New Tool Provides Simple Approach to Pausing Direct Oral Anticoagulants for Surgery

Researchers have developed a “simple, standardized, easy-to-use” strategy to guide decisions about interrupting direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) scheduled to undergo an elective surgery or procedure. The approach was safe and associated with low incidence of peri-operative major bleeding and arterial thromboembolism.

“This is a common clinical problem that occurs in one in six patients with atrial fibrillation each year, or 6 million patients worldwide, and it is increasing in prevalence as the population ages,” James Douketis, MD, from McMaster University in Ontario, presented the results of the late-breaking abstract at the 2018 ASH Annual Meeting. However, “since the DOACs were introduced nearly 10 years ago, few studies have looked at how to manage these patients, [leading to] a lot of variability in clinical practice and inconsistency in guideline recommendations.”

The aim of the Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) study, Dr. Douketis said, was to establish a simple tool that did not require peri-operative anticoagulant bridging or coagulation function testing.

Interruption and resumption of DOACs was dictated by the bleeding risk associated with the planned procedure and the type of DOAC: For procedures with low bleeding risk (i.e., colonoscopy or hernia repair), DOACs were interrupted for 1 day before and after surgery; for procedures with high bleeding risk (i.e., major cancer, heart, or orthopedic surgery), DOACs were interrupted for 2 days before and after surgery. Patients on dabigatran with a creatine clearance <50 mL/min and who were planned for a procedure with a high bleeding risk stopped dabigatran 4 days before and 2 days after surgery.

Researchers evaluated the approach in 3,007 patients with AF receiving apixaban (n=1,257), dabigatran (n=668), or rivaroxaban (n=1,082). Approximately one-third of patients in the trial were scheduled to undergo a high-bleeding-risk surgery, and the median CHADS2 score (a 1- to 5-point scale measuring stroke risk) was 2.1, 2.2, and 2.0 in the apixaban, dabigatran, and rivaroxaban groups, respectively.

Participants were followed weekly for 30 days post-procedure to measure incidence of major bleeding and arterial thromboembolism (primary endpoint).

The researchers expected arterial thromboembolism (including stroke, systemic embolism, and transient ischemic attack) to occur in 0.5 percent of patients and major bleeding in 1 percent. They reported lower-than-expected rates for arterial thromboembolism in all patient groups, but the rates were higher than expected in the apixaban and rivaroxaban groups (TABLE).

An analysis of pre-operative blood samples indicated that more than 90 percent of patients treated per the PAUSE protocol had minimal or no residual DOAC levels Nearly all patients (98.9%) undergoing a high-bleeding-risk procedure had DOAC levels <50 ng/L, prompting the investigators to select 50 ng/L as “a clinically safe threshold to allow a surgery to proceed.”

“This is the first study to demonstrate the safety of a standardized peri-operative management approach in patients with AF who are taking a DOAC, and we hope will establish a standard and will have an effect on clinical practice guidelines,” Dr. Douketis concluded.

The authors report financial relationships with Pfizer, Janssen, Merck, and Sanofi.


Douketis J, Spyropoulos AC, Duncan JM, et al. Perioperative anticoagulant use for surgery evaluation (PAUSE) study: a perioperative management plan for patients with atrial fibrillation who are receiving a direct oral anticoagulant. Abstract LBA-5. Presented at the 2018 ASH Annual Meeting, December 4, 2018; San Diego, CA.

TABLE. Primary Outcomes





Arterial thromboembolism

2 (0.16%)

4 (0.60%)

4 (0.37%)

Major bleeding

17 (1.35%)

6 (0.90%)

20 (1.85%)