Perioperative interruption of direct oral anticoagulants in patients with atrial fibrillation: A systematic review and meta‐analysis

ESSENTIALS: Little evidence exists to guide procedural interruption of direct oral anticoagulants (DOACs). Conducted a meta‐analysis of the interruption of DOACs in patients with atrial fibrillation (AF). The 30‐day risk for thromboembolic and major bleeding events were 0.4% and 1.8%, respectively. Perioperative interruption of DOACs in patients with AF appears to be safe and effective. BACKGROUND: Patients with atrial fibrillation (AF) frequently undergo invasive procedures that require temporary interruption of anticoagulation. There is little evidence to guide the perioperative interruption of direct oral anticoagulants (DOACs). METHODS: A systematic literature search including studies that evaluated the perioperative interruption of DOACs for non‐emergent invasive procedures in patients with AF was performed. The primary outcomes of interest were the 30‐day risk of thromboembolic events and major bleeding. Secondary outcomes of interest included the 30‐day risk of minor bleeding and overall mortality. The systematic review protocol and search strategy were registered online (PROSPERO January 27th 2017:CRD42017056124). RESULTS: A total of 8 publications encompassing 14 446 patients and 17 107 periprocedural interruptions were included in our study. Our analysis revealed a pooled postoperative 30‐day thromboembolic complication risk of 0.41% (95% CI 0.29‐ 0.54), and a pooled 30‐day postoperative major bleeding risk of 1.81% (95% CI 0.84‐3.13). Pooled 30‐day postoperative risks of minor bleeding and overall mortality were 3.08% (95% CI 1.02‐6.20) and 0.67% (95% CI 0.29‐1.23), respectively. Meta‐analysis of the included comparative studies did not reveal any significant differences in these postoperative outcomes following the perioperative interruption of DOACs or vitamin K antagonists. CONCLUSIONS: The perioperative interruption of DOACs in patients with AF was associated with 0.4% thromboembolic and 1.8% major bleeding events at 30 days post surgery. These findings seem reassuring, but require validation in large prospective management studies where pre‐operative DOAC levels are measured and compared with clinical outcomes in this patient population.