Authors: Budd A N et al.
Anesthesia & Analgesia, 142(4):668–681, April 2026
This is a joint consensus statement from the Society of Cardiovascular Anesthesiologists (SCA) and the Society of Thoracic Surgeons (STS) addressing perioperative management of direct oral anticoagulants (DOACs) in adult cardiac surgery.
The document reflects both systematic review and expert consensus, highlighting the rapid growth of DOAC use and the increasing frequency with which anesthesia providers encounter these patients in cardiac surgery. The core focus is on four domains: preoperative cessation, monitoring, bridging, reversal, and postoperative resumption.
A key takeaway is that time-based cessation remains the standard approach. For most patients with normal renal function, stopping factor Xa inhibitors at least 2 days before surgery is considered reasonable, while longer hold times are recommended in renal impairment—up to 3–5 days depending on severity. Dabigatran, due to its renal clearance, requires longer interruption, especially in renal dysfunction.
Routine laboratory monitoring of DOAC levels is not recommended for elective cases, but may be useful in urgent or emergent situations or in patients with risk factors for elevated drug levels. When used, drug-specific anti-Xa assays or dilute thrombin time provide more meaningful information than standard coagulation tests like PT or aPTT.
One of the strongest and most clinically important recommendations is to avoid routine bridging. Bridging with heparin or low-molecular-weight heparin increases bleeding risk without clear reduction in thromboembolic events and should only be considered in very high-risk patients, such as those with recent stroke or extremely elevated CHA₂DS₂-VASc scores.
For urgent or emergent cardiac surgery, reversal strategies become critical. The consensus supports 4-factor prothrombin complex concentrate (4F-PCC) as a first-line option for significant bleeding. Idarucizumab is recommended for dabigatran reversal and has strong evidence for rapid and effective reversal. In contrast, andexanet is specifically discouraged in cardiac surgery requiring cardiopulmonary bypass due to the risk of heparin resistance and potential circuit thrombosis.
The document also discusses emerging techniques such as hemadsorption during bypass to remove DOACs, although this remains investigational. Hemodialysis may be used selectively for dabigatran but is often impractical in urgent surgical settings.
Postoperatively, there is no one-size-fits-all recommendation for restarting DOACs. Most data suggest resumption around 48–72 hours after surgery once hemostasis is secure, but decisions should be individualized based on bleeding and thrombotic risk. A team-based, patient-centered approach is emphasized.
Key Points
- Hold Xa inhibitors ≥2 days and dabigatran longer, especially with renal dysfunction
- Routine DOAC level monitoring is not recommended except in select high-risk or urgent cases
- Bridging is generally discouraged due to increased bleeding risk
- 4F-PCC is preferred for urgent reversal; idarucizumab is first-line for dabigatran
- Avoid andexanet in cardiac surgery due to heparin resistance and thrombosis risk
- Resume DOACs postoperatively based on individualized bleeding vs thrombosis risk
What You Should Know
This is a high-impact, practical document that should directly influence how you manage DOAC patients coming to cardiac surgery. The biggest shifts are avoiding unnecessary bridging and being cautious with reversal strategies—especially avoiding andexanet in bypass cases. If you remember one thing: time-based cessation, selective reversal, and individualized restart decisions are the foundation of safe DOAC management. As DOAC use continues to rise, this framework will become increasingly essential in everyday cardiac anesthesia practice.
We want to thank Anesthesia & Analgesia for allowing us to summarize and share this important work with the anesthesia community.