Perioperative management of patients who are receiving a novel oral anticoagulant
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The use of novel oral anticoagulants (NOACs) is increasing since these drugs are at least as efficacious and safe as vitamin K antagonists (VKAs) for the management of patients with non-valvular atrial fibrillation and venous thromboembolism. Compared with VKAs, NOACs have a faster onset and offset of action, a predictable and consistent pharmacokinetic profile, fewer drug interactions, and ease of use since anticoagulant monitoring is not required. Current perioperative management will be affected by these characteristics, with the potential to obviate the need for heparin bridging. This review aims to summarize the current evidence of perioperative thromboembolic and bleeding risk during anticoagulant interruption, which is derived predominantly from patients receiving VKA therapy, and early studies involving NOACs which mainly focus on patients who are receiving dabigatran. The role of heparin bridging is discussed. We also provide a practical approach for the perioperative management of patients who are receiving NOAC therapy.
KeywordsBleeding New oral anticoagulants Perioperative Thrombosis
Conflict of interest
A. Liew has received educational and research support from AstraZeneca, BI, BMS, MSD, Novo Nordisk, Novartis, Sanofi-Aventis and Medtronic. J. Douketis was a consultant for Boehringer-Ingelheim and served as a consultant during advisory board meetings (by Sanofi-Aventis, AstraZeneca, Boehringer-Ingelheim, Bristol-Myers-Squibb) relating to the development and clinical use of novel antiplatelet drugs (ticagrelor) and anticoagulant drugs (apixaban, semuloparin, [not approved for clinical use] and dabigatran).
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