Predictors of Bleeding in the Perioperative Anticoagulant Use for Surgery Evaluation Study

J Am Heart Assoc. 2020 Oct 20;9(19):e017316. doi: 10.1161/JAHA.120.017316. Epub 2020 Sep 24.

Abstract

Background In the PAUSE (Perioperative Anticoagulant Use for Surgery Evaluation) Study, a simple, standardized, perioperative interruption strategy was provided for patients with nonvalvular atrial fibrillation taking direct oral anticoagulants (DOACs). Our objective was to define the factors associated with perioperative bleeding. Methods and Results We analyzed bleeding as the composite of major and clinically relevant nonmajor bleeding. Putative predictors of bleeding, and preoperative DOAC level were prospectively collected during recruitment. We used stratified logistic regression models for analysis. All statistical analyses were performed in R version 3.6.0. There were 3007 patients requiring perioperative DOAC interruption. More than one third of the included patients underwent a high bleeding risk procedure. The 30-day rates of major and clinically relevant nonmajor bleeding were 3.02% in apixaban (n=1257), 2.84% in dabigatran (n=668), and 4.16% for rivaroxaban (n=1082). Multivariate analysis stratified by region found more bleeding for hypertension (odds ratio [OR], 1.79; 95% CI 1.07-2.99; P=0.027), and prior bleeding (OR, 1.71; 95% CI, 1.08-2.71; P=0.021). Surgical bleed risk classification (high- versus low-risk) as a predictor of bleeding was only significant in the univariate analysis. The prediction model for major and clinically relevant nonmajor bleeding had an area under the curve of 0.71, and the preoperative DOAC level did not improve the area under the curve of the model. Conclusions In patients treated with DOACs who required an elective surgery/procedure and were managed with standardized DOAC interruption and resumption, there we did not find reversible risk factors for bleeding, suggesting that adjustment of the PAUSE management protocol to mitigate against bleeding is not needed.

Keywords: atrial fibrillation; bleeding; direct oral anticoagulant; surgery.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Blood Loss, Surgical* / prevention & control
  • Blood Loss, Surgical* / statistics & numerical data
  • Dabigatran* / administration & dosage
  • Dabigatran* / adverse effects
  • Elective Surgical Procedures / adverse effects*
  • Elective Surgical Procedures / methods
  • Elective Surgical Procedures / statistics & numerical data
  • Factor Xa Inhibitors / administration & dosage
  • Factor Xa Inhibitors / adverse effects
  • Female
  • Hemorrhage* / chemically induced
  • Hemorrhage* / prevention & control
  • Humans
  • Male
  • Medication Therapy Management
  • Perioperative Care / methods
  • Perioperative Care / statistics & numerical data
  • Pyrazoles* / administration & dosage
  • Pyrazoles* / adverse effects
  • Pyridones* / administration & dosage
  • Pyridones* / adverse effects
  • Risk Adjustment / methods*
  • Rivaroxaban* / administration & dosage
  • Rivaroxaban* / adverse effects
  • Stroke / etiology
  • Stroke / prevention & control

Substances

  • Factor Xa Inhibitors
  • Pyrazoles
  • Pyridones
  • apixaban
  • Rivaroxaban
  • Dabigatran

Grants and funding