Perioperative management of patients receiving oral anticoagulants - A systematic review

Background: The safety and efficacy of various management strategies for patients receiving oral anticoagulants (OACs) who need to undergo surgery or invasive procedures are unknown. Methods: We performed a systematic review and synthesis of the English-language literature examining the perioperative management and outcomes of patients receiving long-term OAC therapy. Results: Thirty-one reports were identified. The quality of the identified reports was generally poor; no randomized controlled trials have been performed and duration of follow-up was typically not stated. Overall, 29 thromboembolic events occurred amont 1868 patients (1.6%; 95% confidence interval, 1.0%-2.1%), including 7 strokes (0.4%; 95% confidence interval, 0%-0.7%). Thromboembolic event rates by management strategy were 0.4% (1 of 237) for continuation of OAC, 0.6% (6 of 996) for discontinuation of OAC therapy without administration of intravenous heparin, 0% (0 of 166) for discontinuation of OAC therapy with administration of intravenous heparin, 0.6% (1 of 180) for discontinuation of OAC therapy with administration of low-molecular-weight heparin, and 8.0% (21 of 263) for unspecified or unclear strategies. Major bleeding while receiving therapeutic OAC was rare for dental procedures (0.2% [4 of 2014]), arthrocentesis (0% [0 of 32]), cataract surgery (0% [0 of 203]), and upper endoscopy or colonoscopy with or without biopsy (0% [0 of 111]). Conclusions: Most patients can undergo dental procedures, arthrocentesis, cataract surgery, and diagnostic endoscopy without alteration of their regimen. For other invasive and surgical procedures, oral anticoagulation needs to be withheld, and the decision whether to pursue an aggressive strategy of perioperative administration of intravenous heparin or subcutaneous low-molecular-weight heparin should be individualized. The current literature is substantially limited in its ability to help choose an optimal strategy. Further and more rigorous studies are needed to better inform this decision.