What is the treatment for a patient with nonvalvular atrial fibrillation (AF) and a CHA2DS2-VASc score of 3, currently on dabigatran (Pradaxa) (dabigatran), undergoing right hip arthroplasty?

From the Guidelines

For a patient with nonvalvular atrial fibrillation with a CHA2DS2-VASc score of 3 on dabigatran who is undergoing right hip arthroplasty, the recommended approach is to temporarily discontinue dabigatran before surgery and resume it postoperatively. Specifically, dabigatran should be stopped 48-72 hours before the procedure (72 hours if creatinine clearance is <50 mL/min) as per the guidelines outlined in the 2024 ESC guidelines for the management of atrial fibrillation 1. No bridging with heparin is typically needed. Postoperatively, dabigatran can be resumed 24-48 hours after surgery once hemostasis is achieved, with consideration for starting at half the usual dose for the first 1-2 days in patients at high bleeding risk. During the perioperative period, mechanical thromboprophylaxis with compression devices should be used. The timing of discontinuation and resumption is critical because dabigatran is a direct thrombin inhibitor with a relatively short half-life, and this approach balances the competing risks of thromboembolism (due to the patient's moderate-high risk with a CHA2DS2-VASc score of 3) and perioperative bleeding. Close coordination between the surgical team, anesthesia, and the prescribing physician is essential to manage this perioperative anticoagulation. It's also important to note that the choice of anticoagulant and the decision to discontinue or resume it should be based on the patient's individual risk factors and clinical circumstances, as outlined in the guidelines 1. The patient's renal function should also be evaluated before initiation of direct thrombin or factor Xa inhibitors, and reevaluated when clinically indicated and at least annually 1. Overall, the management of anticoagulation in patients with nonvalvular atrial fibrillation undergoing surgery requires careful consideration of the patient's individual risk factors and clinical circumstances, as well as close coordination between the healthcare team.

Some key points to consider include:

• The patient's CHA2DS2-VASc score of 3 indicates a moderate-high risk of thromboembolism, and anticoagulation should be managed accordingly 1.
• The use of dabigatran, a direct thrombin inhibitor, requires careful consideration of the patient's renal function and the timing of discontinuation and resumption 1.
• Mechanical thromboprophylaxis with compression devices should be used during the perioperative period to reduce the risk of venous thromboembolism 1.
• Close coordination between the surgical team, anesthesia, and the prescribing physician is essential to manage this perioperative anticoagulation 1.

From the FDA Drug Label

To reduce the risk of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (1. 1) Temporarily discontinue dabigatran etexilate capsules before invasive or surgical procedures when possible, then restart promptly (2. 8)

For a patient with nonvalvular atrial fibrillation and a CHA2DS2-VASc score of 3, currently on dabigatran (Pradaxa) undergoing right hip arthroplasty, temporary discontinuation of dabigatran etexilate capsules is recommended before the invasive or surgical procedure when possible. The medication should be restarted promptly after the procedure. The decision to discontinue and restart dabigatran should be based on the patient's individual risk of thrombotic and bleeding events, and the timing of discontinuation and restart should be determined by the surgeon or prescriber, taking into account the patient's renal function and other clinical factors 2. Key considerations include:

• The patient's bleeding risk
• The patient's thrombotic risk
• The timing of the procedure
• The patient's renal function It is essential to closely monitor the patient for signs and symptoms of bleeding or thrombosis during and after the procedure.

From the Research

Treatment for Nonvalvular Atrial Fibrillation (AF) with CHA2DS2-VASc Score of 3

• The patient has a CHA2DS2-VASc score of 3, which indicates a moderate risk of thromboembolism 3.
• The patient is currently on dabigatran (Pradaxa), a direct oral anticoagulant (DOAC) 4.
• The patient is undergoing right hip arthroplasty, a noncardiac surgery.

Perioperative Management

• The CHA2DS2-VASc score is useful in predicting perioperative outcomes in nonvalvular atrial fibrillation patients undergoing noncardiac surgery 5.
• The score can help identify patients who are at high risk of thromboembolic events and may require more aggressive anticoagulation therapy.
• The decision to continue or interrupt anticoagulation therapy during surgery should be based on the patient's individual risk factors and the type of surgery being performed.

Anticoagulation Therapy

• Dabigatran is a effective anticoagulant for stroke prevention in patients with nonvalvular atrial fibrillation 4.
• The patient's CHA2DS2-VASc score of 3 indicates a moderate risk of thromboembolism, and anticoagulation therapy should be continued perioperatively to reduce this risk.
• The management of anticoagulation therapy during surgery should be individualized and based on the patient's risk factors and the surgical procedure 6.