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Periprocedural Direct Oral Anticoagulant Management: The RA-ACOD Prospective, Multicenter Real-World RegistryFunding This work was supported by a governmental grant from the Instituto de Salud Carlos III (PI13/02742).
28 December 2019
14 April 2020
26 June 2020 (online)
Introduction There is scarce real-world experience regarding direct oral anticoagulants (DOACs) perioperative management. No study before has linked bridging therapy or DOAC-free time (pre-plus postoperative time without DOAC) with outcome. The aim of this study was to investigate real-world management and outcomes.
Methods RA-ACOD is a prospective, observational, multicenter registry of adult patients on DOAC treatment requiring surgery. Primary outcomes were thrombotic and hemorrhagic complications. Follow-up was immediate postoperative (24–48 hours) and 30 days. Statistics were performed using a univariate and multivariate analysis. Data are presented as odds ratios (ORs [95% confidence interval]).
Results From 26 Spanish hospitals, 901 patients were analyzed (53.5% major surgeries): 322 on apixaban, 304 on rivaroxaban, 267 on dabigatran, 8 on edoxaban. Fourteen (1.6%) patients suffered a thrombotic event, related to preoperative DOAC withdrawal (OR: 1.57 [1.03–2.4]) and DOAC-free time longer than 6 days (OR: 5.42 [1.18–26]). Minor bleeding events were described in 76 (8.4%) patients, with higher incidence for dabigatran (12.7%) versus other DOACs (6.6%). Major bleeding events occurred in 17 (1.9%) patients. Bridging therapy was used in 315 (35%) patients. It was associated with minor (OR: 2.57 [1.3–5.07]) and major (OR: 4.2 [1.4–12.3]) bleeding events, without decreasing thrombotic events.
Conclusion This study offers real-world data on perioperative DOAC management and outcomes in a large prospective sample size to date with a high percentage of major surgery. Short-term preprocedural DOAC interruption depending on the drug, hemorrhagic risk, and renal function, without bridging therapy and a reduced DOAC-free time, seems the safest practice.
R.F. and J.V.L. contributed toward: (1) conception and design, acquisition of data, and analysis and interpretation of data; (2) drafting the article and revising it critically for important intellectual content; (3) final approval of the version to be published; (4) agreement to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. F.J.S., M.C.C., O.G.L., M.S.M., V.S., P.G., L.M.T., E.F.B., C.G.C., P.S., M.B., N.M., C.M.E., M.L., A.G.L., J.M., F.H., G.Y., R.R., B.C., E.D., B.T., A.P., M.A.V., J.C.A., and S.S. contributed toward: (1) acquisition of data; (2) revising the article critically for important intellectual content; (3) final approval of the version to be published; (4) agreement to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. RA-ACOD investigators contributed toward: (1) acquisition of data; (2) final approval of the version to be published; (3) agreement to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
* A complete list of the RA-ACOD investigators is provided as [Supplementary Appendix].
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