent-specific anti-Xa level when testing is needed; for dabigatran, use dTT. The ACC pathway explicitly recommends considering these tests in advanced renal impairment when a fixed interruption interval is inadequate or unsupported. jaccjacc2020 ACC Expert Consensus Decision Pathway on Management of ...

Do not use an isolated time-since-last-dose estimate as a substitute for reassessing renal function in a patient whose clinical status has changed. Dabigatran is the clearest example: CrCl 30-50 mL/min requires 4-5 days to reach minimal anticoagulant effect before high-bleeding-risk procedures, compared with shorter interruptions in preserved renal function. BMJ+1BMJRegional anesthesia in the patient receiving antithrombotic or ...BMJEndoscopy in patients on antiplatelet or anticoagulant ...

For high-thrombotic-risk patients or procedures in which bleeding would have severe consequences, use team-based planning among the anticoagulation prescriber, proceduralist, anesthesiologist, and surgical team. The goal is not zero time off anticoagulation; it is the shortest interruption that achieves an acceptable residual drug effect for that procedure. jacc+1jacc2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM ...jacc2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and ... - JACC