The perioperative management of NOACS (New, Novel, or Non-vitamin K Oral Anticoagulants) is a matter of ongoing debate. There are multiple detailed guidelines available.
Issues that complicate the consideration of this issue include:-
- The adequacy of reversal that is required depends on the risk of bleeding (low-risk surgery, high-risk surgery, and reversal required for neuraxial blockade)
- The risk of the patient ceasing anticoagulation may vary depending on the indication for anticoagulation. The BRIDGE trial (although focussed on Warfarin) suggests that this risk may be less than commonly thought, so that slightly earlier preoperative cessation of NOAC therapy may not imply greatly increased risk of thrombotic events.
- There has been considerable debate about the quality of evidence, data interpretation, marketing, and some ‘value judgements’ in the development and introduction of NOACs.
- Based on the above, some clinicians would be somewhat more cautious than the cessation times recommended in many guidelines.
- Brief Guideline
- SA Guideline
- Anticoagulants and Regional Anaesthesia table
- NOACs (ASTH Guideline 2014)
Referring to the CHADS2 Score provides an interesting ‘reality check’ about the efficacy of anticoagulant therapy and annual risk of thrombotic events.
There is ongoing controversy about NOACs vs Warfarin which is usefully and provocatively summarised in this commentary:-
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