Yeungnam Univ J Med.  2020 Oct;37(4):321-328. 10.12701/yujm.2020.00353.

Perioperative outcomes of interrupted anticoagulation in patients with non-valvular atrial fibrillation undergoing non-cardiac surgery

• Park BE
• Bae MH
• Kim HJ
• Park YJ
• Kim HN
• Jang SY
• Lee JH
• Yang DH
• Park HS
• Cho Y
• Chae SC

• KMID: 2508178
• DOI: http://doi.org/10.12701/yujm.2020.00353

Abstract

Background
This study aimed to investigate the incidences of and risk factors for perioperative events following anticoagulant discontinuation in patients with non-valvular atrial fibrillation (NVAF) undergoing non-cardiac surgery.
Methods
A total of 216 consecutive patients who underwent cardiac consultation for suspending perioperative anticoagulants were enrolled. A perioperative event was defined as a composite of thromboembolism and major bleeding.
Results
The mean anticoagulant discontinuation duration was 5.7 (±4.2) days and was significantly longer in the warfarin group (p<0.001). Four perioperative thromboembolic (1.85%; three strokes and one systemic embolization) and three major bleeding events (1.39%) were observed. The high CHA2DS2-VASc and HAS-BLED scores and a prolonged preoperative anticoagulant discontinuation duration (4.4±2.1 vs. 2.9±1.8 days; p=0.028) were associated with perioperative events, whereas the anticoagulant type (non-vitamin K antagonist oral anticoagulants or warfarin) was not. The best cut-off levels of the HAS-BLED and CHA2DS2-VASc scores were 3.5 and 2.5, respectively, and the preoperative anticoagulant discontinuation duration for predicting perioperative events was 2.5 days. Significant differences in the perioperative event rates were observed among the four risk groups categorized according to the sum of these values: risk 0, 0%; risk 1, 0%; risk 2, 5.9%; and risk 3, 50.0% (p<0.001). Multivariate logistic regression analysis showed that the HAS-BLED score was an independent predictor for perioperative events.
Conclusion
Thromboembolic events and major bleeding are not uncommon during perioperative anticoagulant discontinuation in patients with NVAF, and interrupted anticoagulation strategies are needed to minimize these.

Keyword

Anticoagulants; Atrial fibrillation; Perioperative period; Surgery; Thromboembolism

Figure

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  Fig. 1. Duration of perioperative anticoagulant discontinuation according to anticoagulant type (non-vitamin K antagonist oral anticoagulants [NOACs] vs. warfarin).

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  Fig. 2. Receiver operating characteristics curve analyses of the HAS-BLED and CHA2DS2VASc scores and duration of preoperative anticoagulant discontinuation for predicting perioperative events. AUC, area under the curve.

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  Fig. 3. Perioperative event rate categorized according to the cut-off levels of the HAS-BLED and CHA2DS2-VASc scores and duration of preoperative anticoagulant discontinuation. Significant differences in perioperative event rates are observed among the risk 0 (0%), 1 (0%), 2 (5.9%), and 3 (50.0%) groups (p<0.001). HAS-BLED score >3.5: 1, CHA2DS2-VASc >2.5: 1, discontinuation duration before surgery >2.5 days: 1.

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