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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e52

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

anticoagulation to prevent thromboembolism, the duration of cessation of anticoagulation should take into account both the pharmacokinetics and pharmacodynamics of the agent, the patient’s renal function, and the bleeding risk of the procedure. Direct measurement of DOAC levels is unavailable in clinical practice, but levels <30 ng/mL, which correspond to the expected plasma DOAC concentration reached after 3 half-lives, when most of the drug (87.5% of the Cmax) has been eliminated, is reached in two-thirds of patients 24 to 48 hours after the last drug intake.11 Similar results were observed for apixaban.12 A drug “hold” of 48 hours in clinical practice typically means 2 full days without drug intake, in addition to the day of the procedure, leading to a longer interval between last drug intake and procedure start longer than 48 hours, usually an additional 12 hours. Meta-analysis of the reports of periprocedural events from the pivotal trials of each of the 4 available DOACs suggested similar outcomes in patients on DOAC or warfarin, with reduced major bleeding during an uninterrupted strategy with DOACs.21 The PAUSE protocol was studied in patients on apixaban, dabigatran, and rivaroxaban, and resulted in low rates of major bleeding (0.9%-1.85%) and thromboembolism (<1%). A high rate (>90%) of minimal anticoagulant level (<50 ng/mL) was achieved. Similar results have been observed with edoxaban in clinical practice.22 Different protocols have not been directly compared. Table 18 presents recommended DOAC interruption times based on agent, renal function, and the bleeding risk of the procedure. 5.	 The timing of resumption of interrupted anticoagulation after surgery is a complex decision that should integrate patient and surgical characteristics. Warfarin, which takes several days (usually 3-5) to become therapeutic, can often be restarted the evening of the procedure. Postoperative bridging anticoagulation has not been shown to be generally beneficial.1,13 In the PAUSE study, DOACs were started on the first postoperative day for low bleeding risk procedures and between the evening of the second and third postoperative days for high bleeding risk procedures. This resulted in a low risk of major bleeding.4 Input from the proceduralist should always be incorporated into decisions. 6.	 Several studies have compared a strategy of

bridging anticoagulation with a comparator of no bridging in patients on anticoagulants who were scheduled to undergo an invasive procedure or surgery. The BRIDGE trial randomized 1 884 patients with AF or AFL to bridging anticoagulation before and after the procedure with dalteparin versus placebo.1 Almost 90% of patients were undergoing low bleeding risk procedures. No bridging was superior to bridging with respect to major bleeding and was noninferior with respect to thromboembolism, although the observed rate (0.4%) was lower than anticipated (1.0%). PERIOP2 (A Double Blind Randomized Control Trial of Post-Operative Low Molecular Weight Heparin Bridging Therapy Versus Placebo Bridging Therapy for Patients Who Are at High Risk for Arterial Thromboembolism) randomized patients, about two-thirds of whom were undergoing high bleeding risk procedures, and 79% of whom had AF, to postoperative bridging with dalteparin or placebo until the INR was >1.9. All patients received preoperative bridging. Bleeding and thromboembolism outcomes were similar.13 These studies also excluded patients with recent bleeding or thromboembolism, and those undergoing spinal and neurological surgery, and in these cases, management should be individualized and may include bridging anticoagulation.1,13 A small randomized trial found that dental extractions could be performed on uninterrupted warfarin without bridging.14 A large multicenter registry also did not find a difference in thromboembolism, but an increase in bleeding, in bridged patients.15 Patients with mechanical valves should be managed as outlined in the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”23

6.8 Anticoagulation in Specific Populations

6.8.1 AF Complicating ACS or Percutaneous Coronary Intervention (PCI)

Recommendations for AF Complicating ACS or PCI Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 A 1 In patients with AF and an increased risk for stroke

who undergo PCI, DOACs are preferred over VKAs in combination with APT to reduce the risk of clinically relevant bleeding.1–5

1 A 2 In most patients with AF who take oral anticoagulation

and undergo PCI, early discontinuation of aspirin (1-4 wk) and continuation of dual antithrombotic therapy with OAC and a P2Y12 inhibitor is preferred over triple therapy (OAC, P2Y12 inhibitor, and aspirin) to reduce the risk of clinically relevant bleeding.1–4,6

Synopsis Encountering a patient with AF at an increased risk for stroke who undergoes PCI for stable CAD or ACS is a common clinical scenario. The addition of APT to OAC after PCI introduces a risk for clinically significant bleeding. RCTs have compared the safety and efficacy of various antithrombotic regimens after PCI is performed in patients with AF. They have consistently shown that DO- ACs, when used in conjunction with APT, are associated

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