Department of Medicine, St. Joseph's Healthcare Hamilton, and McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, New York.
JAMA. 2024 Sep 10;332(10):825-834. doi: 10.1001/jama.2024.12708.
Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.
For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.
When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.
直接口服抗凝剂（DOAC）包括阿哌沙班、利伐沙班、依度沙班和达比加群，常用于治疗心房颤动和静脉血栓栓塞患者。在减少出血和血栓栓塞风险的情况下，如何管理接受手术或非手术治疗的 DOAC 患者是非常重要的。
对于择期手术或非手术，围手术期 DOAC 管理的标准化方法涉及将手术相关出血风险分类为低风险（如小牙科或皮肤手术）、中低风险（如胆囊切除术、腹股沟疝修补术）或高风险（如大手术或关节置换术）。对于低出血风险手术的患者，DOAC 可继续使用，或如果担心出血过多，可在手术当天停药。对于中低出血风险手术的患者，通常应在手术前 1 天停止使用 DOAC，并在手术后 1 天重新开始使用 DOAC。对于高出血风险手术的患者，应在手术前 2 天停止使用 DOAC，并在手术后 2 天重新开始使用 DOAC。采用这种围手术期 DOAC 管理策略，血栓栓塞（0.2%-0.4%）和大出血（1%-2%）的发生率较低，手术和非手术的延迟或取消也很少发生。需要紧急（就诊后<6 小时）或紧急手术（就诊后 6-24 小时）的服用 DOAC 的患者，出血率高达 23%，血栓栓塞高达 11%。术前测量 DOAC 水平的实验室检查可能有助于确定患者是否需要在紧急或紧急手术前使用 DOAC 逆转剂（如凝血酶原复合物浓缩物、依达鲁单抗或andexanet-α）。
当服用 DOAC 的患者需要进行择期手术或非手术时，可以应用标准化的管理方案，而无需检测 DOAC 水平或肝素桥接。当服用 DOAC 的患者需要紧急、紧急或半紧急手术时，如果 DOAC 水平升高或不可用，可能需要使用抗凝逆转剂。
