Po-01-018 pre-operative discontinuation of novel oral anticoagulants in cardiovascular surgery: is two days enough?

Discontinuation of novel oral anticoagulants (NOACs) to minimize peri-operative bleeding risk is integral before invasive cardiovascular surgery (CVS). There is little data on the optimal number of days NOACs should be held pre-operatively in these patients. A retrospective evaluation of major bleeding, and its association with the number of days NOACs were held pre-operatively, and whether or not heparin bridging was used. Major bleeding was defined according to the International Society on Thrombosis and Haemostasis (ISTH). Major bleeding is defined as: either a hemoglobin drop of >20 g/L, 2U blood transfusion, symptomatic/ critical organ bleeding, or fatal bleeding. Baseline and follow-up clinical information were collected for consecutive CVS patients treated with NOACs between 2013-2016 at a single tertiary care centre. Multivariate logistic regression models were employed to evaluate major bleeding and post-operative bleeding risks associated with different NOACs hold periods. In 107 (72.9% male) patients (age= 73.6±7.7 years), 89 (83.2%) of whom had a history of Atrial Fibrillation (AF), NOACs were stopped on average 4.5±2.4 days pre-operation, including: 17 (Group 1) within ≤2 days, 63 (Group 2) ≥3 days without heparin, and 27 (Group 3) ≥3 days with heparin bridging. There were no statistically significant differences in baseline comorbidities between the three Groups. Major bleeding rates ranged from 58.8, 30.6, 55.6% (p= 0.03), and bleeding episode rates ranged between 52.9, 16.1, 44.4% (p= 0.002) in Groups 1, 2, and 3 respectively. Multivariate logistic regression adjusted for age, sex, NOAC type, and procedure type (elective vs. emergent), showed that stopping NOAC ≥3 days (vs. ≤2 days) before surgery without heparin bridging (i.e. Group 2) was independently associated with a significantly lower risks of major bleeding (OR: 0.29 [0.08, 1.00], p= 0.05) and bleeding episode (OR: 0.16 [0.04, 0.61], p= 0.007). Compared to ≤2 days hold, NOAC hold of ≥3 days with heparin was not associated with lower risks of major bleeding (OR: 0.96 [0.25, 3.65], p= 0.95) and bleeding episode (OR: 0.77 [0.21, 2.91], p= 0.70). NOAC discontinuation ≥3 days without heparin bridging before CVS was associated with significantly lower risk of major bleeding and post-operative bleeding episode compared to the ≤2 days stop period.