What are the recommendations for discontinuing non‑vitamin K antagonist oral anticoagulants in patients with atrial fibrillation prior to surgery?

Perioperative Management of NOACs in Atrial Fibrillation

For patients with atrial fibrillation on NOACs undergoing elective surgery, discontinue apixaban, rivaroxaban, and edoxaban 1 day (24 hours) before low bleeding risk procedures and 2 days (48 hours) before high bleeding risk procedures; discontinue dabigatran 1-2 days before low-risk procedures and 2-4 days before high-risk procedures, with timing adjusted based on creatinine clearance. 1

Timing of NOAC Discontinuation by Drug and Procedure Risk

Factor Xa Inhibitors (Apixaban, Rivaroxaban, Edoxaban)

Low Bleeding Risk Procedures:

• Stop 1 full day (24 hours) before surgery for patients with CrCl >25-30 mL/min 1, 2
• This applies uniformly to apixaban, rivaroxaban, and edoxaban regardless of renal function, as these agents have less renal elimination than dabigatran 1, 2

High Bleeding Risk Procedures:

• Stop 2 full days (48 hours) before surgery for patients with CrCl >25-30 mL/min 1, 2
• The 2018 European Heart Rhythm Association guidelines align with these recommendations 1

Dabigatran (Requires Renal Function Adjustment)

Low Bleeding Risk Procedures:

• CrCl >50 mL/min: Stop 1 day (≥24 hours) before surgery 1
• CrCl 30-50 mL/min: Stop 2 days (≥36-48 hours) before surgery 1

High Bleeding Risk Procedures:

• CrCl >50 mL/min: Stop 2 days (≥48 hours) before surgery 1
• CrCl 30-50 mL/min: Stop 4 days (≥72-96 hours) before surgery 1
• The FDA label for dabigatran recommends discontinuation 1-2 days (CrCl ≥50 mL/min) or 3-5 days (CrCl <50 mL/min) before invasive procedures 3

Special Considerations for Neuraxial Procedures

For epidural/spinal anesthesia or any neuraxial intervention, stop apixaban for 72 hours (3 days) before the procedure if CrCl >30 mL/min to ensure >98% drug elimination. 2

• This extended interruption period is critical because residual NOAC levels during neuraxial procedures can cause catastrophic spinal hematomas 2
• Consider extending the interruption period to 5 days in patients with additional risk factors such as age >80 years or renal impairment 2
• The American College of Cardiology guidelines recommend longer interruption times for procedures requiring complete hemostasis, including spinal puncture 1, 3

Procedure Risk Classification

Low Bleeding Risk Procedures (low frequency of bleeding and/or minor impact):

• Dental extractions (1-3 teeth), periodontal surgery 1, 2
• Arthroscopy, cutaneous/lymph node biopsies 2
• Cardiac device implantations 4
• Cataract surgery 1

High Bleeding Risk Procedures (high frequency of bleeding and/or important clinical impact):

• Urologic or GI surgery with anastomosis 2
• Major orthopedic surgery (hip/knee replacement) 1
• Intracranial surgery 1
• Cardiac surgery requiring cardiopulmonary bypass 1

Critical Management Points

No Bridging Anticoagulation Required

Do not use bridging anticoagulation with low molecular weight heparin or unfractionated heparin when stopping NOACs for elective surgery, as it significantly increases bleeding risk without reducing thrombotic events. 1, 2, 4

• The 2018 European Heart Rhythm Association explicitly states "No bridging with LMWH/UFH" 1
• This represents a major departure from warfarin management and is a common pitfall to avoid 2, 4

Resuming NOACs After Surgery

Resume NOACs at least 24 hours after low bleeding risk procedures and 48-72 hours after high bleeding risk procedures, once adequate hemostasis is established. 1, 4

• For minor procedures, NOACs can be restarted as early as 6 hours after the procedure if bleeding has completely stopped 1, 2
• The patient may only leave the facility if any peri-interventional bleeding has completely stopped 1, 5
• If an epidural catheter remains in place, wait at least 2 hours after catheter removal before administering the first dose 2

Practical Dosing Instructions

The number of days refers to full days before surgery during which the patient takes no anticoagulant, and the drug is also not taken on the day of surgery. 1

• For example, if holding a twice-daily drug for 1 day: if the drug is taken at 8 PM and surgery is at 8 AM, 36 hours will have elapsed since the last dose 1
• Patients should receive written documentation specifying the anticipated date and time of their procedure, and the date and time of the last NOAC intake 1, 5

Emergency Surgery Considerations

For emergent surgery or urgent procedures, consider using reversal agents such as idarucizumab for dabigatran or prothrombin complex concentrate (PCC) 50 IU/kg for factor Xa inhibitors, as bleeding rates can reach up to 23% in these situations. 2, 3

• If surgery cannot be delayed, weigh the increased risk of bleeding against the urgency of intervention 3
• The FDA label for dabigatran recommends using idarucizumab when reversal of anticoagulant effect is needed for emergency surgery 3
• Ideally, delay surgery for at least 12-24 hours (one to two half-lives) if possible 6, 7

Common Pitfalls to Avoid

• Never perform neuraxial anesthesia if there is any possibility of residual DOAC levels, particularly in elderly patients (>80 years) or those with renal impairment 2
• Do not use INR to monitor NOAC levels during the transition period, as NOACs can affect INR measurements but this does not reliably reflect their anticoagulant effect 1, 7
• Always assess and document renal function before determining the timing of NOAC discontinuation, especially for dabigatran which has 80% renal clearance 1, 5
• Avoid concomitant P-gp inhibitors (dronedarone, amiodarone, verapamil) in patients with impaired renal function, as these can significantly prolong NOAC elimination 1