Perioperative Management of Direct Oral Anticoagulants in Cardiac Surgery: Practice Recommendations Based on Current Evidence

An increasing number of patients on systemic oral anticoagulants present for cardiac surgery, and cardiac anesthesiologists should be well-informed on their management in the perioperative period. Direct oral anticoagulants (DOACs), including factor Xa inhibitors and direct thrombin inhibitors, are an attractive alternative to warfarin due to fewer dietary and drug interactions, less frequent monitoring requirements, and an improved patient adherence. Since the approval of DOACs by the Food and Drug Administration in 2010, the number of patients on these medications only has increased. The guidelines vary on the periprocedural management of DOACs for cardiac surgery. This review evaluated the current evidence for medication cessation before surgery, based on timing as well as plasma drug concentration. The practice recommendations of various monitoring tests and new evolving point-of-care testing are examined herein. The different reversal agents were discussed by the authors for both elective and urgent procedures. The cardiac anesthesiologist needs to be intimately familiar with the management and current best practices of DOACs for safe and appropriate patient care.