Authors: Budd AN et al.
Anesthesia & Analgesia, 142(4):668–681, April 2026
Summary:
This joint consensus statement from the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons provides evidence-based and expert-driven guidance on the perioperative management of direct oral anticoagulants (DOACs) in adult patients undergoing cardiac surgery. Given the increasing use of DOACs and the high bleeding risk associated with cardiac surgery, standardized approaches to interruption, monitoring, reversal, and resumption are critical for optimizing patient outcomes.
The authors conducted a systematic review and combined available evidence with expert consensus to generate practical recommendations. DOACs, including factor Xa inhibitors (apixaban, rivaroxaban, edoxaban) and direct thrombin inhibitors (dabigatran), are widely used due to predictable pharmacokinetics and reduced monitoring requirements compared to warfarin. However, their perioperative management remains complex, particularly in cardiac surgery where both bleeding and thrombotic risks are high.
For elective cardiac surgery, the consensus supports a time-based interruption strategy. In patients without significant risk factors for delayed drug clearance, holding DOACs for at least two days is generally sufficient. However, longer interruption is recommended in patients with renal impairment, advanced age, low body weight, or other factors that may prolong drug elimination. Specifically, factor Xa inhibitors should be held for at least 3 days in moderate renal dysfunction and 4 days in severe renal dysfunction, while dabigatran may require at least 5 days of discontinuation due to its renal clearance.
Routine measurement of DOAC levels is not recommended but may be considered in urgent or emergent cases or in patients with risk factors for elevated drug levels. When testing is used, drug-specific anti-Xa assays or diluted thrombin time provide more accurate assessment than standard coagulation tests.
Bridging anticoagulation is generally discouraged due to increased bleeding risk and should only be considered in select high-risk patients with significant thromboembolic risk. For patients requiring urgent or emergent surgery, reversal strategies are critical. The use of idarucizumab is recommended for dabigatran reversal, while 4-factor prothrombin complex concentrate may be used for both factor Xa inhibitors and thrombin inhibitors when significant bleeding is present. The use of andexanet alfa is not recommended in patients requiring cardiopulmonary bypass due to concerns about heparin resistance and thrombosis.
Postoperatively, resumption of DOAC therapy should be individualized using a multidisciplinary, patient-centered approach that balances bleeding and thrombotic risks. Timing should account for surgical factors, hemostasis, and patient comorbidities.
Overall, this consensus emphasizes a structured, risk-based approach to DOAC management in cardiac surgery, highlighting the importance of individualized care and multidisciplinary decision-making to improve perioperative safety.
What You Should Know:
DOAC management in cardiac surgery requires careful balancing of bleeding and thrombotic risks. Standardized time-based interruption is generally effective, but patient-specific factors such as renal function and age significantly influence drug clearance. Routine laboratory monitoring is not necessary but may be useful in urgent situations. Bridging should be avoided in most cases due to bleeding risk. Reversal strategies must be tailored to the specific DOAC, and certain agents like andexanet alfa should be avoided in cardiac surgery. Postoperative resumption should be individualized rather than protocol-driven.
Key Points:
- Time-based DOAC interruption is the primary strategy for elective cardiac surgery
- Minimum 2-day hold for most patients, longer with renal dysfunction or high-risk features
- Routine DOAC level monitoring is not recommended but may help in urgent cases
- Bridging anticoagulation generally increases bleeding risk and should be avoided
- Idarucizumab and 4F-PCC are key reversal agents; andexanet alfa not recommended for CPB cases
- Postoperative DOAC resumption should be individualized using a multidisciplinary approach
Thank you to Anesthesia & Analgesia for allowing us to summarize this article.