Periprocedural DOACs vs. Warfarin Meta-Analysis

Study Questions:

What are the periprocedural safety and efficacy outcomes of direct oral anticoagulant- (DOAC) or warfarin-treated patients with nonvalvular atrial fibrillation (NVAF)?


The authors performed a systematic review and meta-analysis of phase III randomized trials comparing DOACs with warfarin in the periprocedural period. This meta-analysis was limited to patients with NVAF. Four trial substudies including 24,024 procedures in 19,252 patients were analyzed. Outcomes assessed included 30-day stroke/systemic embolism (SSE), major bleeding, and death using relative risk (RR).


For procedures that did not require anticoagulation interruption, there was no difference in the rate of SSE (0.6% vs. 1.1%, RR, 0.70; 95% confidence interval [CI], 0.41-1.18) or death (1.4% vs. 1.8%, RR, 0.77; 95% CI, 0.53-1.12) between DOAC- and warfarin-treated patients. There were fewer major bleeding events (2.0% vs. 3.3%, RR, 0.62; 95% CI, 0.47-0.82) in the DOAC-treated patients. For procedures that required anticoagulation interruption, there was no difference between DOACs and warfarin for SSE (0.4% vs. 0.5%, RR, 0.95; 95% CI, 0.59-1.55), major bleeding (2.1% vs. 2.0%, RR, 1.05; 95% CI, 0.85-1.30), and death (0.7% vs. 0.6%, RR, 1.24; 95% CI, 0.76-2.04).


The authors concluded that short-term safety and efficacy of DOACs and warfarin are similar for NVAF patients undergoing surgical procedures, with the exception of less major bleeding with DOACs for low-risk procedures where anticoagulation is continued uninterrupted.


This meta-analysis demonstrates the safety and efficacy of short-acting DOAC medications around the time of surgical procedures. It should be noted that no preprocedural DOAC laboratory testing was used in any of these phase III clinical trials. Clinicians should always assess if a planned procedure can be done safely without interrupting anticoagulation. When anticoagulation must be interrupted, clinicians should reference a nomogram or table that will help guide treatment based largely on a patient’s current renal function.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Anticoagulants, Atrial Fibrillation, Cardiac Surgical Procedures, Embolism, Hemorrhage, Outcome Assessment (Health Care), Risk, Secondary Prevention, Stroke, Vascular Diseases, Warfarin

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