What anticoagulants are recommended after procedures with high risk of thromboembolic events?

From the Guidelines

For procedures with high risk of thromboembolic events, direct oral anticoagulants (DOACs) such as apixaban, edoxaban, or rivaroxaban are recommended as first-line anticoagulants, with administration withheld on the day of the procedure and resumed 24 hours after the procedure, as outlined in the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1.

Key Considerations

• The management of perioperative bleeding risk and DOAC or VKA schedule should incorporate team-based decision-making, especially in high thrombotic risk patients or when undergoing procedures with higher risks of adverse outcome, should bleeding occur.
• The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline provides a comprehensive approach to perioperative anticoagulation management, including recommendations for DOACs and VKAs in patients with high, low, or moderate bleeding risk.
• For patients with high thrombotic risk, delaying elective non-cardiac surgery may permit safer interruption of oral anticoagulants (OACs), and time reversal of OAC is always preferred, but this may not be feasible for urgent or emergency procedures with moderate or high bleeding risk.

Anticoagulant Options

• DOACs, including apixaban, edoxaban, and rivaroxaban, are increasingly used alternatives for perioperative anticoagulation, particularly for orthopedic procedures.
• Vitamin K antagonists (VKAs), such as warfarin, may also be used, but require more frequent monitoring and dose adjustments.
• Low molecular weight heparins (LMWHs) and unfractionated heparin may be used as bridging therapy in patients with high thrombotic risk or those undergoing procedures with higher risks of adverse outcome.

Patient-Specific Factors

• Renal impairment, as indicated by creatinine clearance (CrCl) <30 mL/min, may require dose adjustment or alternative agents.
• The measurement of coagulation parameters, drug levels, or both may identify ongoing drug effects and guide the management of OAC reversal agents.
• Rapid reversal of OAC can be achieved with prothrombin complex concentrates, andexanet alfa for factor Xa inhibitors, or idarucizumab for dabigatran.

From the FDA Drug Label

XARELTO is indicated for the prophylaxis of DVT, which may lead to PE in adult patients undergoing knee or hip replacement surgery. XARELTO is indicated for the prophylaxis of venous thromboembolism (VTE) and VTE related death during hospitalization and post hospital discharge in adult patients admitted for an acute medical illness who are at risk for thromboembolic complications due to moderate or severe restricted mobility and other risk factors for VTE and not at high risk of bleeding

The recommended anticoagulant after procedures with high risk of thromboembolic events is rivaroxaban (XARELTO).

• The dosage is 10 mg once daily for 35 days after hip replacement surgery and for 12 days after knee replacement surgery, taken 6-10 hours after surgery once hemostasis has been established.
• For prophylaxis of VTE in acutely ill medical patients, the dosage is 10 mg once daily for a total recommended duration of 31 to 39 days.
• Rivaroxaban can be taken with or without food 2.

From the Research

Anticoagulants after Procedures with High Risk of Thromboembolic Events

• The use of anticoagulants after procedures with high risk of thromboembolic events is a common practice to prevent venous thromboembolism (VTE) [ 3 ].
• Fondaparinux, a synthetic selective factor Xa inhibitor, has been shown to be more effective than enoxaparin in preventing VTE in patients undergoing major orthopedic surgery [ 3 ].
• Low-molecular-weight heparins (LMWHs), such as enoxaparin, have been found to be effective and safe in the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) [ 4 ].
• A meta-analysis of phase III randomized clinical trials found that LMWH enoxaparin and direct oral anticoagulants (DOACs) have similar efficacy and safety profiles in preventing VTE in patients undergoing major orthopedic surgery and acutely ill medical patients [ 5 ].

Recommended Anticoagulants

• Enoxaparin is a commonly recommended anticoagulant for the prevention of VTE in patients undergoing major orthopedic surgery and acutely ill medical patients [ 3 , 5 ].
• Fondaparinux is also recommended for the prevention of VTE in patients undergoing major orthopedic surgery [ 3 ].
• LMWHs, such as enoxaparin, are recommended for the treatment of DVT and PE [ 4 ].

Safety and Efficacy

• The safety and efficacy of periprocedural anticoagulation with enoxaparin have been demonstrated in patients undergoing peripheral endovascular revascularization [ 6 ].
• A comparative trial found that enoxaparin is as effective and safe as standard heparin for the prevention of postoperative DVT in general surgery patients [ 7 ].