Practical aspects of perioperative management in patients with non-valvular atrial fibrillation receiving direct oral anticoagulants

The article is dedicated to the perioperative management of patients with non-valvular atrial fibrillation (AF) receiving direct oral anticoagulants (DOACs) and undergoing elective surgical interventions or invasive procedures. It discusses key factors influencing the strategy for discontinuing and resuming anticoagulant therapy, including the classification of surgical procedures by bleeding risk, type of anesthesia, creatinine clearance, and the pharmacokinetic properties of specific DOACs. A standardized algorithm is presented to determine the optimal timing for discontinuation and resumption of anticoagulants. The detailed analysis of possible clinical scenarios, such as endoscopic cholecystectomy, tooth extraction, radical prostatectomy, and knee arthroplasty is described. Practical recommendations for perioperative management are offered for each case, considering individual patient characteristics, the risk of thromboembolic and hemorrhagic complications, and the need for venous thromboembolism (VTE) prophylaxis. Special attention is given to challenges in real-world clinical practice, such as a lack of coordination between specialists, differences in the interpretation of guidelines, and the absence of standardized in-hospital protocols. The importance of a multidisciplinary approach is emphasized to ensure balanced decision-making. It highlighted the necessity of an individualized approach when deciding on the discontinuation and resumption of anticoagulant therapy, as well as the importance of standardized protocols to enhance patient safety in AF management. It is recommended to consider the pharmacokinetic properties of the drugs, patient- specific factors, and the planned procedure, along with potential risks. The use of clear algorithms and active multidisciplinary collaboration among clinicians can help minimize both thromboembolic and hemorrhagic complications in the perioperative period.