Current Cardiology Reports

, 19:124 | Cite as

Management of Elective Surgery and Emergent Bleeding with Direct Oral Anticoagulants

  • Scott Kaatz
  • Charles E. Mahan
  • Asaad Nakhle
  • Kulothungan Gunasekaran
  • Mahmoud Ali
  • Robert Lavender
  • David G. Paje
Invasive Electrophysiology and Pacing (EK Heist, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Invasive Electrophysiology and Pacing


Purpose of Review

The purpose of this review was to offer practical management strategies for when patients receiving direct oral anticoagulants require elective surgery or present with bleeding complications.

Recent Findings

Clinical practice guidelines are now available on the timing of periprocedural interruption of treatment with the newer direct oral anticoagulants based on their pharmacodynamics and pharmacokinetics and based on findings from cohort studies and clinical trials. An antibody that reverses the effects of dabigatran is now available, and a factor Xa decoy is being developed as an antidote to apixaban, betrixaban, edoxaban, and rivaroxaban.


The timing of interruption of direct oral anticoagulants for elective surgery is based on multiple factors, including pharmacologic properties and interactions, the patient’s renal function, and the type of planned surgery. There is little role for low-molecular-weight heparin bridging. Idarucizumab is the treatment of choice for dabigatran-related life-threatening bleeding, while andexanet alfa is being developed to reverse factor Xa inhibitors.


Direct oral anticoagulants (DOAC) Reversal Bleeding Surgery Idarucizumab Andexanet alfa 


Compliance with Ethical Standards

Conflict of Interest

Dr. Scott Kaatz has received research funding from Janssen; Speaker honorarium from Janssen, Boehringer-Ingelheim, Bristol Myer Squibb, Pfizer, CSL Behring, and Daiichi Sankyo; and consultant fees from Boehringer Ingelheim, Bristol Myer Squibb, Pfizer, Janssen, Daiichi Sankyo, Portola and Roche.

Dr. Charles E. Mahan has received speaker honoraria from Janssen, Bristol Myer Squibb, Pfizer, Portola, and Boehringer Ingelheim; and consultant fees from Janssen, Pfizer, Portola, and Daiichi Sankyo.

Drs Asaad Nakhle, Kulothungan Gunasekaran, Mahmoud Ali, Robert Lavender, and David G. Paje have nothing to disclose.

Human and Animal Rights and Informed Consent

This review article did not involve human or animal experimentation.


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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Scott Kaatz
    • 1
  • Charles E. Mahan
    • 2
  • Asaad Nakhle
    • 3
  • Kulothungan Gunasekaran
    • 1
  • Mahmoud Ali
    • 3
  • Robert Lavender
    • 4
  • David G. Paje
    • 5
  1. 1.Division of Hospital MedicineHenry Ford HospitalDetroitUSA
  2. 2.Department of PharmacyUniversity of New Mexico, Presbyterian Healthcare ServicesAlbuquerqueUSA
  3. 3.Department of Internal MedicineHenry Ford HospitalDetroitUSA
  4. 4.Division of General Internal MedicineUniversity of Arkansas for Medical SciencesLittle RockUSA
  5. 5.Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborUSA

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