Peri-interventional management of new oral anticoagulants (NOACs) significantly differs from the management of vitamin K antagonists. Indeed, the relatively short half-lives of NOACs and their fast onset of action allow a reduction of the pre-procedural interruption interval and a rapid re-initiation after the intervention. Although heparin bridging is not recommended, current guidance is based on expert opinion and robust clinical evidence is still lacking.

The Dresden registry is a large prospective registry that includes patients treated with NOACs in the district of Dresden in Germany. In this article, the authors assessed the management and safety of peri-operative NOAC use in a large cohort of patients. The authors included 2179 patients in the study, including 595 patients who underwent 863 surgical procedures. The incidence of major cardiovascular events and major bleeding complications was low (1.0 and 1.2% after major procedures, respectively). Preoperative heparin bridging did not reduce the incidence of cardiovascular events but was associated with an increased risk of major bleeding compared to the ‘no-bridging’ approach. This was particularly true in patients who underwent major procedures.

This study reports that a short preoperative interruption of NOACs is safe in patients who undergo both minor and major procedures. Based on these results, a strategy with a short preoperative interruption without heparin bridging may be safe; however, the benefit should always be balanced with the risk in high-risk patients.

– David Faraoni

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