Clinical question: How long should patients with atrial fibrillation (AF) on a direct oral anticoagulant (DOAC) hold anticoagulation when undergoing endoscopy?
Background: Given limited direct evidence, recommendations on the timing and duration of DOAC cessation vary for patients with AF undergoing procedures. Efforts to mitigate the risk for thromboembolism and post-procedural gastrointestinal (GI) bleeding after digestive endoscopy need to be considered when directing patients when to hold and resume anticoagulation therapy.
Study design: Prospective clinical trial
Setting: Outpatient procedure center
Synopsis: This study established a standardized periprocedural DOAC management strategy based on medication pharmacokinetics, including creatinine clearance and procedure risk. The authors analyzed outcomes for 556 adult patients with AF who were treated with DOACs, undergoing an elective digestive endoscopy, and who were able to adhere to the defined DOAC interruption protocol. The mean duration of DOAC interruption was 3.9 ±1.6 days. There were low rates of thromboembolism (0.7%) and GI bleeding (2.5%).
Procedure details were unavailable for those with bleeding complications and most complications occurred around 10 days post-procedure, suggesting that holding anticoagulation longer post-procedure would not have been preventative. Notably, procedures were elective, and thus, results might not directly apply to inpatient medicine.
Bottom line: The adoption of this standardized regimen for a temporary interruption of DOAC should be considered for most patients with AF undergoing elective digestive endoscopic procedures, given the low rates of thromboembolism and GI bleeding complications.
Citation: Hansen-Barkun C, et al. Periprocedural management of patients with atrial fibrillation receiving a direct oral anticoagulant undergoing a digestive endoscopy. Am J Gastroenterol. 2023;118(5):812-19.
Dr. Rossetti
Dr. McFarlane
Dr. Rossetti is a clinical associate professor and Dr. McFarlane is a clinical assistant professor in the division of hospital medicine at The Ohio State University Wexner Medical Center in Columbus, Ohio.
