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

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.