Interruption of non-vitamin K antagonist anticoagulants in patients undergoing planned invasive procedures: how long is long enough?

This editorial refers to ‘Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study’†, by A. Godier et al., on page 2431. Planned surgical interventions are frequenty performed in non-vitamin K antagonist anticoagulant (NOAC)-treated patients with an annual rate of ∼10%.1–3 The management of patients undergoing surgery with moderate or high risk of bleeding treated with NOACs aims to interrupt anticoagulant therapy, resulting in minimal residual anticoagulant effect at the time of surgery, and to resume anticoagulation as soon as is safe after surgery. Such careful management of peri-operative anticoagulation in NOAC-treated patients aims to protect patients from stroke risk while avoiding unnecessary risk for peri-operative bleeding. There are two major considerations for the peri-operative management of NOAC-treated patients.3 , 4 First, NOACs have a rapid onset of action such that the peak anticoagulant effect occurs within ∼2 h after oral intake. Off-set is also relatively rapid, with half-lives of ∼12 h for patients with normal renal function, with prolonged half-lives, particularly for dabigatran, for patients with impaired renal function. Secondly, widely used and reliable laboratory tests are lacking to quantify residual anticoagulant effects of NOACs. Accordingly, there is guidance from manufacturers and regulatory agencies on appropriate duration of interruption of oral anticoagulation before surgical interventions. The guidance depends on the type of intervention, renal function, and the specific NOAC.